Medical ethics

Diseases and ailments have distressed humanity since primitive times. Man’s effort in curing disease by finding its cause has helped in the evolution of society since the ancient times. Medical research has led to the development of human awareness, evolving with consecutive civilizations. It is known to all that the ancient India has played an efficient role in the development of medicine, especially in medical ethics and surgical training methods. However, around 3000 years later, the medical world faces serious concerns over the corrosion of long-held value systems and magical codes of medical practice. In this era of massive technical advancements and innovative therapies, the influence and power of insensitive materialism and uncontrolled commercialization grows threateningly. In the wake of serious threats on availability of ethical and advanced medical practices to the people across the world, relying on age old Indian medical tactics – especially ethics and surgical methods – could prove relevant.

In short, the record of ancient India covers –

• the pre-Vedic period (around 6 000 BC),
• the Indus and Saraswati civilizations (2500 – 1550 BC),
• the Vedic period (1700 – 500 BC), and
• the advent of Jainism and Buddhism (up to 325 BC), and finally
• the Mauryan period which expands till 500 AD.

The Vedic Period

Ancient medical practices linked the concept of healing more to the spiritual and divine manifestations. Much before the advent of formal writing, Sanatana Dharma or Vedic religion practiced healing therapies for spiritual benefits. The Vedas, ancient scriptures around 5000 years old, are the roots of the modern medical medicines. Atreya, Kashyapa Dhanvantari, and Bhela were the authors of these ancient scriptures who stressed on the spiritual philosophy and medical ethics as part of mainstream healing practices.

The Concept of Dharma

Dharma (right behavior) is the foundation of the ancient Indian society; dharma commanded a man to live in society as a well-civilized being, subduing his selfish desires for the sake of others. Practicing Dharma helped a man in maintaining a high standard of ethics and a determined code of conduct. Additionally, the non-material virtues were always preferred over materialistic pursuits. The philosophy of Dharma was extensively propounded by Swami Vivekananda in the beginning of the 20^th century. Swamiji instilled amongst his disciples the ethics of – ‘Service to man is service to God’.

The Samhita Period

The early Vedic period was embraced by the Samhita (compendium, dissertation) period (about 800 – 700 BC). During this time, Indian civilization produced highly evolved forms of ethics, rational thinking and conscience; profound intellectual turmoil ushered in an era of scientific method that transformed the magic of spiritual medicine into conventional scientific medicine. This new age revolution is strongly reflected in the samhitas of Susruta and Charaka. These great works of medical literature detailed scientific research, patient examination and experimentation that served as reference works for students and practitioners. Thus we have one of the best developed medical systems from antiquity.

Charaka Samhita

Charaka, the protégé of Atreya, represented the school of physicians. The Charaka Samhita provides an elaborate code of conduct, stating that the medical community has to be motivated by compassion for living beings; thus, he who treats his patients only on humanitarian grounds without desiring any money or personal benefits in return, supersedes all other physicians.

Charaka Samhita is a part of the Vedas. Charaka is the name of Maharishi Charaka and Samhita denotes text or encyclopedia. The text specifically covers following topics –

• seasons,
• diet,
• thinking,
• therapies and
• other important guidelines on general health.

Charaka Samhita (CS) tells us about the moral and holistic method of treatment. The text of the Charaka Samhita as it survives dates back to the Gupta period or roughly 300-500 CE. The surviving text is considered to be an edition by one Dr Dhabala, based on an earlier work of the period between 100 BCE and 100 CE, so that the bulk of the material in the CS might actually predate the SuS by a few centuries.

