|Year : 2014 | Volume
| Issue : 4 | Page : 366-370
Contribution of Ayurveda in foundation of basic tenets of bioethics
Kiran A Tawalare1, Kalpana D Nanote2, Vijay U Gawai3, Ashish Y Gotmare4
1 Department of Kriya Sharir, Shri Ayurved College, Nagpur, India
2 Department of Rachana Sharir, Shri Ayurved College, Nagpur, India
3 Department of Kaumarbhritya, Government Ayurved College, Nanded, India
4 Department of Roga Nidan and Vikriti Vijnan, Shri Ayurved College, Nagpur, Maharashtra, India
|Date of Web Publication||18-Jun-2015|
Kiran A Tawalare
Asst. Prof., Department of Kriya Sharir, Shri Ayurved College, Nagpur - 440 009, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Ethics deal with the set of principles of right conduct. The four basic principles of bioethics - autonomy, beneficence, non-maleficence and justice are known as "principlism". Though these four principles are influenced by the western world; in the medical field they are adapted as universal ethics. Originally, Ayurveda, the Indian medical system, has strongly advocated ethical code of conduct for physicians, but does not get its due recognition till this date. Proposed article aims to compare universally accepted basic tenets of bioethics and ancient Ayurvedic ethics. For this purpose classical texts of Ayurveda and literature regarding principlism was collected and analyzed thoroughly. It was found that the essence of ethics is very well-defined and described in the fundamental texts of Ayurveda in the form of Sadvritta, Chatushpada, Yogya, Vaidyavritti and Aachara Rasayana. Hence, Ayurveda should be considered as a trailblazer in establishing the basic tenets of bioethics.
Keywords: Ayurveda, bioethics, Chatushpada, Sadvritta, Vaidyavritti, Yogya
|How to cite this article:|
Tawalare KA, Nanote KD, Gawai VU, Gotmare AY. Contribution of Ayurveda in foundation of basic tenets of bioethics. AYU 2014;35:366-70
| Introduction|| |
Western medical ethics are guided by four central moral principles - autonomy, beneficence, non-maleficence and justice, collectively known as "principlism". It has been developed by Beauchamp and Childress and promoted by Raanan Gillon as the four principles plus scope in America since 1970s. It has been popularly accepted, especially in the medical world, as a set of "universal" guidelines for bioethics. Universal acceptance is the theory's important merit. However, the theory is developed from common American moral sense. It reflects the image of certain aspects of American society, where principle of autonomy often overrides and may for this reason alone, be non-transferable to other societies.  For example - In Chinese traditional culture, emphasis on family background and common good to society may cause patients to sacrifice their autonomous decision making. This cultural value is very likely to suppress the concept of rights and autonomy.  Similarly in India, the value of trust still holds good to a large extent. Although in western countries ethics of autonomy (patient's right) is predominant, in Ayurveda ethics defer as it is physician's preference whether to speak the truth or not about the life-threatening condition of the patient to avoid harm to the patient.  Thus the basic tenets cannot be applied world-wide, as it fails to fulfill the needs of cultural diversity.
Before 200 BC,  Charaka described the importance of healthy life - health (Aarogya) as an excellent source to acquire virtue (Dharma), wealth (Artha), gratification (Kama) and emancipation (Moksha).  Masters have set the goal of life science as curing those afflicted by diseases and protecting those who are healthy. Sanctity of human life is the foremost in patient care.  According to Charaka, person should pursue three desires - desire for living a healthy life (Praneshana), desire for wealth (Dhaneshana) and desire for the great beyond after this life (Paralokeshana).  Out of these desires one should consider the desire to live before all because on death everything departs, which is similar to the principle of the universal declaration of human right "everyone has the right to life liberty and security of person." 
In Ayurveda, the issue of ethics is closely comparable with Dharma.  In compendia, there are no separate sections on ethics, but the flavor of ethical spirit runs throughout the text, which indicates, how the base of ethics inculcate. Textbooks of Ayurveda offer many guidelines on good medical practices. Qualities of good patient and good physician are mentioned in the form of Chatushpada. The Adhyayana Vidhi enlightens the procedure of medical education and rules for setting subsequent practices. Sadvritta and Vaidya Vrutti are other mile stones which elaborate set of rules for professional good conduct. Acharyas of Ayurveda also guides the physician how to interact with the patient.  Through this article, the authors intend to communicate the essence of ethics from ancient medical system in light of four principlism and open the treatise of the basic concept of ethics in Ayurveda to streamline the needs of cultural diversity.
| Aim|| |
- To study the Ayurvedic ethics in view of basic "principlism" of bioethics
- To fulfill the needs of pluralism of bioethics.
| Materials and Methods|| |
Classical texts of Ayurveda viz. Charaka Samhita, Sushruta Samhita, Ashtanga Sangrah and Ashtanga Hridaya were consulted as research references of ancient ethical morals. Literature available regarding modern ethical science was also collected. These references from both streams of knowledge were compared and analyzed critically.
