Bṛhat

Reclaiming Medical Ethics
The medical ethics was an important feature of the Āyurvedic curriculum, duly emphasized by ancient practitioners. Caraka’s Oath can be regarded as the summation of this tradition, and veritably, its epitome.

The oath-taking ceremony is perhaps one of the most profound moments in the life of a young doctor through medical school. There is a certain sense of gravity that the oath tends to impart, which harkens to the seriousness and difficulty of the years ahead. To me, it was the moment I realized that down the line, I might have to contend with the daunting challenge of balancing ethics and empathy with day-to-day patient decisions — decisions which tend to be sterile and algorithmic in nature and quite divorced from the human being they affect. The oath administered is one written by Hippocrates in about 5th century B.C., and each medical school in the world generally has its own “modern” version, adapted to the values to which it subscribes; this practice extends to medical schools in India as well.

For about 1500 years after its composition, the oath was hardly in use. It was rediscovered and revived in the Middle Ages by Church scholars who modified it to conform to medieval Christian doctrines, replacing references to pagan Gods with the Christian one. In the centuries that followed, the oath then slowly evolved to take shape as the modern foundation of medical ethics.

The main components of the Hippocratic oath are broadly, the principles of respect, justice, and non-maleficence (“do no harm”); virtues such as compassion, humility, and truthfulness; and values concerning the practice of medicine, such as confidentiality, privacy, dignity, consent, and non-prejudice. These principles have formed the bedrock of modern medical ethics and continue to be relevant to date.

While the oath isn’t necessarily legally binding, it has the effect of a ritualistic “rite of passage”, so to speak. While the practice of medicine no longer occupies “divine” status as before, the usefulness of the oath perhaps lies solely in its capacity to serve as a reminder to young physicians in the beginning of their medical education of their responsibility to practice medicine in an ethical manner — and this, in a roundabout way, stems from the fact that there is a certain implied social contract that a higher moral standard is applicable to doctors. For centuries, this unspoken agreement is the reason that an appeal to the conscience of doctors is made, and it is stressed that the character of a physician is just as important as the level of knowledge and skill they possess.

Caraka’s Oath

The ethical practice of medicine was an important feature of the Āyurvedic curriculum, duly emphasized by ancient practitioners. Caraka’s Oath can be regarded as the summation of this tradition, and veritably, its epitome. It contains a thorough and eloquent passage detailing the dedication and principles required of a physician and places the welfare of the patient above any personal considerations or discomfort of the physician. It speaks of a protocol of conduct, demeanor and a higher standard of morality that was to be exercised by a physician – including his bearing, speech, attitude, and his interactions with patients. It also speaks of the right of privacy and confidentiality in a manner that is arguably far ahead of its time. The physician was not to refuse treatment to anyone, and not to practice medicine solely for the accumulation of wealth. Caraka also espoused quite the “progressive” attitude towards the practice of euthanasia.

Caraka’s oath of initiation for students beginning the study of medicine also prescribes rigorous rules and austerities to be practiced by medical students, in accordance with the aims of puruṣārtha which are most conducive to an effective and rigorous period of study, and in line with the eternal principles of dharma.

Most medical schools in the world also offer credits for ‘CME’ or Continuing Medical Education, so as to keep physicians up-to-date with newer developments, knowledge, and practices in their fields. In this regard, Caraka remarks that the science of medicine is limitless, and a student must, even upon graduation, pursue knowledge with the same vigor and curiosity – a sentiment that echoes the never-ending ancient Indian thirst for knowledge and truth. Clearly, Caraka incorporates all the elements that modern medical ethics espouses, and it needn’t be force-fitted onto our contemporary sensibilities, but rather, is harmoniously in line with them.

