Love in Medical Ethics in South Asia

- V. Manickavel, M.D.
College of Medical Sciences-Nepal, Kathmandu University,
Bharatpur, Chitwan, Nepal
Eubios Journal of Asian and International Bioethics 9 (1999), 40-42.

In South Asia or in Western countries the origin of medical practice undoubtedly is based on love, compassion, the care for a fellow human being. The suffering of a neighbor and the responsibility one takes on seeing the neighbor's pain and the efforts to alleviate them is the foundation of medical practice through out the world. However, this basis some times gets clouded over as may be happened in the modern medical practice. That is the reason, we are all sitting here and wondering about the foundations. It may be that the medical knowledge is a dominating factor in the modern practice but still we cannot say that the modern practitioners are interested only in the rewards and not practicing the ethics of dedication out of love. We still cannot ignore the long hours in their students' days and in the training time. These long hours are a grueling task only for those who did not feel the under current of love. But love, the basis of medical ethics, which governs the medical practice shine in a different manner in South Asia, which we will discuss in this essay.

I will be restricting with the Hindu medicine and to a certain extent I will be talking about Buddhist medicine. But, I do find it difficult to separate them which is partially due to their antiquity and the over lapping culture.

The ancient record of medical practice including medical ethics in the sub continent of India and may be in the entire South Asia is in Ayur Veda, which literally means the knowledge of long life. In this book, the knowledge of long life did not get restricted only to human beings. There are lengthy treatise on the long life of elephants and horses which were the precious possessions of the kings, the patrons of the Hindu medicine.

The tradition of medical practice in South Asia started out with intuition. Medical wisdom according to the recorded details is not just the product of a single creative mind. It had progressively evolved and adaptations were made on the way as the Hindu religion did during its times. In spite of the changes, the wisdom remains basically the same at all times (i.e.) the love to help others. This love to help others is not just in the relief of physical suffering alone but in the help to find internal transference, internal freedom, and Nirvana. Before, we look at those, I would like to describe briefly the medical practice as given in these books.

The medical wisdom or knowledge is traditionally considered as eight limbed in other words eight different types of knowledge are needed for the medical practice.

Hindu Modern
1) Salya Surgery
2) Salakya Eye, Ear, Nose and Mouth=Ent
3) Kaya-Cikitsa Therapy=Treatment
4) Bhuta-Vidya Demonical=Mental=Psychiatry
5) Kaumara Bhrtya Pediatrics
6) Agada Medicinal Drugs=Pharmaco-Kinetics
7) Rasayana Elixirs Of Life
8) Vaji Karana Turning Into Stallion

Here I have equated those old wisdom to the medical knowledge of modern day practice except nos. 7 and 8 are not considered in the main line of modern practice however the growth hormone extracts from fetus for rejuvenation treatment in some European countries and the much publicised 'viagra' comes under these knowledge. Surgical knowledge which is expounded in the book Charaka is latter in origin compared to the book by Sushrutha.

Further, in each section there are ten points are to be considered, i.e., I consider as ten steps in the treatment of the patient, from the first to tenth:
Ten factors to consider in the treatment
Sarira The organism
Vrtti Means of maintenance and proper conduct
Hetu The cause of diseases
Vyadhi Nature of pain and diseases
Karman Action: treatment
Karya Effect: result by treatment
Kala Influence of seasons
Kartr Agent: Physician
Karana Means and instruments
Vidhivinis'caya Decision-treatment

The first point to consider is the organism. The human beings are broadly sub divided into types (may be equal to A1, A2 type) but the planetary positions of the time of birth of the patients was considered as important as the body frame (fat, lean, moderate) and the proneness to diseases were determined by that.

The second point to consider in the treatment was how the patient maintains oneself, in both, the moral and physical habits. Moral habit was a strong determining factor. However some of the ancient surgical physicians who were out castes themselves practiced on criminals, and run-aways. This moral habit is beginning to attract the modern medical practice in the name of life style.

In the same category of the life style, the ancient Hindu physician had to study the correlations of one's dietary habits and the environmental pathogens for the cause of diseases. Organisms alone did not cause diseases. Both organisms and the dietary factors were considered as contributory in the causes of the disease.