| Discussion - Basic Tenets of Bioethics and Ayurveda|| |
Autonomy literally means the "self-law" or "self-governance."  This ethical principle refers to every individual's right of self-determination, independence and freedom of making their own choices.  It implies that one can freely act according to one's own plan. In other words autonomy can be defined as the ability of a person to make his own decision. The principle of respect for autonomy involves the respectful attitude toward the patient and profession. That corresponds to Charaka's Vaidyavritti. Charaka describes the friendliness (Maitri), compassion toward the diseased (Karunyaarteshu), attachment to the remediable (Shakyasyapriti) and indifference to those who are moving toward the end (Upekshanam) as fourfold attitude of physician. 
Charaka gives advice to the physician to take efforts and provide health to all patients by all means. Physician should not think ill of patients even at the cost of his life. He should not approach other's woman and any other property even in imagination.  This concept of morals from Ayurvedic text resembles with Kantian idea of western ethics that patient should always be regarded as an end but not for means.
Charaka insists to acquire the code of good conduct (Sadvritta) for those who desire to promote their well-being. He explains in good conduct that one should worship God, preceptor (Guru), elderly people, accomplished teachers; should take the initiative in talk; remain cheerful; should have a presence of mind even in difficult circumstances; should donate; help the poor. He even recommends wearing white clothes, cutting hair and nails, use of flower and fragrance. One should not be attached to women, friends and servants with sinful attitude. One should never insult women. One should not be in the habit of breaking rules. One who follows the code of conduct acquires virtue.  This ancient moral Sadvritta is comparable to Kant's self-legislation. 
In Ayurveda, physician (Bhishak), drug (Dravya), attendant (Upasthata) and patient (Rogi) are mentioned as the four pillars of treatment (Chatushpada). This quadruple, if endowed with qualities, leads to alleviation of disorder. This quadruple, comprising 16 qualities (four of each) is the basis of success of treatment. Yet, the physician who is excellent in theoretical knowledge, has extensive practical experience, dexterity and cleanliness, beholds supreme position. Besides these, learning (Vidya), rationality (Vitarka), clear-cut knowledge (Vijnana), memory (Smruti), swift in action (Tatparta) and treating patient appropriately (Kriya) also are the qualities of a physician (Vaidya). 
Charaka advises not to prescribe medicine for women without permission of their husband or guardian.  While entering into a patient's house, physician should take along some known person whose entry is permitted, with head lowered, having good memory, with stillness, thinking carefully and moving accordingly. Having entered there, physician should not engage his speech, mind and senses anywhere except the patient's disease and care. He should not entertain the other entities of the patient's body. He should have respect for female patients. Thus in the light of morals of bioethics one should not enjoy oneself in patient's house while the patient is suffering from disease. 
In western bioethics patient's right to autonomy requires informed consent and dictates that the patient's medical situation is truthfully revealed. However Charaka infers that speaking truthfully about the disease is not absolute, if by doing so, one might harm the diseased or the others. Thus Ayurveda ethics confer preference to the physician, whether to speak the truth or not. This is the fundamental ethical expression of Ayurveda's basic morals.  Today, in India ethic of trust still holds good to a large extent, while in western countries ethic of right is predominant [Table 1] and [Table 2]. 
|Table 2: Drawbacks of present bioethics and advantages of accepting Ayurvedic ethics|
Click here to view
Beneficence is the duty always to act in the best interest of patient or the action that is done for benefits of others. This action can be taken to help prevent or remove harm to others.  The goal of medical science is to promote the welfare of patient. To achieve this goal, physician should possess the skill and knowledge that enables him to assist others.
Sushruta gives guidelines for the physician to enter the profession. That physician should enter in the profession, who has completed the study of the texts, understood the interpretations, who has made himself thorough through practical training and recapitulating the teachings of the science always and obtained the permission from the king.  This is suggestive of the existence of the rules regarding the control and regulation of medical practice during ancient times, similar to registration of a medical practitioner of present days. "Don't behave like a quack." This is the warning given to the physicians to be always careful in conduct and behavior with patient to avoid loss of reputation and respect in society.