Antiquity and Timelessness of Caraka’s Code of Medical Ethics

Caraka is said to have written a description of the code of ethics to be followed by practitioners of Āyurveda in his Saṃhitā a few hundred years prior to Hippocrates. Even if we put aside its antiquity, its universal exposition of values and their timeless nature shine through his document. Medical ethics is erroneously attributed solely to Western philosophy and medical training, yet has always been an inseparable part of medical education in ancient India and the inspirational legacy of ancient Indian physicians. Ancient India’s contributions to medicine and ethics are remarkable and continue to have immense value almost 3000 years later, despite the wholesale adoption of the system of Western medicine by the post-colonial state. Perhaps our education system is to be blamed, but few Indian physicians even know of the ethical and moral principles outlined by our ancient Āyurvedic texts, and are instead more familiar with the Hippocratic Oath.

The Religious Element

I swear by Apollo the physician, and Asclepius, and Hygieia and Panacea and all the gods and goddesses as my witnesses, that, according to my ability and judgment, I will keep this Oath and this contract.
(translation by Michael North)

An oath, even considering the Oxford definition, is inherently and inescapably religious – it involves the appeal to either God or a sacred or revered object that a statement is true or that a promise shall be kept. While the original oath written by Hippocrates begins by invoking “Apollo, Asclepius, and by Health and Panacea”, along with all the Gods and Goddesses; Caraka prescribes a hōma to be conducted at the time of initiation, with the student required to offer libations to and utter mantras evoking Brahman, the God Agni, the celestial physician Dhanvantari, the Lord of creation Dakṣa, the celestial physician-twin Aśvins, the God of Gods Indra, and Ṛṣis who were authors of texts related to the life-sciences. The student, supervised by his guru, was also required to worship a number of physicians by making respectful salutations to them, and in the presence of these physicians, brāhmaṇas, and Agni as witness, take upon himself the instructions of his teacher and the contents of the oath.

The practice of Āyurveda is constantly demonized as being unscientific, regressive and riddled with superstition, and its system of medical ethics is conveniently ignored. Since the traditional schools that subscribe to these rituals, lineages, and knowledge systems have been all but dismantled, the least the modern Indian state could probably do is honor Caraka’s superior code of ethics that has unquestionably withstood the test of time — even if by the popularization and implementation of a “secularized” version.

Given the seemingly universal content of the oath, one might wonder why the recent controversy regarding the adoption of this oath in place of the (foreign) Hippocratic was even an issue – after all, the important thing is to champion and encourage ethical behavior, irrespective of the source — especially given its relegation to a secondary status in our modern, commercialized healthcare system. The All India Institute of Medical Sciences in New Delhi already incorporates an abridged version of an excerpt from Caraka’s oath, translated as follows:

Not for the self, not for the fulfillent of any worldly material desire or gain, but solely for the good of suffering humanity, I will treat my patients and excel all.

However, this one line, isolated from the rest of Caraka’s original oath and unbeknownst to those uttering it, is perhaps not enough of a nod to the ancient physician as he rightfully deserves. It is also not bold enough of a move as entirely rejecting the Western oath altogether and instead subscribing to our own version of it would be, even if concessions are made and it is not administered in its original Sanskrit and ritual setting but translated to a local language, or even English.

In this era of rapid technological advances and innovative therapies, the influence of materialism and the unconscionable aspects of rampant commercialization have already been irrevocably incorporated into our healthcare systems and also into society at large, and physicians are not particularly immune. It is important that India reclaims and rediscovers not only its own code of ethics as prescribed by its ancient physicians and Āyurvedic traditions, but also contextualizes the underlying principles upon which they are based, in order to address the ethical dilemmas that modernity and scientific progress are bound to throw up, with ease, rootedness and authenticity.

The Oath of Initiation

The teacher then should instruct the disciple in the presence of the sacred fire, Brahmanas and physicians.

(saying) ‘Thou shalt lead the life of a celebate, grow thy hair and beard, speak only the truth, eat no meat, eat only pure articles of food, be free from envy and carry no arms.

There shall be nothing that thou should not do at my behest except hating the king, causing another’s death, or committing an act of great unrighteousness or acts leading to calamity.

