Denial of Treatment

Successful treatment of any disease is dependant not only on the accurate diagnosis but also its prognosis. Diagnosis is of utmost importance for the physician not only for ascertaining the nature of the disease and its aetiology but also for it prognosis, whether the disease is in the curable (sādhya), palliable (yāpya) or incurable (asādhya) stage. The physician is advised time and again to take up a case only when he is assured of its treatability. Curable types may be easily amenable to cure (sukhasādhya) or prove difficult to alleviate (kṛcchrasādhya). Easily curable ones respond to simple measures in a short time (sukhasādhyaḥ sukhopāyaḥ kālenālpena sādhyate), unlike difficult cases.^[1] The palliable disease can never be eliminated from the root. A disease is known to be palliable or relievable if it assures the survival of the patient as long as the treatment is being done but he does not survive on withdrawal of the treatment.^[2] The irremediable type is not amenable to any type of treatment.^[3]

Thus, according to the basic principles of treatment, the enlightened physician should not take the incurable patient in hand. The palliable patient should be maintained with appropriate therapy and the curable one should be treated carefully with proper medicine leading to cure.^[4] Caraka clearly lays down that no medicine is to be prescribed for incurable diseases.^[5] Here Suśruta is of the same opinion. The physician is advised to proceed with the treatment if the manifested signs and symptoms do not prognosticate death and if the ailment is of recent origin.^[6] The teachers are in fact emphatic that incurable cases should not be taken up for treatment.^[7] Failure or negligence in treatment rendered the physician liable to punishment as is known from other sources.^[8] This is probably the reason for the reluctance of physicians in taking up difficult cases.

Generally the sānnipatika type of any disease, which is caused by the involvement of all the doṣas, is incurable because of the mutual contradiction involved in the treatment.^[9] Diseases more than a year old which are undiagnosed or neglected are difficult to treat.^[10] Patients suffering from physical weakness and several complications are also regarded as having unfavourable prognosis. Weakness renders the patient unable to withstand the effects of the disease and medicines.^[11] A serious patient can be taken up for treatment provided he is strong (balavant), conscientious (ātmavant), resourceful (upakaraṇavant), and has not developed complications of loss of vitality, muscular wasting, thirst, fever fainting, dyspnoea, cough, rigidity, anorexia, indigestion and flaccidity or spasticity of the limbs.^[12] Erroneous diagnosis and wrong treatment increase the difficulty of treatment and can even render the disease condition incurable which is otherwise curable.^[13]

Did this, therefore, imply that incurable patients were left with no recourse to any form of medical aid? Our study indicates that sometimes palliative medications are prescribed for clinical conditions otherwise termed incurable. Caraka^[14] and Suśruta^[15] concur that of the four varieties of vātaja prameha (urinary disorders) including madhumeha (Diabetes mellitus) are incurable. Yet both authorities give recipes for their palliation.^[16] We notice that even for diseases involving all the three doṣas some form of treatment is recommended. For sānnipātaja gulma it is recommended that the therapies indicated for individual be combined.^[17] Caraka has listed twelve vātika diseases like lock-jaw, facial paralysis, hunch-back, atrophy of limbs, etc., as serious that may get cured only by careful treatment; otherwise these diseases cannot be cured at all.^[18]

There appears to be an ambiguity in the statement but Cakrapāṇidatta clarifies it does not imply a doubtful situation about the success in their treatment. Rather these two alternatives are given here simply to indicate that the efficient and experienced preceptors can cure them with their expertise. Ordinary physicians, however, do lack in that type of profound knowledge and expertise, and their attempts to treat such patients may or may not be successful.^[19] Thus, when the preceptor advises his students to refrain from treating complicated and serious cases, his instruction to all intents and purposes is meant for average students. It appears, therefore, such patients could be taken up by competent and experienced physicians.