Further, the physician was required to make the decision, after the thorough study of the detailed history of pain and diseases (discomfort). The course of action (i.e.) treatment also included the knowledge of effect (equivalent to the side effects of drugs). The Hindu physician needed to acquire another special knowledge of effect of time (season) before the treatment was started. Here, also, the knowledge of the planetary positions of the patient was considered as essential. If the patient's planetary position showed no scope of life, the physician was advised against offering the treatment. However, if any alternates to negate the positional influence of the planets available, the patient was advised to do that and then normally treatment began. Similarly, the physician should consider the effect of time of the day in the treatment (i.e.) something equivalent of the modern chronobiology. Another aspect, the self analysis of the agent who administered the treatment was considered as essential in the medical ethics of the Hindu physician. The competency of oneself in the treatment of a patient was necessary in analyzing all the previous parameters to make the medical decision. Finally, in the holistic development of a fully competent Hindu physician, the tenth knowledge of several medical instruments was also considered as necessary. Most of these ten aspects of medical wisdom in the treatment of the patient have corollaries in the modern medical practice. Some are more emphasized than others. In the modern medicine the emphasis of instrumentation is more, and less on the life style, food and personality.

Some more points were considered in the study of personality in the Hindu medical knowledge. Accordingly the human health is the result of the balance of three elements- air, phlegm and bile. People are born with the combinations of these elements and different levels of mixing exists. On that basis the human beings were broadly divided into three categories. This grouping was taken as an important contributory factor in designing the treatment course. Each of these three groups were known to react differently in different seasons to various kinds of ailments, infections and pains.

The Hindu medical practice strongly considered certain four other aspects in the treatment and healing of a patient. Two legs of the table of healing, namely the medical person and medicament are easy to understand in terms of modern knowledge (i.e.) medical person or knowledge and treatment. But the third aspect of the patient as trust is also as the part of treatment is very interesting. As we looked before, the patients' planetary influences were analyzed first for the positive outcome before the treatment commenced. If I can equate this aspect of treatment in the modern medical practice, the newly emerging science of Psychoneuroimmunology of Ader and Cohen and positive thinking as advocated in the cancer treatment by Norman Cousin come closer. According to them, that with positive thinking one can condition oneself to cure. That is why I have called this leg as Trust of the patient. The fourth leg of the treatment was considered as nursing care. My colleagues in nursing will be glad to see this as part of the treatment and healing rather than as a separate entity in the modern medical practice.

In contrary to the modern medical practice, the ancient physician was advised not to treat a patient ailing for a long time (about a year) and of poor risks. The guidelines to decide on these some were "scientific" and some did not fit that description. The patients of low morality were usually discouraged not to be taken up for treatment. Further the physician was advised to look for the omens and dreams before she starts the treatment.

Now, let us look at some of the social aspects of Hindu medical practice. This knowledge was considered as supreme and sacred. So, only brahmins were allowed to study and acquire this knowledge. I imagine women were not allowed. However, some non-brahmins also practiced. It is also stated that this knowledge of long life is common to all. But, because of the occupational hazards like touching the diseased persons (may be of lower births) wounds, and handling dead bodies during the training of the physicians and tasting the body secretions for diagnosis, these brahmins were considered as polluted brahmins.

It had been recorded that, as early as the second century, hospitals capable of treating several hundred patients with nursing attendants and dietary and drug dispensing facilities existed during the king Parakrama the great (1164-1189 A.D.) in Sri Lanka. Several hospitals were known to exist attached to temples, monasteries and educational institutions and we find them more, as Buddhism spread in South Asia.

In addition to the treatment centers to human beings, there have been records showing hospitals established exclusively for animals, definitely due to the influence of Jainism. In general, kings founded the hospitals and appointed one physician for every ten villages and many more were appointed for the king's armies, elephants and horses. The association of physician and king was critical in the spread of many hospitals. The medical training usually under a physician lasted several years. The student on completion of an examination and upon the recommendation of the teacher obtained the license to practice, from the king. The competent physician ascended to the top as king's physician, where he was responsible for king's long life and for tasting king's food for poisons.

With this background, let us look at the uniqueness of South Asian medical ethics. Where I consider love is playing the major role. As we discussed in the beginning, love is the corner stone for all the medical practice. In South Asia the traditional medical practice was very closely linked with the religious beliefs and practices. In this part of Asia, personal salvation, Nirvana is the ultimate goal of a person and helping others in that goal, helps one to achieve ones own personal salvation. This is the under current we see in the medical ethics of South Asia. The strong body will help one to attain a strong mind, and the other aspects of Nirvana (i.e.) attention, concentration, meditation and samadhi or Nirvana or enlightenment. To achieve this a physician was advised to give, out of love, the comfort for one body so that she also be helped in her own journey to enlightenment.

