Interface between Physicians and Society

The questions of how a physician should conduct himself in society and what should be the nature of his relationship with his patient have been dealt with in the Saṃhitās as part of the guidelines on good medical practice. The authors have determined the duties and obligations of doctors and patients have for each other, providing a catalogue of rules of professional conduct that physicians are bound to, including guidelines on what constitute appropriate interactions with patients and colleagues.^[1] For a better understanding of these questions, we may turn to the initiation ceremony of the student as depicted by Caraka which is an exposition on medical ethucs and etiquette. Facing the sacred fire and in the presence of brāhmaṇas and physicians, the teacher gives a long speech to the student outlining the code of conduct that the latter is expected to follow.^[2] Though the first part of these teacher’s rules pertains to the period of studentship, the rest and in fact, the greater part of the speech bears relevance to professional conduct of the physician.^[3] There are essentially three aspects of the Carakian code of ethics and etiquette for the physician: (a) as a member of society (b) as a member of a profession and (c) as an academia.

(a) The physician as a member of society:

i. To achieve success in the medical profession, earn wealth as well as fame and attain heaven after death, he is expected to show respect and pray for cows, brāhmaṇas and all other living beings.^[4]

ii. He should refrain from adultery and from coveting property belonging to others.

iii. His appearance and apparel should be modest.^[5]

iv. He should abstain from wine, refrain from committing sins and avoid have any association with those committing sinful acts.

v. His speech should be pleasant, pure, righteous, blissful, excellent, truthful, useful and moderate.

vi. His behaviour should be in conformity with the time and place, based on recollections of the past experience (or heedful of past experience).^[6]

vii. Even though actually possessed of wisdom, he should not exhibit it to others. Many people get very much irritated to hear such self-praise even from a saint.

(b) The physician as a member of the medical profession:

i. He should make efforts to cure the patient.

ii. He must never give way to any ill will towards your patients even at the cost of your life.

iii. He should not prescribe medicines for those who are despised by the king or noble persons and those who despise the king or noble persons.

iv. He should not treat all those who are excessively abnormal or deformed (vikṛta), wicked or who are of miserable or unpleasant (duḥkha) character, customs and behaviour or who have not been absolved of the allegations against them or who are going to succumb to death.

v. He should not attend to female patients in the absence of their husbands and guardians.

vi. He should not accept any presents given by a woman without the permission of her husband or guardian.

vii. He should enter the residence of the patient accompanied by a person who knows the place, and who on his part, has obtained permission to enter there. While doing so you should be well clad, with your head bowed down, having a good memory, having concentration of mind and acting with proper thinking. After having entered there your speech, mind, intellect and senses should be entirely devoted to nothing except the welfare of the patient and things concerning him only.

viii. He must take not to disclose family customs (secrets) should not be disclosed to outsiders.

ix. Even having known that the patient’s span of life has come to a close, he should not disclose this to the patient himself or to the son or father etc. of the patient because it may cause shock to the patient or to his relatives.

(c) The physician as a member of the academia:

i. He should always make efforts for acquisition of knowledge and fullness of equipment.^[7]

ii. It is not easy to acquire comprehensive knowledge of the “Science of Life”. Therefore, he should make honest efforts to be in constant touch with this science and learn similar noble qualities even from his enemies without having any sense of jealousy. He must consider the entire universe as their preceptor and adopt proper advice which brings even if it is given by an enemy.^[8]

This long set of rules delineated by the teacher professional etiquette and behaviour helps us to have a comprehensive view of how the physician should conduct himself in his private and public spheres of life. This set of directives dubbed by Menon and Haberman as “the medical students” oath of ancient India” is seen as the equivalent of the Hippocratic Oath.^[9] This parallelism was first noticed in the sixth volume (1925) of the proceedings of the Charaka Club of New York which described “the Oath of the Hindu Physician.”^[10] Dagmar Wujastyk opines that the passage is not conceived as an oath but as exposition on the correct method of teaching, though she goes on to say that the student is to agree to the teacher’s demands at the end of the speech, and thus can be understood as a pledge to uphold the rules set out by the teacher, that is, to swear an oath.^[11] It is noteworthy that the ceremony is performed in the presence brāhmaṇas and physicians with the chanting of hymns and offerings of oblations to the sacred fire rendering it a “religious oath” in the opinion of Menon and Haberman.^[12] The rituality of the occasion conveyed to the student in no uncertain terms the solemnity of the pledge he undertakes. At the same time, the ceremony serves to remind the attending physicians of their own pledge to their professional code. Unlike the Hippocratic Oath, the ancient Indian medical student does not swear to an oath at the termination of his studies but at the commencement. Inclusion of rules of professional behaviour at the initiatory stage itself would have been useful for the student as an amateur clinician, when according to Wujastyk, he accompanied the teacher on clinical visits.^[13]

