Perspectives on the Role of Honesty in the
Doctor-Patient Relationship (Dagmar Wujastyk)
JOHN NEMEC:
Okay, so , we have two more papers and then,
hopefully we can have some time for questions
collectively at the end.
It is my pleasure to introduce our second
speaker, Dagmar Wujastyk, who comes from the
University of Zurich,
where she is a research fellow and writing
her habilitation cases, which in the German
and continental systems, you write two Phd
thesis.
She's written one and she's on her second.
Her doctorate is from Bonn University in Germany
and she's worked at Cambridge as well,
and she is the author of a book published
by Oxford University Press, in 2012, titled,
Well Mannered Medicine: Medical ethics and
etiquette in classical Ayurveda
As I said, she's coming here from Zurich via
Austria, by way of London.
So we thank her for enduring a rather arduous
journey here by multiple planes and we are
very happy you're here, so welcome.
DAGMAR:
Bear with me a moment...
So, can everyone hear me okay?
Is that any better?
Okay, great.
Today I'll be talking about traditional South
Asian medicine, about Ayurveda,
which translates as the knowledge of long
life, or the science of longevity.
Ayurveda is not a trademarked word, not a
trademarked name, so it can mean different
things to different people.
You will find if you get an Ayurvedic treatment
in the U.S. it probably will be vastly different
from a treatment you would get in India in
an Ayurvedic hospital.
I will be --- It's a living tradition practiced
in India today.
The practice in India today is regulated by
the government, as is Ayurvedic education.
But I will today be speaking about the scholarly
tradition of Ayurveda, or classical Ayurveda,
which is characterized by it's texts written
mostly in Sanskrit,
a textual tradition that spans about 2,000
years.
Really, there is still literary production
up to today in this classical tradition.
I've chosen some pictures to sort of characterize
what I knew when I talk about classical Ayurveda.
So I already talked about it being a literate
tradition,
there are some print editions of some of the
major Ayurvedic works,
there are some plant materials,
probably from the 16th century onwards you
should add metals and minerals,
but sort of early Ayurveda used mostly plant
materials in therapies,
and then finally, the bottom picture, shows
a Rishi because, Ayurveda understands itself
to be a revealed knowledge.
The oldest text --- I'm going to talk a bit
about textual transmission.
I said before that it's about a 2,000 year
old tradition.
We can't be sure exactly how old it is.
The oldest text that has been transmitted
down to us is the Charaka Samhita (Carakasamhita)
the collection of Charaka, which is usually
dated to about the first century, CE.
Now the reason to date it to the first century
is sort of fairly vague,
it's because there is mention of a Charaka
at Kanishka's court, who was a doctor.
So that would have been the first century
CE,
so we think that probably the Charaka Samhita
dates to probably about that time.
However, the Charaka Samhita is the chara's
collection, which means it is a compilation
of older texts.
And indeed, the transmission history is very
complicated so that we really don't know how
old the contents of this work are.
If Charaka lived in the first century, the
text, as he compiled it, would have older
materials,
but then the texts were also redacted again
in the ninth century by Dridhabala,
so in a way it's both older and younger than
the first century CE.
The next text I'll be speaking about will
be the Sushruta Samhita,
which again is dated about the third century,
but has about the same problem as the Charaka
Samhita.
We don't know exactly when these texts were
written, of when they were compiled.
We don't know where they were written, well,
broadly South Asian continent,
so you can see how with the problems of dating
it and placing it,
it's difficult to make out a cultural context
for these texts.
But broadly speaking, they are Hindu, early
Hindu, post Vedic, but they also display a
lot of Buddhist influence.
We will come across it in my talk today.
Generally speaking, these texts are medical
texts, but they comprise a lot more than just
medicine.
They take a broad view on medicine.
So, you will find chapters on logic, on philosophy,
there will be speculations about the nature
of reality.
There are whole chapters on ethics and etiquette,
on good conduct, and I'll be talking about
those quite a lot today.
I would like to talk about a specific aspect
of Ayurvedic ethics, or Ayurvedic medical
ethics,
namely the role of honesty in the doctor patient
relationship.
In most of the Ayurvedic texts, certainly
the earliest ones, but really also the later
ones,
and I've checked texts up to the 18th century,
you will find definitions of the perfect doctor,
the ideal physician.
These are standardly formulated as the four
pillars of medicine.
So, you've got the perfect physician, the
perfect patient, the perfect medicine, the
perfect nurse, or helper.
They all read pretty much the same.
I've taken an example from Sushruta's collection.
Sushruta is a surgical text, it has a lot
of surgery.
