Well-Mannered Medicine: Medical Ethics and Etiquette in Classical Ayurveda.
Dagmar Wujastyk's Well-Mannered Medicine is by no means just about medicine, but about lying, dignity, risk, and death. The Ayurvedic texts that Wujastyk has surveyed also offer "a wider view of human life that includes psychological, social, philosophical, and spiritual perspectives" (p. 2). Her initial sets of questions revolve around whether we can even speak of medical ethics in the Ayurvedic context. What is "etiquette"? And what are the "moral principles" at work that give shape to and underpin the passages that we might categorize as "ethical" in nature?
After laying out her questions, Wujastyk then turns to a famous passage in the Caraka-samhita, known as the "Oath of Caraka." This "oath" is often considered to be the Sanskrit equivalent of the Greek Hippocratic oath. This is then followed by a useful review of the literature on the topic, including a valuable and succinct synopsis of the problems of dating the Sanskrit Ayurvedic corpus (pp. 16-20).
In chapter one Wujastyk discusses the "four pillars" of treatment: physician, medicine, attendant, and patient, noting that there seems to be no discernible "ecological ethic" at work in these texts (p. 26). She then turns to a list of the sorts of specialists included under the heading of "attendant," mostly wet-nurses, kitchen staff, and botanists (p. 27), as well as midwives and friends in the special situation of childbirth, for all of which the texts provide descriptions of appropriate skills, but are silent on their actual training. Throughout this book we encounter elegant, clear, and correct translations of sometimes very complex passages. At first, the book struck me as being perhaps a little too schematic in its design, but the way in which Wujastyk has organized her materials actually works very well. She opens each section with translated passages, and then provides context for them, giving information about where they occur in the texts, and she then raises questions about connections and meanings, then compares her materials across the texts in question.
This chapter provides us with an excellent sense of the "formalities" of early Ayurvedic practice. There are thorough discussions across texts of the different categories of doctor, ranging from "the good physician who deserves the title vaidya" to "the fraud/quack" (p. 43). There is very interesting information here on comportment, cleanliness, and sartorial habit, an ethics expressed in etiquette, as it were.
The patient is everywhere and nowhere in these texts. As Wujastyk states, "the medical treatises offer no case histories" (p. 51), such as what we find in Greco-Roman texts, with the patient as a person remaining "strangely absent" (p. 59). There is an excellent discussion in this chapter on the treatment of the poor: Caraka advises against treating them, while Susruta urges physicians to treat poor people "as if they were family," that is, "for free" (pp. 58-59).
Chapter two is dedicated to the materials concerning the medical student's education and his ultimate entry into the profession. There is some thought-provoking material here on the nature of medical texts and their circulation. Wujastyk writes, "Caraka seems to be describing an actual physical object, rather than an abstract body of knowledge," with descriptors found in the Caraka-samhita that seem "more likely to apply to a written text than a memorized one" (pp. 70-71). What were early Ayurvedic "classrooms" like? It also appears that the student had to choose a textbook before choosing a preceptor. The Susruta-samhita also adds advice on how to study, which includes a fascinating description of how knowledge is imparted by rote (pp. 72-74), with the ultimate goal of producing a good doctor who "should be not only versed in theory but also skilled in practice" (p. 74). But doctors who also taught were given advice on how to choose a good student: there are guidelines in many of the early texts on "how to identify who is suitable to study medicine and who is not" (p. 74), but it is only Susruta who "makes mention of the student's class background (varna) and he does not rule out that sudras may be taught," albeit without Vedic mantras. Wujastyk notes that "for the other medical authors the question of social background (in terms of class, varna, at least) does not seem to feature in this context" (p. 78).
Wujastyk then moves on to the initiation of the medical student, and she does an excellent job of tracing certain elements of this ceremony back to the grhya-sutras in their descriptions of brahmacarin initiation, characterized by the bringing of firewood (p. 81).
The Kasyapa-samhita provides some very interesting material regarding the nudity of female patients. Kasyapa "shows a much greater emphasis on taking care when associating with women" (p. 97), as does the Astanga-samgraha (pp. 98-99). Wujastyk remarks upon the striking "resemblance of the medical student's initiation ceremony to that of the Vedic student" (p. 99), and concludes that the initiation for medical students was based on that of students of the Vedas, but they do not necessarily "share the same significance" (p. 100). At this point in the book a rich discussion ensues on the position of the physician in brahminic society, and Wujastyk pays special attention to the "negative image" of the physician presented in the Manu-smrti. As she writes, for Caraka, "the title 'doctor' [Sanskrit vaidya] is earned, not inherited" (p. 101). She points us to a variant reading on Caraka-samhita, Cikitsa-sthana 1.51-53, which swaps in "thrice-born" for "twice-born," indicating that the "third birth on completing medical studies--that medical studies would follow the second birth of the initiation into Vedic studies--that medical studies do not stand in place of religious studies but follow and complement them" (p. 101). Wujastyk does an excellent job of placing diverse Ayurvedic materials within wider textual and social contexts, concluding at the end of this chapter that "[i]n their rules of professional conduct, then, the medical authors again display an affinity--though not a complete correspondence--with brahminic religious law literature" (p. 105).
The six chapters that follow are much shorter in length than the first two, but each is dedicated to issues that are smaller in scope. Chapter three is devoted to the "continuing education" of the physician through his participation in symposia and debates (pp. 106-9). The Caraka-samhita, in fact, encourages doctors to engage in "self-examination" and in "questioning one's abilities before embarking on the treatment of others" (p. 109) throughout his professional career.