Caraka’s comprehensive account of the physician’s social and professional behaviour stands in contrast to the brevity of Suśruta’s rules but their comparison is noteworthy in two aspects. The general demeanour of the medical practitioner, according to Suśruta, should be cheerful, friendly and honest,^[14] which is quite in contrast to Caraka’s biding of maintaining a solemn disposition with complete concentration on the task at hand. Of course both the authors emphasise that welfare of the patient is to be uppermost in the mind of the attending physician. Suśruta’s prescription of a cheerful and friendly disposition is important for the patient: the physician appears as a pleasant and optimistic person which puts the patient at ease and finds it easier to open up to him. This is particularly important in surgical procedures when the patient is anxious and needs to be put at comfort. Interestingly, Suśruta cites “snigha’ as one the desirable characteristics of the ancillary staff of a physician, which is to say they should be affectionate.^[15] It thus appears that the ancient Indian physician was expected to complement his purely professional proficiency with soft skills.

The second aspect is the observation of absolute confidentiality of the case and the family customs on the part of the physician is an aspect that Caraka accentuates but not stressed by Suśruta. While discussing the signs of impending death, Caraka emphatically states that if the prognostication is not favourable, the physician should refrain from announcing the patient’s imminent death unless specially requested to do so. If such a pronouncement should cause the patient to collapse or distress to others, it is better to restrain oneself even if there is a request from family and friends.^[16] Besides, the insistence that one should enter the house of the patient only when accompanied by a person known to the household and who has attained permission implies the physician should always be called for a visit. This explains the repugnance of Caraka for the fraudulent practitioners who flock to the patient as soon as they hear of someone’s sickness and who are full of self praise.^[17] As we have noted in the initiation ceremony, he cautions students against blowing their own trumpets and bides them to practice restraint. Reticence is absolutely essential while attending to women. In the absence their husbands or other male guardians, Caraka disallows the physician to take up the case of female patients or to accept any gifts from them without, again, their guardians” permission.

Suśruta, too, has words of caution for physicians in their interactions with female patients-sitting at the same place with women, staying (saṃvasa) or joking with them should be avoided. Besides, other than food, the physician is expressly forbidden to accept offered by women.^[18] The word saṃvasa can imply “living or associating with” or even “to have sexual connection with”. These instructions may not apply only to female patients. It seems likely that the physician is strictly forbidden to have any association with the women in the house during his visit to the patient’s house.^[19] In short, modesty in appearance, sobriety and restraint in demeanour as well as humility in wisdom are the true hallmarks of an ideal medical practitioner.

The patient is also expected to possess certain attributes without which therapeutic success is not achievable. Longevity, capability of enduring suffering, curability of disease, financial well-being, self-control, theism and obedience to the clinician are the attributes of a good patient.^[20] Caraka also mentions obedience and absence of fear as good qualities of the patient along with good memory and uninhibited expression.^[21] Suśruta explains that when a patient seeks the medical help, he has complete faith in the physician, and believes that his doctor will not belie him. The trust he reposes in his doctor is greater than that he has in his relatives, his sons or even his parents. He may mistrust them but not his physician in whose hands he places himself.^[22] Consequently, the doctor-patient interaction is just not like any other professional relationship between a consultant and a client, detached and dispassionate; rather it behoves the physician to be supportive and caring.

Given the absolute conviction on the healer, it becomes obligatory for the physician to conduct himself with paternal concern for the well-being of the patient.

tasmāt putradevenaṃ pālayedaturaṃ bhiṣak.^[23]

Therefore, it is the clinician’s duty to look after him as his own son.

The ancient medical writers envisaged the paternalist model of physician-patient relationship, in which the physician’s authority is accepted unquestioningly for necessarily “father knows best”, while the patient’s autonomy considerably reduced. As a father figure, the physician expects the complete obedience and adherence on the part of the patient, who is a mere child, ill-equipped to understand his own good. He assumes the innate goodness of the physician. It is not a formal contractual relationship nor is there any social distance between the two.

