Ayurvedic Ethics and Modern Medical Ethics
In this paper, I will conduct a comparative analysis of Ayurvedic ethics and modern medical ethics. I will argue that ethics are culturally constructed and thus, I will not search for ethical universality or argue for ethical relativism, but rather, posit a need for an ethical pluralism. I will confront and recognize the indeterminacy of ethical variability in today's transcultural world and that the proponents of biomedical ethics need to recognize that alternative medical systems of ethics do exist, and rather than proclaim outright rejection of the other, there may be, through a cross-cultural dialogue, tremendous benefits in negotiating mutual understanding. I am not suggesting that this approach will yield a transcultural model of ethics, but it could turn varieties of ethical expectations in specific medical circumstances into commentaries on what one ethical model illuminates and another ethical model obscures. Furthermore, instead of a forswearing one another's medical system, I will posit that an approach of mutual understanding and negotiation would not only provide a means for cross-cultural dispute resolution, but also open a dialogue to mainstreaming Ayurveda.
The problem of cross-cultural ethical variability first requires an understanding of how ethical rules of a medical system are socially constructed. Therefore, an examination of both the biomedical mind-body dichotomy and the Ayurveda model of holistic identity will establish a basic understanding of how these ethical systems are constructed. Biomedicine's construction of a mind-body dichotomy posits that the mind and body are ontologically distinct and do not affect the other. The inner state of the patient's mood and affect are not relevant—emphasis is on the patient's body rather than listening to the patient's "voice" (Moreno Leguizamon 2005:3305). The mind is ruled as immaterial, invisible and emotional, whereas the brain is physical, material and a structural and functional organ that is part of the body (Moreno Leguizamon 2005:3305). The notion that the mind does not exist for biomedicine is illustrated by recent changes in the field of psychiatry. In the realm of mental disorders, biomedicine has trumped psychiatry with neurological science suggesting that the psychiatric discipline deals with mental issues of unknown origin, whereas neurology determines the cause of the syndrome and turns it into a real disease and takes responsibility for treating that disease. In biomedical psychiatry—the medicalization of mental illness—the organic brain is the target of abnormal behaviour, diagnosed as a genetic aberration that requires a regime of pharmaceutical interventions (Lakeoff 2005:6). The biomedical body is constructed as a stand-alone machine—functional, systemic, structural, physical and material. The body symbolized as a machine metaphor constructs the patient as an object comprised of organs and tissues—organic components to be observed and measured from an external standpoint. Biomedicine defines health and illness as the body's ability to correctly function and perform. Thus, biomedicine views both body and person as solid and bounded—abnormal functioning signifies some physical problem in the individual body part that is the result of illness or injury requiring treatment.
In contrast to biomedicine's mind-body dichotomy, Ayurveda posits a health-illness dichotomy that embraces a holistic approach—maintaining that all facets of existence are interrelated and interdependent—a balance and harmony between the body, mind and soul, and the environment (Moreno Leguizamon 2005:3308). Ayurveda, like biomedicine, is scientific medicine. Ayurveda has both a highly abstract meta-theoretical framework for explaining diseases and, similar to biomedicine, Ayurveda is based on validation and experimentation (Moreno Leguizamon 2005:3307). Ayurveda holds that humans are part of nature with the idea that, what happens in the world around us, happens inside our body (Moreno Leguizamon 2005:3307). In contrast to biomedicine which posits the body, person and illness as objects, Ayurveda comprehends these aspects as processes and patterns of relationships intrinsically linked to the socio-cultural, climatic and cosmic world in which the body and person lives (Langford 1995:330). Thus, consideration of familial, social, geographical, dietary and cultural location of the patient are all taken into account when diagnosing a particular illness and recommending a course of treatment (Moreno Leguizamon 2005:3306). Similar to biomedicine, Ayurveda recognizes viruses and bacteria as causes for illness, but Ayurveda views the body and environment as a vast source of microorganisms, and posits that these pathogens are secondary sources rather than primary causes. It is the soul, mind, senses and the body that determine health and life, and any one of these factors could be the potential source of illness. Ayurveda ascribes three causes of illness: 1) mistakes of the intellect; 2) misuse of the senses; and 3) the effect of the seasons (Moreno Leguizamon 2005:3308). Furthermore, Ayurveda discriminates between curable and incurable disease, and focuses primary on health as a function of illness prevention rather than biomedicine's focus on treatment of disease (Moreno Leguizamon 2005:3308). Lastly, unlike biomedicine's focus on body and illness, Ayurveda's focuses on the emotional and the person which not only signifies the distance from biomedicine's biological model, but also posits Ayurveda's knowledge of a "life model", which emphasizes interactions between the physical body and the subtle body comprised of the soul, the mind and the senses (Moreno Leguizamon 2005:3309).