Henry Zimmer, who had spent considerable time in the study of ancient Hindu medicine, had shown how this approach of the physician to the treatment is very close to the four noble steps in the attainment of Nirvana in Buddhism. The first step in the attainment of Nirvana is the recognition that universal suffering like the patient's pains and complaint is real. The second step is the recognition of the deep-rooted ignorance as the cause of suffering. Similarly the physicians also approach identifying the particular nature of sickness and suffering. The third step in Buddhist Nirvana is to understand that ignorance is curable and the physician determines the cure for the treatment. All these steps lead to the fourth step, the attainment of Nirvana in Buddhism and proper therapy in the medical treatment. In this way Buddha equates the attitude of the physician towards the task of healing is equated to salvation doctrine of Buddha.

The Hindu physician according to the ethical practice was thus more like a spiritual leader responsible for protective healing but understood the limits of healing. Still helped the patient in offering the treatment according to the disease and the patient. Assisting one to free from the disease and acquire health and longevity was the primary importance to the physicians. This was to fulfill their karmas and serve the community. This spiritual pursuit and the love played the important role in providing the medical care by the Hindu physician. With his wisdom of long life he was advised to find the cause, symptom and remedy of the disease. In turn able to reset the antagonistic tendencies of the patients' earthly individual nature: (to be afflicted by disease) and his divine transcendent essence. Helping an individual to bring the maturity that the quiescent gem of individual divine being in ones perishable body was considered as a noble action of the physician. This moral inheritance of helping the individual transference was linked in an intimate fashion with the spiritual inheritance of the physician.

In spite, that, the central axiom of Hindu medicine is the release of individual souls from the crutches of senses and suffering through' a well balanced elaborate technique of inner quest of spiritual experience, the Hindu medical ethics is cautions and conservative. Yet the emphasize on the spirituality and the responsibility of well being and long life was stressed.

This is well illustrated in the oath of the Hindu physician of ancient times:

Hindu physician oath

1) You must put behind you desire, anger, greed, folly, pride, egotism, jealousy, harshness, calumny, falsehood, sloth and improper conduct.

With short-cut nails, ritually clean and clad in the orange garment, you must be pledged to truth, and full of reverence in addressing me...

2) If, however, you behave perfectly, while I profess false views, I shall be guilty of sin and my knowledge shall bear me no fruit.

3) (after having finished your studies) with your medicaments you shall assist brahmins venerable persons, poor people, women, ascetics, pious people seeking your assistance, widows and orphans and any one you meet on your errands, as if they were your own relatives. This will be right conduct...

The very first point in this oath summarizes the love as the anchor in the medical practice. The human negative emotions described here emphasize the importance of love in providing long life to others. Even though the other points look out of place but, when we look more carefully, that, love is the basis. For example taking care of the teachers and their families. This is in striking parallel with the oath taken by Greek physicians following Hippocratic tradition.

This love for other beings is illustrated in the prayer offered by the medicine man when he wanted to prepare medication from the medicinal plants. According to the ethical practice he was advised that he should seek the permission from the plants themselves to use them for treating a patient who could be cured from the ailments. Then the physicians prayed that the life essence stay with in the plant, so that the cure would be effective. The loving consideration of other organisms and their purpose, is emphasized and not just love out of intuition or duty bound or just the nature. The same attitude is shown in the prayer of the carpenters who wanted a dead tree for making things, prayed to the tree that the life essence be gone so that he could cut the tree and use. Even though, he had selected a dead tree, still he was advised to offer the prayers to make sure that the life essence completely gone out of the tree.

This life essence, the under current, the thingness is universal and present in all the things, as fluidity in water, as windiness in wind, as stoniness in stone, as treeness in tree, as animalness in animal and as humanness in human. Recognizing the oneness in all these stem from love.

Long time ago, Henry Zimmer had written that "In her/his daily routine the practitioner, relentlessly and continually faces an enormous responsibility, she/he experiences again and again the failure of well established treatments, as well as unexpected recoveries in seemingly hopeless cases." This is still true in the medical practice in South Asia as in elsewhere. However the medical ethics governing the Hindu medical practice emphasizes the responsibility to others based on love both for spiritual and physical well-being gives the moral strength to go through the daily ordeals.


The author would like to thank the College of Medical Sciences-Nepal for the support and to Prof. R. Ramaswamy for his enthusiastic encouragement and to the International Society of Medical Education (Reg. USA) for the financial support.

Macer, Darryl R. J. Bioethics is Love of Life An alternative textbook on cross-cultural ethics Christchurch, New Zealand, and Ibaraki, Japan: Eubios Ethics Institute, 1998.
Zimmer, H. R., 1948, Hindu Medicine, The Johns Hopkins Press, Baltimore, USA

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