Even where cases appear hopeless, there are instance in the texts of such cases being taken up for treatment. We may refer to the advice given to the surgeon for the treatment of aśmari or urinary calculi. The first line of treatment of the condition is with medications, alkalis, decoctions and bladder wash. In the event that non-operative treatment is unsuccessful and death appears inevitable, surgery may be considered if an expert surgeon feels there is doubt in the inevitability of death (akriyāyāṃ dhruvo mṛtyuḥ kriyāyāṃ saṃśayo bhavet), i.e., when there is a glimmer of hope for the patient in surgically removing the stone. However, the consent of the authorities is essential for carrying out the procedure.^[20] Here we have an instance of an attempt to alleviate the pathological condition even when the various options are exhausted. Considering the risk involved in the operation, the text makes it clear that recourse to surgery hinges on the surgeon’s expertise and the consent of the authorities.

Yet another example is a type of bhagandara or fistula-in ano caused by foreign bodies. It is incurable but may be treated only after the patient is warned about its incurability.^[21] In incurable cases, the physician probably took palliative measures, as for example, Suśruta provides recipes for the palliation of the incurable pramehas.^[22] While handling cases of unfavourable prognosis, patients are warned before the initiation of the process of treatment.^[23] In certain cases where medical intervention is fraught with tremendous risk or involves the administration of venomous substances, permission of the authorities had to be taken. One such case is the treatment of dūṣyodara, a type of abdominal enlargement, by cobra venom or poisonous roots and bulbs.^[24] The antidote for the disease could either cure or kill the patient; hence Ḍalhaṇa’s advice here is:

It being, however, possible in some cases to save the life of a patient by the application of this medicine, it should be used, as the last resort with permission of the king.^[25]

Thus, all incurable cases do not appear to have been abandoned from treatment. An interesting verse of Suśruta provides testimony to the rejection of incurable patients whose cases may be taken up by other physicians.

madhumehitvamāpannaṃ hiṣagbhiḥ parivarjitam.
yogenānena matimān pramehiṇamupācareta.^[26]

“The patient of prameha who has been abandoned by the physicians as incurable, and has reached the stage of madhumeha, should be treated by the following recipe.”

The approach of our two classical treatises to some clinical conditions makes interesting contrast. While madhumeha (Diabetes mellitus) is an incurable condition according to Caraka,^[27] Suśruta, however, holds that it as treatable with śilājatu.^[28] This drug is, thus, an addition to the pharmacopeia at the time of the composition of this compendium. Again in the case of vitiligo (svitra) we notice difference of opinion. As opposed to the declaration by Caraka of the difficulty involved in the treatment of vitiligo, whose remission is dependent more on the purgation of the patient’s sins than on pharmacology, we have Suśruta’s assertion that the disorder is completely curable.^[29] The latter text gives more than ten recipes for healing this skin condition^[30] and even for restoring the natural skin pigmentation.^[31] It also gives a number of medicated ghṛtas and oils,^[32] particularly a formulation of turvaka oil^[33] and nīla-ghṛta are claimed to cure even the incurable kuṣṭha conditions (apyasādhyaṃ nṛṇāṃ kuṣṭ ṃ niyacchati).^[34]

In cases where absolutely no palliative was available, the only recourse to the patient was to seek relief in the cures of the sages who were well-versed in the administering elixirs, and performance of penance, japa and yoga. Therefore, it may not be correct to say that no medicine can be prescribed for incurable cases.^[35]

Other than clinical reasons, when the patient is not in a position undergo a particular therapy or where treatment would be ineffectual owing to incurability of his condition or imminence of death,^[36] the physician may deny medical intervention on several other grounds ranging from the person’s temperament traits to his psychological disposition, social and religious attitudes, as well as his social standing.

Thus, Caraka advises that the patient should be rejected if:

(a) temperamentally he is fierce (caṇḍa), rash/reckless (sāhasika), cowardly (bhīru), ungrateful (kṛtaghna), fickle-minded (vyagra);^[37]

(b) he is afflicted with grief (śokapīḍita);^[38]

(c) he does not believe in God (yādṛcchika);^[39]

(d) he is hateful towards good persons, kings and physicians and is hated by them (sadrājabhiṣajāṃ dveṣṭā tadviṣṭa);^[40] is inimical to the physician (vair ), an imposter and considers himself to be a physician (vaidyavidagdha);^[41] devoid of faith in the physician (śraddhāhīna);^[42] a sceptic (śaṅkita)^[43] and who does not carry out the instructions of the physician;^[44]

(e) he is not absolved of the allegations against him (anapavādapratīkāra);^[45]