Recognizing the body-mind dichotomy of biomedicine and the health-illness dichotomy of Ayurveda is necessary to understanding how a medical system is historically, culturally and politically constructed. Parts of this construction are the attendant ethics, which shape the doctor-patient relationship. Western medical ethics are guided by four central moral principles: autonomy, beneficence, nonmalificence and justice (Wujastyk 2012:124). Respect for autonomy gives each patient the right to make individual choices, and that those choices are respected within societal laws, institutional values and policies and the sensibilities of staff and other patients (Baycrest 2006:5). Furthermore, the patient has the right to know and make autonomous judgments based on that information. This principle represents a significant historical shift in the doctor-patient relationship from medical paternalism to patient rights (Wujastyk 2012:124). Beneficence dictates that medical personnel is obliged to do good and advance the welfare of another's well-being within the group's norms (Baycrest 2006:5). Nonmalificence mandates that medical staff prevent harm, removing sources of harm or causing no harm to a patient. The fourth principle in biomedical ethics is justice, which demands that each patient is treated fairly. Procedural justice asks for fair treatment in the process of decision making—that all interested parties are heard and all options are discussed in the decision making process. Distributive justice requests fair treatment in the allocation of limited resources, based on each patient, in accordance with their needs (Baycrest 2006:6).
In a medical setting, classical Ayurveda medicine identifies four agents that participate in ethical interactions: the physician, the attendant, the patient and the medicine, which are conceptually framed as the four pillars treatment (Wujastyk 2012:27). The ethical quartet of the medical practitioner's conduct includes: kindness and compassion to the patient, affection towards those who can be treated and, a calm and even-tempered composure toward those in their natural state (Wujastyk 2012:110). In the CarakaSamhita, the cornerstone of medical ethics are: compassion, integrity, respect, honest, courage and conscientiousness (Jayasundar: 2012:178). The doctor-patient relationship in Ayurveda is overtly paternal and requires that the patient trust their physician, and that the doctor exercise benevolence towards the patient. The Susruta argues that a patient might mistrust members of their family, but must surrender themselves over to the care of their physician—patient compliance signifies trust in the physician, and for that respect, the doctor must protect their patient like a "son" (Wujastyk 2012:125). It is the doctor who decides what is best for the patient, what is the right course of treatment. All information concerning the patient is managed by the doctor and. based on his discretion, the physician can deny information, deceive and even lie to the patient as legitimate course of action if it ensures patient obedience, facilitates therapeutic treatment or shields the patient and/or family from disquieting news (Wujastyk 2012:126).
In this paper I will introduce a variety of case studies, and explore how the doctor, patient and family interact, and make decisions based on their meanings of health and illness, social beliefs, moral values and culture-specific sense of medical duty toward patient treatment and care. In each of these scenarios, I will illustrate how biomedical doctors and Ayurveda practitioners might handle the situation. Furthermore, I will propose a set of ethical dilemmas that a physician might face and discuss how biomedical ethics versus Ayurvedic ethics would treat the problem. In discussing each case study, I will examine the strengths and weaknesses of each medical approach and expose potential ethical conflicts among doctor-patient-family relations. To draw out the various ethical approaches, I will focus on palliative and end-of-life decision-making and clinical research. I will discuss how culture matters in ethics and the multitude of culture-specific customs a physician, patient and family might attempt to navigate medical issues.
The hegemony of Western global bioethics demands critical analysis. Transcultural diversity is a global reality, coupled with the fact that culture is a dynamic, not a static entity, and that cross-cultural medicine is wrought with conceptual obstacles. This reality demands an investigation that comprehensively uncovers the socio-cultural issues that matter to diverse patient populations. For example, an 85-year-old male patient diagnosed with a terminal illness that cannot be successfully treated. The physician has discussed this matter with the family, who has urged the physician not to tell their father the gravity of his illness. Instead, the family wishes to care for their father's end-of-life time in the comfort of the family's home. The ethical questions are: Should the physician inform the patient of this medical status? How should a physician respond to this situation?