Sushruta devoted a complete chapter Yogyasutriyam (practical training) to make a student fit for surgical work. In the view of Sushruta, though the student has understood the element of the science fully, he must be made a competent (Yogya). Because by acquiring only theoretical knowledge and no practical training, he becomes unfit and incompetent for surgical procedures. With this purpose, Sushruta explained and demonstrated different kinds of Yogya Vidhi. For example practice of excision (Chhedana Karma) can be done on pumpkin (Pushpaphala) and cucumber (Trapusa); scraping (Lekhana Karma) can be practiced using broad sheet of dead animal leather with hair; puncturing (Vedhana) can be practiced using veins of dead animal and stalk of lily plant; probing (Eshana Karma) can be practiced using holes in pieces of wood eaten by moths; suturing (Sivana Karma) can be practiced using thin and thick cloths; bandaging (Bandhana) could be using models or mannequins prepared from mud or clothes. Thus one who desires to become skilled in the use of instruments (Shastra), alkali (Kshara) and thermal cautery (Agnikarma), should practice on similar objects and become skilled in surgical art. Sushruta says that, in this way the intelligent, who has made fit himself by using methods and techniques suitable for practical training described in the texts, does not falter in his actions. We must appreciate Sushruta's effort to give utmost importance to practical training and make every student fit to perform surgical procedures. 
As for the code of "prevention" in treatment of disease, Charaka says that plan of action should be ready 'in order to prevent the flood' to avoid hazards. In the same way preventive treatment can be applied after observing the premonitory symptoms (Poorvarupa) of the future disease.  Avoiding the cause of disease (Nidanparivarjana) is the treatment in brief to protect the health of a person [Table 1] and [Table 2]. 
Principle of non-maleficence asserts that "do not harm" or "risk no harm on other."  Therefore medical services of the health care professionals reach the optimum standard of patient care through proper training, competent and acquired skills. In health care, harm - by narrower definition - could be pain, dysfunction or death. However broader definition of harm is often required in ethical consideration. This principle includes not doing harm, preventing harm and removing harmful condition.  Physician should not provide ineffective treatments to the patient as these offer risk with no possibility of benefits and thus have a chance of harming patient. Physician must not do anything that would purposely harm the patient without the action of benefit because many medications, cause harm in addition to benefit.
In concern with principle of non-maleficience basic texts of Ayurveda consist of many evidences. In Ayurveda science, evacuative (Shodhana) therapy includes emesis (Vamana), purgation (Virechana), enema (Basti) and nasal medication (Nasya). For each procedure, Charaka has described the fit and unfit person for the therapy, along with the adverse effects of the therapy in an unfit person and also the treatment for adverse effects.  Acharya expounds complications due to carelessness of the physician (Vaidyanimitta Vyapada), which should be avoided by a good physician.  This shows the dignity of Acharya in preventing and removing harm.
Pathyapathya Kalpana is another milestone in the light of the principle of non-maleficence. In the section of treatment (Chikitsa Sthana) Charaka has summed up every disease with the regimen of indicated and contra indicated diet to avoid the risk of harm. In modern science also certain guidelines are given for people to maintain a proper diet which shows resemblance of both streams towards avoiding harm. 
Principle of justice involves being fair in allocation of resources and in the physician's obligation to the patients. According to this principle all person in the society should be treated fairly. 
Sushruta advises the physician that he should be in easy reach of all people especially the poor ones who may not have the courage to come to the physician easily. Hence master suggests to wear white clothes (Shuklavastra) which symbolizes cleanliness and similarity to all,  which can be compared with the "white coat" ceremony as a rite of passage for students entering medical college.  Wishing good of all in word and deed (Kalyanabhivyaharen), living friendly with all the living beings (Bandhubhuten), showing compassion towards the suffering and wishing happiness for all is the philosophy of the medical profession, which all physicians should inculcate in their life.  Charaka says that, the physician should not think ill of the patient even at the cost of his life [Table 1]. 
Precisely core findings of the review are as below-
- Goal of ancient medical science Ayurveda - curing those afflicted by diseases and protecting those who are healthy
- Basic requirements of treatment are physician, drugs, attendant and patient which build up good doctor patient relationship
- Attitude of the physician - Friendliness, compassion toward the patient, attachment to the remediable and indifference to those who are moving toward end. Wearing white clothes and adopting the code of good conduct
- Qualities of good physician - He should be excellent in theory and practical knowledge, dexterity, cleanliness are the major qualities. Besides that, he should be careful, humble, without envy, truthful, content, vigilant, pure, righteous and blissful
- Manner of medical practices - First diagnose the disease and then decide the treatment. Consent should be taken before examination of female patient. Be always initiative in talk with the patient. Physician should not boast about himself while treating patient. With clean mind and skilled hand make practice fruitful.
| Conclusion|| |
The above review reveals that, Ayurveda places great emphasis on ethics. Concepts similar to respect for autonomy, beneficence, non-maleficence and justice are found in Ayurvedic texts. Ayurvedic ethics are more oriented toward the principle of beneficence, non-maleficence than the principle of autonomy. Hence, Ayurveda should be recognized as a pioneer in foundation of four basic tenets of bioethics and can help to fulfill the needs of pluralism.
| Acknowledgment|| |
Acknowledge for general support by departmental chair and technical help. The authors express heartfelt thanks for support and guidance by M. U. Kothekar, Snehvibha Mishra, Gayatri Vyas and Kishor Patwardhan for their invaluable support.
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[Table 1], [Table 2]