So, some of the things about being equipped
with instruments is sort of typical for Sushruta,
but the gist of the definition is the same
in all of the works.
So, Sushruta says,
"the physician who has accurately studied
the precepts and principles of the subject,
has observed its practice and practiced himself,
who is light-handed, clean, and strong, equipped
with instruments and drugs, confident, sensible,
determined and skilled, honest and pious is
known as a pillar of treatment."
So you can see there is a very strong emphasis
on knowledge and skill, but also an emphasis,
let's say, on a good character,
an honest character; and is complimented by
the patient, who is,
"A patient who is long-lived, resolute, curable,
wealthy and also prudent, faithful, and attentive
to what the doctor says, is known as a pillar
of treatment."
So you can see the kind of relationship the
doctor and patient would have had.
It's a paternalist relationship.
This is not surprising in a text that is over
2,000 years-old.
The doctor knows best, the Ayurvedic doctor
knows best.
He's skilled, he's supposed to really know
what is best.
He gets to decide what will be done, and by
the way,
I'm saying he, now all the old texts only
speak of male physicians.
Of course today in India, there are plenty
of female physicians,
and I think actually that right now in Ayurvedic
education and colleges
there might be more female graduates than
male graduates.
But, you know, 2,000 years ago this was a
apparently not the case.
The physician decides what is best, he decides
what will be done, which information will
be given, what therapy will be done.
His decisions are not random, and they are
informed by certain rules that he has vowed
to keep.
The Ayurvedic texts, all of the older ones,
but also some of the newer ones, describe
initiation rites for the medical student,
in which the teacher tells the student how
he is supposed to behave during his apprenticeship,
but also how he is supposed to behave after
he has commenced his own practice.
In Charaka's version of this, the teacher
advice is that the student
"should speak gently, purely, justly, joyfully,
in a wholesome manner, truthfully, affectionately,
and moderately."
So he should speak truthfully.
This is not just about bedside manner.
This is supposed to be his general conduct,
how he would behave in everyday life,
as well as in the context of his practice
as a physician.
Generally speaking, the medical authors all
advocate honesty as good conduct.
I told you before that there are whole chapters
dedicated to good conduct, to healthy living,
but also to moral living.
Charaka, for example, in his collection, states
outright in a chapter on good conduct that
"one should not tell lies"
He is very vocal about it, telling lies is
bad conduct, telling the truth is good conduct.
Honesty is generally portrayed as a good thing,a
virtuous thing, it's the right thing.
It contributes to both an individual's, but
also a society's happiness and health.
We can see that a little bit from the quote
below which is from the seventh century work
called the Heart of Medicine,
Ashtanga Hridayam Samhita, attributed to an
author, or rather compiler, called Vagbhata.
"charity, good conduct, compassion, truthfulness,
celibacy, gratitude, rejuvenative therapies,
and benevolence form the virtuous group that
prolong a virtuous life" (Vagbhata 'Heart
of Medicine')
The advice about good conduct is connected,
both with health and with having a virtuous
life,
so, they are very much interlinked.
They cannot be taken away from each other.
For the medical authors, good conduct is not
just a matter of etiquette and social rules.
It's not just about how to move in polite
society,
it's really about a metaphysics that understands
human behavior to have far reaching consequences
for the individual, for society, for the environment.
To have good conduct means, for the individual,
happiness and health,
but it also contributes to society's happiness
and health, and even has consequences for
the environment.
By contrast, bad conduct, say lying, would
make an individual unhappy and would cause
disease,
and it would have similar implications for
society as a whole.
So, we can just say, honesty is important
in the Ayurvedic classes.
Honesty is part of good conduct, nobody should
lie, everybody should be honest.
The physician should be truthful, he should
be honest, he should speak truthfully.
Yet, in the Ayurvedic works, you find several
contexts in which physicians are told
that they should lie in certain circumstances,
or at least, withhold the truth or use deception
actively.
So, there are three circumstances in which
this would be the case.
The first is that they should lie to shield
patients and their relatives, or any others,
from harm.
The second would be to ensure patient compliance,
to make sure that patients would get the therapies
they need.
And the third is to bring about a certain
therapeutic effect.
And I will now explore these scenarios and
see how, or talk about,
the tension between the ethic of Ayurvedic
truthfulness and the coexisting ethic of medical
expedience.
So, my first example is really very simple,
it's about shielding patients and their relatives
from harm.
I mentioned the initiation rites for medical
students,
in which the teacher advised the student that
he should speak gently and truly and so on,
truthfully.