Chapter four contains an excellent discussion on the question of when a doctor should either discontinue or refuse treatment as he interprets the signs of impending death--the rista or arista--which "enable the physician to withdraw his services, or not to commence treatment at all, once a patient is diagnosed as incurable" (p. 112). Here Wujastyk includes material on incurable diseases, ones that are "unmanageable" (anupakrama) and those that are controllable (yapya), in what amounts to "triage, an important feature of all formal medicine" (pp. 112-13). But this material is all about the fame and reputation of the doctor, and the topic is framed in the text "as a discourse on career advice," since a failure of treatment "means the physician was unsuccessful" (p. 114). And at the end of the day, "[t]he physician's basic dictum is to not accept patients he cannot cure" (p. 115). But just what are the rewards of medical practice? Wujastyk addresses issues such as wealth, compensation, and philanthropy in her very brief fifth chapter (pp. 117-23). It seems that patronage was crucial, and as Caraka himself suggests, "physicians from a vais'ya background may practice for money and protection from lords and wealthy persons" (p. 122), leading Wujastyk to conclude that perhaps practicing medicine in the classical period was "a calling rather than a profession" (p. 122).
Chapter six, on "veracity in the doctor-patient relationship," is Wujastyk's best chapter, and in many ways it is the only one in the entire book that directly addresses an ethical conundrum. Here, we have "lies" taking the form of non- or partial disclosure of information to patients and their families. Wujastyk argues, and I think rightly, that it is "medical paternalism" that drives these dynamics, especially since there appears to be no factoring in of the autonomy of the patient in Ayurveda. A doctor at times must make a "well-considered and deliberate choice to give partial or wrong information . . . perfectly in accord with accepted standards of behavior in the paternalistic model.... [S]peaking untruths...becomes a correct action of positive moral value." Perhaps Susruta says it best, stating at Sutra-sthana 25.43-44 that a patient might distrust all of his kin, but that he "gives himself over, and does not distrust him. Because of that, the physician ought to protect that patient like a son" (p. 125). Paternalism, indeed!
Caraka actually defines lying as "an urge of blameworthy recklessness, and leaves no doubt whether lying is an unacceptable action," and is presented as "a clear and unambiguous social rule" (p. 132), but as Wujastyk stresses, "the medical authors do allow for circumstances in which it would be permissible or even desirable for a physician to lie to his patient." She continues: "The concept of honesty pertains to a physician's character rather than to his actions, while truth itself is a qualifiable concept" (p. 132). "To do no harm"--to act with "beneficence" and in accord with "the fundamental paradigm of medical paternalism" (p. 133)--trumps any textual insistence on honesty in cases in which speaking truthfully would harm the patient and bring distress to his family. But deception itself is also used as a "therapeutic method... to facilitate medical treatment by ensuring patient compliance" (p. 133), especially in contexts in which meats must be used. The medical authors grant doctors tacit permission to disguise meats under other names, and according to Vagbhata, certain meats should be "prepared so as to be unrecognizable" (p. 134). The great commentator Cakrapanidatta sees no contradiction in such therapy: it is perfectly fine, especially in the context of a wasting illness, to speak untruthfully "for the sake of another's life," especially when a doctor must trick a patient "into using a substance that is medically efficacious," resulting in an act that is "not of vice but of virtue" (p. 137). There is also a third context in which "deception is used to shock the patient into believing his life is at stake" in order to cure types of mental illnesses caused by irregularities in bile (p. 140).
Chapter seven basically amounts to a brief list of topics that readily crop up in contemporary debates on medical ethics, but about which the Ayurvedic authors have little or nothing to say. Concerning violence, for instance, there is no acknowledgement of the fact that treatments such as the cauterization of wounds could cause fear in a patient or excruciating pain. And while "physical and psychological pain are used as a therapeutic tool to treat mentally ill patients," there is "no discussion of the moral implications of this therapeutic choice" (p. 143). The texts are silent on abortion, but I would urge Wujastyk to examine the passages in the Susruta-samhita that describe and discuss the surgical extraction of a fetus in order to save the life of its mother: while none of this is couched in ethical terms in the text, a surgeon must obtain permission from the king before he can proceed. The texts are also silent on euthanasia: there are no passages that discuss a situation in which a doctor might choose to gently ease a suffering patient into death, but there are many passages that advise to withhold treatment from hopeless cases (pp. 145-46).
In her conclusion, Wujastyk remarks that "benevolent paternalism" constitutes "the emotional background of medical interaction" (p. 150), but perhaps the best concluding statement of all is the commentator Cakrapanidattas characterization of the rules of Ayurveda. The rules "do not teach the achievement of righteousness. Rather, they teach the achievement of health" (p. 153). Wujastyk admirably places Ayurveda precisely where it needs to be: out of the hands of nationalist-extremists and into the disciplinary realms of the histories of medicine and science. Much of this material is about professionalization and the history of the medical discipline as it existed in the early centuries of the first millennium. We need more books on Ayurveda like this one, and I would like to note here that this book has won a permanent place on my graduate syllabus--it is a wonderful book from which to teach, and Weil-Mannered Medicine would be an excellent addition to courses on South Asian culture, ethics, and the history of education.
MARTHA ANN SELBY
UNIVERSITY OF TEXAS
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|Author:||Selby, Martha Ann|
|Publication:||The Journal of the American Oriental Society|
|Article Type:||Book review|
|Date:||Jan 1, 2017|
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