The oath of medical ethics
Source: By Monojit Majumdar: The Indian Express
The National Medical Commission (NMC), the regulator for medical education and practices that replaced the Medical Council of India in 2020, has suggested to medical colleges that the traditional Hippocratic Oath should be replaced by a “Charak Shapath”.
The minutes of NMC’s meeting with medical colleges on 7 February 2022, chaired by Dr Aruna V Vaniker, president of NMC’s under-graduate medical education board (UGMEB), record, “No Hippocratic Oath. During white coat ceremony (with parents) the oath will be ‘Maharishi Charak Shapath’ present on the NMC website”.
The Kerala unit of the opposition Congress has criticised the proposal as an attempt to “saffronise medical education”, and senior leader and Thiruvananthapuram MP Shashi Tharoor has tweeted, “I am all in favour of introducing Indian elements into Indian education, but not at the expense of universal values and standards. Why can’t the Charaka Shapath supplement, rather than supplant, the Hippocratic Oath that doctors worldwide take?”
The Indian Medical Association (IMA), the national representative platform of doctors of modern medicine, is yet to issue a statement on the proposal, but statements by individual doctors on social media suggest the medical community is divided in its opinion.
Hippocrates and Hippocratic Oath
The Hippocratic Oath is attributed to Hippocrates of the island of Kos, a Greek physician of the classical period (4th-5th centuries BC, until the death of Alexander the Great in 323 BC), broadly corresponding to the period from the death of the Buddha (486 BC) to the rise of the Mauryas (321 BC) in India.
Among the great contemporaries of Hippocrates were the Athenian philosopher Plato and his teacher Socrates, and Plato’s student and Alexander’s tutor, the polymath Aristotle.
The Corpus Hippocraticum is a collection of 70 books on medicine; however, most scholars agree that the Hippocratic Oath was probably not the work of the individual identified as the historical Hippocrates, the “father of modern medicine”. The oath seems rather to be “more Pythagorean (who lived a century or more before Hippocrates) in its moral and ethical flavour… (and it) might have been enriched by other authors in antiquity”. (‘Ethical Aspects of the Hippocratic Oath and its Relevance to Contemporary Medicine’, Sisir K Majumdar (1995), Bulletin of the Indian Institute of History of Medicine, Hyderabad).
Basically, the Hippocratic Oath is a charter of ethical principles that physicians over the ages have sworn to uphold in the practice of their profession. The earliest available fragments of what is understood to be the original oath date back to the late 3rd century AD, and a millennium-old version is now in the library of the Holy See.
Classical oath and its legacy
Two translations of the pagan oath from the Greek original, by WHS Jones (‘The Doctor’s Oath’, Cambridge University Press, 1924) and Ludwig Edelstein (‘The Hippocratic Oath: Text, Translation, and Interpretation’, Johns Hopkins Press, 1943), are frequently referred to:
“I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them.
I will not give poison to anyone though asked to do so, nor will I suggest such a plan. Similarly I will not give a pessary to a woman to cause abortion. But in purity and in holiness I will guard my life and my art.
I will not use the knife either on sufferers from stone, but I will give place to such as craftsmen therein.
Into whatever houses I enter, I will do so to help the sick, keeping myself free from all intentional wrongdoing and harm, especially from fornication with woman or man, bond or free.
Whatsoever in the course of practice I see or hear (or even outside my practice in social intercourse) that ought never to be published abroad, I will not divulge, but consider such things to be holy secrets.” (Extracts, BMJ, October 1998)
Modern codes of medical ethics such as those formulated by the American Medical Association (AMA) and the British Medical Association (BMA) are broadly rooted in the Hippocratic Oath, but they also draw heavily from other sources — such as the work of the English physician and ethicist Thomas Percival (1740-1804).
No one version of the oath
There is no universally accepted version of the physician’s oath. Many medical schools around the world hold a ceremony in which graduating doctors swear to a broad charter of ethics that are sometimes customised by individual institutions. A version of the ‘physician’s code of ethics’ is commonly displayed in hospitals or clinics in most places, including India.
The AMA describes its Code of Medical Ethics as a living document that has evolved as medicine and society have changed. The AMA’s Code was adopted in 1847, and underwent updates in 1903, 1949, 1957, and 2008.
The World Medical Association (WMA) adopted an international code of medical ethics in 1949, which was amended in 1968, 1983, and 2006. In May last year, the WMA published a proposed modernised version of the international code, “outlining physicians’ duties towards their patients, other physicians, health professionals and society as a whole”, according to the WMA website.
According to the WMA, some of the duties of physicians in general are to:
* always exercise his/her independent professional judgment and maintain the highest standards of professional conduct;
* respect a competent patient’s right to accept or refuse treatment;
* not allow his/her judgment to be influenced by personal profit or unfair discrimination;
* be dedicated to providing competent medical service in full professional and moral independence, with compassion and respect for human dignity;
* deal honestly with patients and colleagues, and report to the appropriate authorities those physicians who practice unethically or incompetently or who engage in fraud or deception;
* certify only that which he/she has personally verified;
* respect the local and national codes of ethics.