Susruta Samhita

Among medical historians, the historical provenance of Susruta has long been a controversial subject. Susruta’s era has variously been placed between 900 BC and 100 AD, a possible reflection on the lack of direct evidence. However, the discovery and review of the Bower Manuscript, which includes references to ancient Indian medicine, places Susruta in the 5th century BC or earlier.It is mentioned that he taught surgery at the eastern University of Benaras, on the banks of the river Ganges. An accomplished surgeon, philosopher and above all a great teacher, his compilation of the Susruta Samhita,(SuS) a monumental treatise of seminal value, established him as arguably the brightest jewel in the history of surgery in the ancient and medieval period. Allen O Whipple commented in 1963 that Susruta must be considered the greatest surgeon of the medieval period. K K Bhishagratna, the highly respected authority on the life and works of Susruta, wrote, to Susruta may be attributed the grandeur of inspiring the art of handling a lancet or forceps to the status of a practical science’. The training of doctors and their code of ethics and practice, in ancient India holds a salutary position in the history of medicine. The high ideals of medical practice and the responsibility of the physician are emphasised in Charaka’s poignant statement: ‘No other gift is better than the gift of life’.

Four Limbs of Medical Treatment

According to ancient Indian medicine, the following are the four limbs of medical treatment

The Patient

The Physician

Medicine

Nurse and Attendants

The ideal condition for each of these four limbs is described in the ancient medical literature.

Ethical principles & Qualities of a Physician

Ethical Principles

Charaka clearly outlined four ethical principles of a doctor:

• Friendship towards the sick
• Sympathy towards the sick
• Interest in cases according to one’s capabilities and
• No attachment with the patient after his recovery

The Charaka Samhita emphasises the values central to the nobility of the profession thus, ‘Those who trade their medical skills for personal livelihood can be considered as collecting a pile of dust, leaving aside the heap of real gold’.

Furthermore, ‘He who regards kindness to humanity as his supreme religion and treats his patients accordingly, succeeds best in achieving his aims of life and obtains the greatest pleasures.

Qualities

Charaka enumerates six qualities of a successful physician

• Having knowledge
• Critical approach
• Insight into allied sciences
• Sharp memory
• Promptness
• Perseverance

Since there is no limit to knowledge, Charaka advises the physician to try to learn every moment. According to Susruta, study, discussion, perusal of foreign literature and devoted services to the masters of the particular techniques are essential for gaining wider knowledge and improving skills. One cannot come to the right conclusion by studying just one aspect of a subject. Hence the physician must learn other viewpoints to become proficient.

Physician’s duty & Obligations as per Susruta Samhita

In the Susruta Samhita, the doctors’ duty and obligations to the patient are greatly emphasized upon: The patient may doubt anyone from his family and friends, but he has complete faith in his physician. He [the patient] gives himself up in the doctor’s hand and has no misgivings about him. Therefore, it is the physician’s duty to look after him as his own. Prospective medical students were carefully selected on the basis of the criteria of the noble ethos of this profession. Students were required to study for six years before being permitted to practise the art of curing patients. At the beginning of training, an earnest injunction was delivered to the student. This oath came several centuries before the Hippocratic Oath was introduced. As per the injunction, the student had to ‘  renounce lust, anger, greed, ignorance, vanity, selfishness, envy, rudeness, miserliness, falsehood, sloth and all other acts that bring a man to disgrace. At the proper time, you must cut your nails and hair, and assume the saffron robe of the student. You must live the truthful, disciplined life of a student and obey and respect your teacher. All actions should be beneficial to me, otherwise your study will be fruitless and you will never achieve fame’. Significantly, the conduct of the teacher was also subject to scrutiny, thus: ‘If I [the teacher] act unjustly towards you even when you totally abide by me and faithfully perform my instructions, may I deserve sin, and may my knowledge never be displayed or come to fruition’. The current erosion of ethical practices has been of sufficient concern to professional associations, organizations controlling registration, as well as parastatal structures, to set out detailed guidelines on ethical practices and to provide uninterrupted medical education in this field. The following points would make the argument more clear:

• The teaching of moral conduct, in most curricula in South Africa, is dialectical.

• Despite well-intentioned clinical vignettes, teaching is invariably in lecture halls far removed from clinically relevant situations.

• Standard schoolbooks address the subject in a obligatory manner.