(f) he is unable to arrange the essential items (karaṇa) for the treatment.^[46]

Patients of negative and aggressive temperament are deemed therapeutically unsuitable as the desired results are not obtained; hence, treatment is contraindicated in those of fierce, reckless and other incompatible dispositions.^[47] It is essential that the mind should be focused on the procedure. In the context of administration of therapy for removal of morbid matter, Caraka says that if the procedure is carried out when mind is cleansed of inauspicious impurities (like passion etc.,) and is concentrated on the therapy, then the appropriate clinical effects (samyag-yoga) are produced.^[48] Cakrapāṇi explains that desired clinical results are not obtained in ungrateful and other such persons because of their sinful disposition.^[49] The question that arises here is does ungratefulness refer to such behaviour on part of an individual in his social interactions or is it such conduct towards physicians only? If it is to be taken in the first sense where the individual is socially known to be so, then it becomes necessary on the part of the physician to acquire knowledge of his behaviour.

Faith in the physician is also essential for clinical success. In most cases, the patient has to take several precautions and abide by the physician’s instructions regarding the list the avoidances until completion of the healing process. Treatment is a long drawn process involving repetition of procedures for elimination of morbid doṣa/doṣas depending on the severity of the condition. A kuṣṭha patient undergoes emetic and purgation therapies as well as blood-letting followed by oleation. These therapies may have to be repeated several times as it is unwise to expel a large quantity of morbid doṣa at a time.^[50] The condition may require application of alkalis^[51] which is followed by application of ointments, administration of medicated decoctions,^[52] dietary restrictions,^[53] medicated baths,^[54] etc. Abidance by the physician’s instructions and the resourcefulness to be able to fulfill all the requirements are, hence, essential qualities of the patient. The antipathy of Saṃhitā authors towards pretenders has been discussed in chapter 2.

Those who are denied medical treatment by Suśruta are the hunter, the fowler, a wicked person and a sinner (vyādhaśākunikapatitapāpakāriṇāṃ ca na pratikartavyam).^[55] The restriction on hunters and fowlers appears strange for very often medicinal preparations require the flesh of carnivorous birds, animal skins etc. Consequently, it can be surmised that physicians had to often interact with them. As regards “the wicked” and “the sinner”, their identification could be subjective and here the physician could exercise his prerogative of refraining to attend to a patient. In this context, there may have been a legal aspect that the physician had to bear in mind. If we go by the Arthśāstra, the state, in order to keep criminal activities under observation, can punish those physicians who secretly treat the wounds of such persons, and do not report to the concerned officer.^[56] The medical practitioner thus had to be careful not to jeopardise his situation by attending to persons of dubious reputation.

Another kind of patient disapproved by the authors is the unbeliever, i.e., one without faith in the Vedas. Reproval of nāstikas is evident at a few places in the texts particularly in Caraka wherein they are declared the worst of the sinful.^[57] Before attending to a patient, the physician is advised to look for signs of favourable or unfavourable prognostication. It is interesting to note that messengers of some religious affiliations are not regarded as auspicious by Caraka. A messenger who has not completely shaved off all his hair (i.e., leaving a tuft on the crown of the head) or one whose hair is unmatted (amuṇḍajaṭa [amuṇḍajaṭaṃ]) is a harbinger of a propitious diagnosis.^[58] Brahmanical ascetics shave their heads leaving a tuft of five to seven hairs on the crown while four categories of individuals have clean shaven heads -Vedic students, widows and world renouncers^[59] as well as criminals.^[60] Should “clean shaven” refer to renouncers including Buddhist and Jaina monks, it would seem to indicate that the physicians of the Caraka school did not regard patients of these sects favourably.

Suśruta reproves messengers who wear old clothes or whose apparel is not white.^[61] Such apparel can also be taken to signify individuals of other religious denominations. Those who denied the authority of the Vedas did not accept brahmanical rites and rituals which are an integral part of therapeutics propounded in the Saṃhitās. This may have been the possible reason why the prognostication of cases involving patients of other sects is not considered auspicious.