Thou shalt dedicate thyself to me and regard me as thy chief. Thou shalt be subject to me and conduct thyself for ever for my welfare and pleasure. Thou shalt serve and dwell with me like a son or a slave or a supplicant. Thou shalt behave and act without arrogance, with care and attention and with undistracted mind, humility, constant reflection and ungrudging obedience. Acting either at my behest or otherwise, thou shalt conduct thyself for the achievement of thy teacher’s purposes alone, to the best of thy abilities.

If thou desirest success, wealth and fame as a physician and heaven after death, thou shalt pray for the welfare of all creatures beginning with the cows and Brahmanas.

Day and night, however thou mayest be engaged, thou shalt endeavor for the relief of patients with all thy heart and soul, Thou shalt not desert or injure thy patient for the sake of thy life or thy living. Thou shalt not commit adultery even in thought. Even so, thou shalt not covet others’ possessions. Thou shalt be modest in thy attire and appearance. Thou shouldst not be a drunkard or a sinful man nor shouldst thou associate with the abettors of crimes. Thou shouldst speak words that are gentle, pure and righteous, pleasing, worthy, true, wholesome, and moderate. Thy behavior must be in consideration of time and place and heedful  of past experience. Thou shalt act always with a view to the acquisition of knowledge and fullness of equipment.

No persons, who are hated by the king or who are haters of the king or who are hated by the public or who are haters of the public, shall receive treatment. Similarly, those who are extremely abnormal, wicked, and of miserable character and conduct, those who have not vindicated their honor, those who are on the point of death, and similarly women who are unattended by their husbands or guardians shall not receive treatment.

No offering of presents by a woman without the behest of her husband or guardian shall be accepted by thee. While entering the patient’s house, thou shalt be accompanied by a man who is known to the patient and who has his permission to enter; and thou shalt be well-clad, bent of head, self-possessed, and conduct thyself only after repeated consideration. Thou shalt thus properly make thy entry. Having entered, thy speech, mind, intellect and senses shall be entirely devoted to no other thought than that of being helpful to the patient and of things concerning only him.

The peculiar customs of the patient’s household shall not be made public. Even knowing that the patient’s span of life has come to its close, it shall not be mentioned by thee there, where if so done, it would cause shock to the patient or to others. Though possessed of knowledge one should not boast very much of one’s knowledge. Most people are offended by the boastfulness of even those who are otherwise good and authoritative.

There is no limit at all to the Science of Life, Medicine, So thou shouldst apply thyself to it with diligence. This is how thou shouldst act. Also thou shouldst learn the skill of practice from another without carping. The entire world is the teacher to the intelligent and the foe to the unintelligent. Hence, knowing this well, thou shouldst listen and act according to the words of instruction of even an unfriendly person, when his words are worthy and of a kind as to bring to you fame, long life, strength and prosperity.

Thereafter the teacher should say this:

Thou shouldst conduct thyself properly with the gods, sacred fire, Brahmanas, the guru, the aged, the scholars and the preceptors. If thou hast conducted thyself well with them, the precious stones, the grains and the gods become well disposed towards thee. If thou shouldst conduct thyself otherwise, they become unfavorable to thee.

Notes:

1. Caraka Samhita translation, Prof. Priyavrat Sharma Published by Chowkambha
2. Sritharan, K et al. “Medical oaths and declarations.” BMJ (Clinical research ed.) vol. 323,7327 (2001): 1440-1. doi:10.1136/bmj.323.7327.1440
3. Hulkower, Raphael D. “The History of the Hippocratic Oath: Outdated, Inauthentic, and Yet Still Relevant.” Einstein Journal of Biology and Medicine 25 (2016): 41-44.
4. Menon, I., & Haberman, H. (1970). THE MEDICAL STUDENTS’ OATH OF ANCIENT INDIA. Medical History, 14(3), 295-299. doi:10.1017/S0025727300015593
5. Amihay Levy & Abraham Ohry, The Physician’s Oath Today: Necessity or Anachronism, 6 MED. & L. 219 (1987)
6. North, M. “I swear by Apollo physician”…: Greek medicine from the Gods to Galen. Exhibition website, History of Medicine Division, National Library of Medicine and National Institutes of Health. http://www.nlm.nih.gov/hmd/ greek/greek_Oath.htm
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