• Medical ethics is usually taught by those having obtained subject certification, rather than by mere credible exemplars.

• There are basic shortcomings in value systems and social attitudes.

The reality is that, despite concentrated efforts by professional bodies and committed teachers and the institution of appropriate legislation, further decline in ethical practice is likely to continue unchecked.

Qualities of Nurses and attendants

The Charaka (Vol I, Section xv) states these men should be,

• of good behaviour,
• distinguished for purity,
• possessed of cleverness and skill,
• imbued with kindness,
• skilled in every service a patient may require,
• competent to cook food,
• skilled in bathing and washing the patient,
• rubbing and massaging the limbs,
• lifting and assisting him to walk about,
• well skilled in making and cleansing of beds,
• readying the patient and skilful in waiting upon one that is ailing and
• never unwilling to do anything that may be ordered

Characteristics of an Ideal Patient

One of the limbs of medical treatment is the patient himself. It is needless to say that the treatment of a cooperative, intelligent patient is much easier and considerably helps to improve the prognosis. According to Charka following are the four qualities of a good patient

• A good memory,
• Willingness to follow the instructions of the physician,
• Fearlessness and
• Not hiding any relevant information about his symptoms and disease

Surgical Standards

Notwithstanding all its refinements and advanced techniques, modern surgery could yet benefit from the seminal contributions of ancient Indian society to the human spirit. In the context of the current erosion of value systems, we can draw great inspiration from the code of practice, nobility of profession and ethos of service to humanity that was exhibited by Indian surgeons of old. While it would be impractical now to totally embrace the value systems of ancient India, among which was that of selfless conduct, the infusion of some aspects of their philosophy into modern teaching and instruction can still be beneficial.

Surgical Training in Ancient India

Around 2000 years earlier, the traditions of the ‘barber surgeon’, surgical apprenticeship and residency, clear guidelines existed for the training, evaluation and registration of surgeons. In the Susruta Samhita, it is stated that ‘ practice can be started only after having read and thoroughly studied the science of medicine; having seen and performed the operations himself; having passed the appropriate tests and thence obtained the permission of the governing authority’. Being fundamentally a surgical treatise, the Susruta Samhita lays more emphasis on practical training. Susruta insisted that the enormous amount of oral training should be balanced by practical efficiency. He thus stated, in colourful and poetic language, that ‘he who wishes to be expert in the use of surgical operations should practice the same experimentally on similar problems’;

Thus: ‘the surgeon who knows the structure of the body cannot be misled into errors of anatomical ignorance.’ Furthermore, it was held that ‘only he can be considered an expert [surgeon] who is well versed in the practical and descriptive anatomy. Therefore, one should start the procedures [of surgery] after clearing away the doubts by actually seeing [the surgical anatomy concerned] and consulting [the appropriate literature]’.

Sound academic knowledge and practical experience were considered to be of complementary value and equally important for the surgeon; thus, the surgeon ‘who is good in practical work because of his boldness, but lacks theoretical knowledge, is not respected in the cultured society; actually he deserves punishment by the government.

In addition, in order to broaden your knowledge and outlook, you should study the subject regularly, take part in scientific debates and discussions, observe the allied sciences and take training from specialists of those branches. Surgery was considered as an independent field.

Conclusion

The four cardinal aims set before doctors are

• Preservation of life
• Curing of illness and Lessening of suffering
• Prevention of diseases
• Advancement of knowledge

The aims set before the physicians in ancient India, while including the above four aims were far wider, loftier and nobler. They were no less than the spiritual emancipation and eternal happiness of the patient, the nurse and the doctor, and the building up of a sane society.

It must be noted that the ethical principles and moral admonitions are incorporated into and form part and parcel of the body of such authoritative ancient medical texts like Charaka Samhita and Susruta Samhita and others.

The ancient system of incorporating ethics into medical education is worthy of adoption in modern times. Nowadays we see a sharp decline in professional ethical behavior.