Four categories of matted-haired individuals are identified by Olivelle. They are those who have withdrawn or forced to withdraw from society-the forest hermits, known as Vaikhānasa or Vānaprastha, the aged, the political exiles^[62] and Śaivaite ascetics. Avadhūtas and other Śaivaite ascetics let their hair grow and become matted as a symbol of their liberated status and freedom from normal ascetic rules.^[63] Messengers carrying skull, stone, ash, bones, husk or burning charcoal in hand are also not regarded favourably by Suśruta.^[64] These objects remind us of the Lākulā ascetic who imitate the terrible form of his god Rudra and carries cranium begging bowl, skull-topped staff, a garland of human bones, covered in ash and has his hair matted or shaved.^[65] The Pāśupatas, the oldest Śaiva sect, of which the Lākula is a sub-branch, bore the mark of their sect-the ashes in which they bathe three a day.^[66] Do these declarations, therefore, display an antipathy towards such Śaivaite ascetics? Other types of messengers censured by Suśruta are those smeared with oil and mud, wearing red garlands or have applied red paste.^[67] Smearing of bodies with oil and mud is common among wrestlers who as Olivelle points out coincidentally shave their heads completely or at least cut it very short.^[68]

Faith of the patient in the therapy or the physician is yet another necessary tenet of treatment. Among several factors that contribute to negative results of the therapy is the absence of faith in the therapy. Hence, the physician is warned against conducting it on such a patient.^[69] Faith in the therapy cannot be disassociated from confidence in the physician. As we have noted in chapter 2, there are instances in the texts where expression of respect to the physician is declared mandatory on part of the patient. Caraka emphasises that people must specially extend their respectful regard to a physician.^[70] A physician who does not abide by these tenets and takes on such patients suffers defamation because of his sinful acts.^[71] A physician who does not abide by these tenets and takes on such patients suffers defamation because of his sinful acts.^[72]

Footnotes and references:

[1]:

Caraka Saṃhitā Vimānasthāna 8.33.

[2]:

Suśruta Saṃhitā Sūtrasthāna 23.10.

[3]:

Caraka Saṃhitā Vimānasthāna 8.34.

[4]:

Caraka Saṃhitā Nidāna-sthāna 2.27.—tratāsādhyaṃ parityājyaṃ, yāpyaṃ yatnena yāpayet. sādhyaṃ cāvahitaḥ siddhairbheṣajaiḥ sādhayedbhiṣak.

[5]:

Caraka Saṃhitā Sūtrasthāna 1.63.

[6]:

Caraka Saṃhitā Cikitsāsthāna 27.19.

[7]:

Caraka Saṃhitā Cikitsāsthāna 28.52-53.

[8]:

Arthaśāstra IV.1; Manusmṛti IX.284.

[9]:

For instance, Caraka Saṃhitā Nidāna-sthāna 3.12.

[10]:

Caraka Saṃhitā Nidāna-sthāna 5.12-15.

[11]:

Caraka Saṃhitā Nidāna-sthāna 6.16.

[12]:

Suśruta Saṃhitā Cikitsāsthāna 5.6.

[13]:

Caraka Saṃhitā Cikitsāsthāna 28.235-236.

[14]:

Caraka Saṃhitā Nidāna-sthāna 4.38-39.

[15]:

Suśruta Saṃhitā Nidāna-sthāna 6.8, 24.

[16]:

Caraka Saṃhitā Cikitsāsthāna 6.33-34; Suśruta Saṃhitā Cikitsāsthāna 11.9.

[17]:

Caraka Saṃhitā Cikitsāsthāna 5.64.

[18]:

Caraka Saṃhitā Cikitsāsthāna 28.72-73.

[19]:

Cakrapāṇidatta on Caraka Saṃhitā Cikitsāsthāna 28. 72-74.

[20]:

Suśruta Saṃhitā Cikitsāsthāna 7.27-29.

[21]:

Suśruta Saṃhitā Cikitsāsthāna 8.33-34.

[22]:

Suśruta Saṃhitā Cikitsāsthāna 11.9.

[23]:

Suśruta Saṃhitā Cikitsāsthāna 14.3; Cikitsāsthāna 19.81.

[24]:

Suśruta Saṃhitā Cikitsāsthāna 14.8.

[25]:

Bhisagratna, Kaviraj Kunja Lal (Ed.), An English Translation of the Sushruta Samhita Vol. II, p.394.