Under the Western biomedical model, the patient's right to autonomy requires informed consent and dictates that the patient's medical situation is truthfully revealed. Furthermore, depending on the country, such as Germany, discussing the dying patient's condition with the family before securing consent from the patient is considered a breach of patient confidentiality and is possibly subject to criminal prosecution (Chattopadhyay & Simon 2007:168).
Under the Ayurvedic medical system in India, a physician will recognize the dying patient's situation not as an individual event, but rather as a shared family affair, and depending on the circumstance, may even involve the community. The physician would most likely share cultural-specific values, norms and illness meanings with the family (Chattopadhyay & Simon 2007:170). Ayurvedic ethics directs a physician to "speak gently, purely, justly, joyfully, in a wholesome manner, truthfully, affectionately and moderately" (Wujastyk 2012:132). However, the Caraka infers that speaking truthfully is not absolute and states: "And even if you know that the lifespan of the diseased is diminished, you should not tell the truth in a situation which, by speaking, would harm the diseased or another" (Wujastyk 2012:133). Ayurvedic ethics defers preference to the physician, to determine whether or not such truthful information might potentially add further harm and suffering to the patient. This of course is a fundamental ethical expression of Ayurveda's paternal beneficence.
By examining both the biomedical and the Ayurvedic ethical approach to terminal illness, we learn that physicians may act ethically, but do so in different ways depending upon the socio-cultural situation. In India, the physician would respect a family's wishes not to tell the patient the naked truth of their terminal condition, yet in Germany the physician legally must respect the patient's autonomy and right to informed consent, otherwise a physician's could be held liable for damages (Chattopadhyay & Simon 2007:168). As I have shown in this example, there are a diverse number of ethical customs to end-of-life care and decision-making.
There is convincing evidence that Ayurvedic medicine has some efficacy with cancer patients. Ayurvedic physician, Balendu Prakash in Dehradun, North India, claims he has cured cancers using a treatment known as Rasayan shastra, which is one of the eight Ayurveda specialties (Pai 2001:331). Dr. Prakaj Shah, Additional Director of the Gujarat Cancer and Research Institute in Ahmedabad, India, asserts that Ayurveda has benefit in the treatment of cancer and needs to be studied prospectively in a proper scientific manner (Pai 2001:331). As a result, the Indian Cooperative Oncology Network wants to begin prospective, randomized, blinded trial for 120 patients with acute lymphoblastic leukemia, who will undergo three years of conventional chemotherapy, after which they will randomly receive a placebo or Ayurvedic medicine (Pai 2001:331).
The subject of clinical biomedical research in cross-cultural settings is becoming increasingly important as pharmaceutical companies seek new groups of people to conduct clinical trials in non-western countries. Ethical rules shape and govern how research scientists behave toward their research subjects morally and professionally. Furthermore, ethical guidelines have prescriptive, explicative, protective and creative purposes (Christakis 1992:1080). Based on the socio-cultural beliefs of a particular people, research ethics are likely to vary cross-culturally, which can lead to ethical conflicts.
Professional Ayurveda struggles to maintain its status as a science. This contest is further exacerbated by the ever-increasing global hegemony of clinical biomedical research standards and procedures that make it difficult for the Ayurvedic practitioners to verify the efficacy of its medicines. Therefore, a serious consideration of cross-cultural clinical ethics requires exploration since Ayurveda has no tradition of clinical research. Physicians of Ayurveda are instructed to read their texts and to practice, not on humans, but dead animals, dolls or large fleshy fruits to teach cutting away or cutting around tumors and growths (Bhagwati 1996:432). Furthermore, although Ayurveda is experiential, it is not experimental, and though Ayurveda is a science, it is limited to observation and experience—an approach of rational application—the knowledge of how a number of causes combine to produce an effect (Christakis 1992:1083). Ayurvedic practitioners face a number of ethical restrictions when treating patients. Prudent observation is vital for effective treatment, otherwise treatment will fail with misdiagnosis. Furthermore, Ayurvedic practitioners are also discerning when it comes to treatable and untreatable cases, thus avoiding responsibility for terminal patients. Moreover, Ayurvedic texts suggest that no harmful treatment should be administered and therapy should proceed until the patient utters their last breath (Christakis 1992:1083). Ayurvedic practitioners also employ deception, especially in the care of the dying, by withholding medical information from the patient and will deceive the patient with soothing reassurances. Another problem lies in the Western notion of respect for the patient and their right to informed consent can create further ethical problems when conducting clinical biomedical research in India. Non-Western definitions of personhood differ from the highly individualistic nature of Western culture and its emphasis on individual rights, autonomy, self-determination and client privacy, whereas Hindu personhood is largely defined by relations to others within society. This has important implications for clinical research subjects whose consent process is not only subject to their own decision to participate, it will also be necessary to secure consent from the family or in some cases even the community (Christakis 1992:1086).