Charaka and Charak Samhita
Like several other sages mentioned in the literature of ancient India, the historicity of Charaka is uncertain, and the compendium of medicine that carries his name is unlikely to have been the work of a single individual.
The Charak Samhita is a medical pharmacopoeia and collection of commentaries and discussions on medical practices that is dated to the 1st-2nd centuries AD.
Along with the compendium of Susruta (c. 4th century AD), which is about surgery, the Charak Samhita is considered the foundational text of ancient Indian medicine, which was an evolved system of understanding and treating disease that resembled that of Hippocrates and Galen (2nd century AD), and was in some ways ahead of the Greeks.
The ancient Indian interest in physiology is understood to have drawn from yoga and mysticism, and to have been enriched by the growth and spread of Buddhism to new lands, the arrival of the first Christian missionaries, and the contact with Hellenic practitioners of medicine.
In theory and praxis, ayurvedic medicine today remains broadly unchanged from these ancient Indian principles.
Ancient Indian system of medicine
At the heart of ancient Indian medicine is the doctrine of the three ‘doshas’ (humours). It was believed that a balance of the three vital fluids, wind, bile/ gall, and mucus/ phlegm is essential for good health — and that these humours were tied closely with the scheme of the three ‘gunas’ or universal qualities — virtue/ lucidity (sattva), passion/ energy (rajas), and dullness/ torpor (tamas). To the three primary humours, wind, bile, and phlegm, some authorities added a fourth, blood.
The functions of the body are regulated by the five ‘winds’ or vayu — udana, which emanates from the throat and accounts for speech; prana, from the heart, responsible for breathing and swallowing; samana, in stomach, involved in digestion; apana, in the abdomen, ensuring excretion and procreation; and vyana, which causes the motion of blood. (A L Basham, The Wonder That Was India, 1954)
Food is seen as the key to good health: it is why the body exists — and as bad food causes sickness, good food heals. A passage from the Charak Samhita describes a debate among sages which concludes with the view, “The use of good food is one cause of the growth of a person, and the use of bad food is a cause of diseases” — even though the debate is not conclusively closed. (Wendy Doniger, On Hinduism, The Hindus)
Surgery reached great heights in ancient India. Basham noted that the caesarian section was known, bone-setting was highly evolved, and plastic surgery was “developed far beyond anything known elsewhere at the time”.
The medical ethics of Charaka
The physician was an important and respected member of ancient Indian society, and medical practice followed rules of professional conduct and ethical principles. Basham quotes from a part of the sermon that Charaka instructs a physician to preach to his pupils at a ceremony at the end of their apprenticeship.
“…You must strive with all your soul for the health of the sick. You must not betray your patients, even at the cost of your own life… You must not get drunk, or commit evil, or have evil companions… You must be pleasant of speech…and thoughtful, always striving to improve your knowledge.
“When you go to the home of a patient you should direct your words, mind, intellect, and senses nowhere but to your patient and his treatment… Nothing that happens in the house of the sick man must be told outside, nor must the patient’s condition be told to anyone who might do harm by that knowledge to the patient or to another.” This ethical code is universal, and remains just as relevant and applicable today.
The Indian Express has reported that undergraduates at the country’s premier health institute, AIIMS, have been taking the Charak Oath during their annual convocation for several years now. Dr M C Misra, former director of AIIMS, has told The Indian Express that the Charak Shapath was already part of the annual convocation when he took charge in the post in 2013.
The AIIMS Charak Shapath is: “Not for the self; Not for the fulfilment of any worldly material desire or gain, but solely for the good of suffering humanity, I will treat my patient and excel well.”
Discussion and inclusiveness
The Charak Samhita speaks, unsurprisingly, of the “welfare of cows and Brahmans”. But it also underlines the importance of the physician praying, “every day on rising and going to bed for the welfare of all beings”, (Basham) and of debate and discussion among the learned.
The passage in the Charak Samhita mentioned above (quoted in Wendy Doniger, ‘On Hinduism’, ‘The Hindus’) describes a debate among sages who were invited by a king to determine the origin of disease. The sages put forward their theories, which were in several cases the essence of major philosophical and medical traditions of ancient India.
One said that the individual is born from the soul, so disease too must come from the soul; a second said that the mind, when overwhelmed by energy and torpor, gives rise to both the body and the pathological changes in it; a third said that creatures and disease both come from rasa; a fourth argued that since the individual is created from the six material elements of earth, water, fire, wind, space, and soul, disease too is born of these same elements; a fifth submitted that just as an individual must have a father and mother, so too must disease; but the sixth rebutted that while a blind person isn’t necessarily born of another blind person, all creatures are the product of karma, and so is disease.
As the sages argued, one of them advised the rest not to take rigid positions — typical, Doniger says, of the way all of the shastras strive to be open minded and inclusive. “Not until you shake off the torpor of factionalism from what you want to know will true knowledge emerge.”