Concern for the well-being of the patient should necessarily take precedence in the practice of medicine, and Dhanvantari assures his students that such a well-meaning practitioner alone fulfils his duty, would be entitled to wealth, fame and blessings in this life and a heavenly life in the other world.^[24]

dharmartho kirtimityartha satanga grahanamuttamam.
prapnuyat swargavasanga ca hitamarabhya karmana.

This approach may be juxtaposed with medical ethics from another part of the ancient world. The Hippocratic practitioner “is the servant of his art, and the patient must cooperate with the doctor in combating the disease.” The primary objective of the physician is to practice his art diligently and protect the patient from harm. It has been described as an ethic of outward achievement than of inner intention.^[25]

Plato looked at the physician-patient relationship in a different light:

“No physician, insofar as he is a physician, considers his own good in what he prescribes, but the good of his patient, for the true physician is also a ruler having the human body as a subject, and is not a money-maker”.^[26]

The moral duty of the physician here is given precedence.

Though the paternalistic ideal is upheld as the highest ideal the question of remuneration is also important. The patient is expected to reciprocate the services of the physician in some form or the other.^[27] One of the objectives of medical practice is the attainment of artha (wealth) though those who practice simply for acquisition of wealth are condemned.^[28]

Footnotes and references:

[1]:

D.Wujastyk, Well-Mannered Medicine, p.1.

[2]:

Caraka Saṃhitā Vimānasthāna 8.13.

[3]:

The first part relating to the student’s life will be discussed in chapter 3 of this thesis.

[4]:

Caraka Saṃhitā Vimānasthāna 8.13.

[5]:

Suśruta prescribes white unassuming apparel with shoes, an umbrella and a stick in hand for the physician; Suśruta Saṃhitā Sūtrasthāna 10.3.

[6]:

The word in brackets are taken from I.A. Menon and H.F. Haberman, “The Medical Students” Oath of Ancient India”, in Medical History, 1970, Vol. 14(3): pp.295-299.

[7]:

Caraka Saṃhitā Vimānasthāna 8.13.

[8]:

Caraka Saṃhitā Vimānasthāna 8.14.

[9]:

I.A. Menon and H.F. Haberman, “The Medical Students” Oath of Ancient India” pp.295- 299.

[10]:

S. Basu Majumdar, “Oath of the Hindu Physician and the Sūtra-Sthāna of Caraka and Suśruta Saṃhitās” in S. Basu Majumdar and N. Sharma Mukherjee, Essays on History of Medicine, pp.89-102.

[11]:

Dagmar Wujastyk, Well-Mannered Medicine, p.102.

[12]:

I.A. Menon and H.F. Haberman, “The Medical Students” Oath of Ancient India”, pp.295- 299.

[13]:

Dagmar Wujastyk, Well-Mannered Medicine, p.91.

[14]:

Suśruta Saṃhitā Sūtrasthāna 5.6.

[15]:

Suśruta Saṃhitā Sūtrasthāna 34.14.

[16]:

Caraka Saṃhitā .Indriyasthāna12.62-63.

[17]:

Caraka Saṃhitā Sūtrasthāna 29.9.

[18]:

Suśruta Saṃhitā Sūtrasthāna 10.9.

[19]:

Dagmar Wujastyk, Well-Mannered Medicine, p.96.

[20]:

Suśruta Saṃhitā Sūtrasthāna 34.21/2-22/1.

[21]:

Caraka Saṃhitā Sūtrasthāna 9.9.

[22]:

Suśruta Saṃhitā Sūtrasthāna 25.43-44.

[23]:

Suśruta Saṃhitā Sūtrasthāna 25.44.

[24]:

Suśruta Saṃhitā Sūtrasthāna 25.46.

[25]:

L.Edelstein, Ethics of the Greek Physician in O. Temkin and C.L.Temkin (Ed.), Ancient Medicine: Selected Papers of Ludwig Edelstein, Baltimore, 1967, p.324.

[26]:

P. Carrick, Medical Ethics in the Ancient World, Washington, D.C., 2001, p.173.

[27]:

Caraka Saṃhitā Cikitsāsthāna 1:4.57.

[28]:

Caraka Saṃhitā Cikitsāsthāna 1:4.58.