It is apparent that a basic application of biomedical ethics in a non-Western environment is problematical. To navigate a setting of cross-cultural ethics requires neither finding a simplistic ethical universality, nor does it mean evading the complexities of ethical relativism, but rather confronting the indeterminacy of a pluralist model of ethical variability (Christakis 1992:1089). In India and globally, Ayurveda has generated a certain amount of interest as an alternative form of medicine, but has yet to be recognized as a medical system equal to that of biomedicine. Today, Ayurvedic remedies are used for chronic and non-epidemic types of diseases. However, socio-political forces continue to block a collaborative atmosphere in a pluralistic medical environment. In Sri Lanka, biomedical practitioners are directed not to associate professionally with Ayurvedic practitioners. Allopathic practitioners are advised to withhold opinions to medical requests made by alternative practitioners and not to conduct requests for investigations or handling referrals from Ayurvedic practitioners. The Ayurvedic Medical Council in Sri Lanka reciprocates by asking that practitioners avoid using Western drugs (Arseculeratne 2002:8). Furthermore, there is a general attitude of mistrust in using biomedical science to verify the empirical evidence of traditional herbal remedies and procedures for fear of losing intellectual property and being vulnerable to exploitation by the modern pharmaceutical industry (Arseculeratne 2002:9).
This paper suggests a potential solution calls for a more open-minded attitude on behalf of proponents of Western bioethics, and that of Ayurvedic medicine, to open a dialogue for mainstreaming Ayurvedic medicine. Both medical systems could potentially benefit from an ethos of trust and mutual respect. An atmosphere of trust and respect could be used to identify mutual strengths and weaknesses of each other's practices, foster standardization and quality control of Ayurvedic treatment and procedures, create a evidence for Ayurvedic remedies with high-quality research, encourage accountability, transparency and advocacy for Ayurvedic practitioners, and facilitate opportunities for patients to make better informed decisions about the healthcare options (Gopichandran & Kumar 2012:276).
Positioning ethics as a form of local knowledge can turn varieties of ethical expectations in specific medical circumstances into commentaries on what one ethical model illuminates and another obscures. As I have discussed in the end-of-life example, the ethical preference of the Ayurvedic physician to withhold medical information from the dying patient, based on the wishes of the family, and not wanting to create further harm to the patient, is an ethical expression of Ayurvedic's paternal beneficence. However, from a Western biomedical standpoint the ethics of this approach circumvents a core principle of the doctor-patient relationship—the "patient's right to know"—necessary for an autonomous patient to make an informed decision. From this example, we can supplement our understanding of moral values and meanings of life, illness, suffering and death across cultures, rather than ignore or consider it mistaken. Furthermore, accepting a pluralist view on the end-of-life decision making provides us with a wider range medical approaches and possibilities for creation, revision, analysis, and initiation of healthcare policy making in end-of-life care.
The global expansion of biomedical research in non-Western countries increases the opportunity for traditional and biomedical practice to converge, putting clinical research ethics under pressure to act in accordance with local settings and cultural norms. Holding a pluralistic view of medical systems would enable clinicians to expand their discourses between each other, create an atmosphere of mutual understanding for each other's ethical beliefs, and further appreciate what ethical systems are designed to achieve and how they function. New possibilities are created when biomedicine's sometimes myopic view of illness, being located only in the physical body, could benefit tremendously from Ayurveda's holistic approach, that addresses not only the physical, but also the mental, spiritual, social, cultural and environmental aspects of illness causing factors.
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