[26]:

Suśruta Saṃhitā Cikitsāsthāna 13.3.

[27]:

Caraka Saṃhitā Nidāna-sthāna 4.38-39.

[28]:

Suśruta Saṃhitā Cikitsāsthāna 13.10-17.

[29]:

Suśruta Saṃhitā Cikitsāsthāna 9.29.

[30]:

Suśruta Saṃhitā Cikitsāsthāna 9.15-29; 34-40.

[31]:

Suśruta Saṃhitā Cikitsāsthāna 9.21-22; 34-38.

[32]:

Suśruta Saṃhitā Cikitsāsthāna 9.7-9.

[33]:

Suśruta Saṃhitā Cikitsāsthāna 9.7.

[34]:

Suśruta Saṃhitā Cikitsāsthāna 9.29/1-33. Iron preparations can also cure incurable kuṣṭha: Suśruta Saṃhitā Cikitsāsthāna 10.12.

[35]:

Caraka Saṃhitā Sūtrasthāna 1.62-63.

[36]:

Caraka Saṃhitā Vimānasthāna 3.45; Caraka Saṃhitā Siddhisthāna 3.5.

[37]:

Caraka Saṃhitā Siddhisthāna 2.4.

[38]:

Caraka Saṃhitā Siddhisthāna 2.4.

[39]:

Caraka Saṃhitā Siddhisthāna 2.5.

[40]:

Caraka Saṃhitā Siddhisthāna 2.4.

[41]:

Caraka Saṃhitā Siddhisthāna 2.5.

[42]:

Caraka Saṃhitā Siddhisthāna 2.5.

[43]:

Caraka Saṃhitā Siddhisthāna 2.5.

[44]:

Caraka Saṃhitā Siddhisthāna 2.6.

[45]:

Caraka Saṃhitā Vimānasthāna 3.45.

[46]:

Caraka Saṃhitā Siddhisthāna 2.5; Caraka Saṃhitā Vimānasthāna 3.45.

[47]:

Cakrapāṇidatta on Caraka Saṃhitā Siddhisthāna 2.4.

[48]:

Caraka Saṃhitā Sūtrasthāna 6.17.

[49]:

Commentary to Caraka Saṃhitā Sūtrasthāna 2.4.

[50]:

Caraka Saṃhitā Cikitsāsthāna 7.39-41.

[51]:

Caraka Saṃhitā Cikitsāsthāna 7.54-55.

[52]:

Caraka Saṃhitā Cikitsāsthāna 7.61-82.

[53]:

Caraka Saṃhitā Cikitsāsthāna 7.82-83.

[54]:

Caraka Saṃhitā Cikitsāsthāna 7.91-92.

[55]:

Suśruta Saṃhitā Sūtrasthāna 2.8.

[56]:

Arthaśāstra 2.36.10.

[57]:

Caraka Saṃhitā Sūtrasthāna 11.14-15.

[58]:

Caraka Saṃhitā Indriyasthāna12.67.

[59]:

P. Olivelle, Hair and Society in Olivelle, Language, Texts and Society: Explorations in Ancient Indian Culture and Religion, London and New York, 2011, pp.332-333.

[60]:

P. Olivelle, “Hair and Society”, p.335.

[61]:

Suśruta Saṃhitā Sūtrasthāna 29.8.

[62]:

P. Olivelle, “Hair and Society”, p.335.

[63]:

P. Olivelle, “Hair and Society”, p.337.

[64]:

Suśruta Saṃhitā Sūtrasthāna 29.11/1.

[65]:

G. Flood, G., “The Śaiva Traditions” in G. Flood (ed.), The Blackwell Companionto Hinduism, New Delhi, 2008 Indian Reprint, p. 207.

[66]:

G. Flood, “The Śaiva Traditions” p.207.

[67]:

Suśruta Saṃhitā Sūtrasthāna 29.12/1.

[68]:

P. Olivelle, “Hair and Society”, p.323.

[69]:

Caraka Saṃhitā Cikitsāsthāna 1:4.38.

[70]:

Caraka Saṃhitā Cikitsāsthāna 1:4.50.

[71]:

Caraka Saṃhitā Vimānasthāna 3.45.

[72]:

Caraka Saṃhitā Vimānasthāna 3.45.