But in the same talk, the teacher physician
then goes on to describe the future practice
and how the apprentice,
the later physician, should behave in the
house of the patient.
There he says,
"if you know that the lifespan of the diseased
is diminished, you should not tell this in
a situation in which by speaking about it,
you would harm the diseased, or another."
(Charaka Samhita)
So, basically, there is a differentiation
between speaking truthfully and telling all
there is to tell.
So this is really about, sort of, withholding
information.
It's not exactly lying, but it is withholding
the truth.
Of course, it's based on the idea that there
would be harm if the information was disclosed.
So, it's using the concept of paternalism,
of beneficence,
according to which the wellbeing of the patient
is central to any communication
or any interaction between physician and patient.
Sort of quite simple to understand.
The second example, or context, in which a
physician can lie, or use deception is a bit
more complicated.
This is about ensuring patient compliance,
making sure that the patient gets the treatment
that he or she needs.
It occurs in the context of wasting disease,
consumption.
So, there are certain foods that are recommended
to be given to patients who suffer from wasting
disease.
These people are dehydrated, they are emaciated,
and certain meats, particular meats,
are said to be particularly nourishing and
strengthening.
We get a list of meats that are particularly
good for these patients.
The problem is that these are the exact meats
that patients would not have wanted to eat.
So, Charaka gives a list of replacement names.
So, you're giving the patient the meat they
wouldn't want to eat but you call it something
else.
And I've given the list here, but I'll read
you the passage, Charaka says:
"to one who is dehydrated he should give peacock
and other meats under the name peacock, namely
vulture, owl, and blue jay, well prepared
according to the rules.
He should give crows under the name of partridge
and fried snakes under the name of fish, as
well as earthworms under the name of fish
entrails"
--- I'm not sure fish entrails are that much
better than earthworms.
"A physician should give cooked jackals, large
mongooses, cats, and young jackals under the
name of hare.
To increase flesh he should give lions, bears,
hyenas, tigers, and meat eaters of such a
kind under the name of antelope.
To increase flesh the doctor should give the
seasoned meat of elephant, rhinoceros, and
horse in the name of buffalo."
He concludes:
"He should employ deception about those meats
that aren't liked because they are unusual,
because that way they can be eaten easily.
Knowing what it was, feeling disgusted, the
patient would not even eat, or would cause
what was eaten to come up again.
Therefore he should let such meats be administered
after they have been disguised as something
else."
Now there are many parallel passages in the
other works.
Charaka is not the only one who speaks about
that.
I've got another example, a shorter version
of the same thing in the Ashtanga Hridayam
Samhita, in the essence of medicine,
you have it in Sushruta, you have it in later
works as well.
This brings up some questions.
Who were the patients who did not want to
eat these kinds of meats?
The list of meats that are unusual include
several animals who are not actually meat
eaters.
This was supposed to be a list of meat eaters,
but we also have elephant, rhinoceros and
horse,
and perhaps you also noticed beef was not
mentioned at all.
So, beef is today thought of the sort of meat
Hindus would never want to eat.
In the Ayurvedic works beef is used a lot
as a strengthening meat and it is never discussed
at all as an ethical problem.
If we look at this list of meat eaters plus
elephant, rhinoceros and horse this seems
to be going into the direction of religious
food law.
Indeed, an 11th century commentator on Charaka's
collection called Chakra Parmita, a very important
writer, commentator, and also author in the
Ayurvedic tradition,
glosses Charaka's word unusual --- if we look
back he said that they aren't liked because
they are unusual--- he glosses this with they
are not to be eaten.
Just as a abhaksita, which is a technical
term used in religious law literature, brahmanic
law literature, early Hindu law literature.
For example we find a list of forbidden meats
in Manu's Dharmashastra, in Manu's books of
law, one of the oldest and probably one of
the most important Hindu law books,
we find a list that pretty much corresponds
to Charaka's list, and also has animals that
are not meat eaters.
I should also say before concluding that,
clearly, this is Hinduism at work, that we
also find a list in the rules of discipline
for Buddhist monks that corresponds to Charaka's
list as well.
If the meats listed in Charaka's book were
subject to food law that his contemporaries
actually adhered to, their use in therapy
should really have serious ethical implications.
You could imagine a number of problems arising.
Patients could be spiritually tainted by eating
forbidden foods.
Maybe they should do some ritual to make up
for the use of impure foods.
Maybe intentionality would have played a role.
Did they know what they were taking and does
that make a difference?
In the Sushruta Samhita, we have this in the
parallel passage.
Sushruta Samhita says,
"A man should eat meats of meat eaters according
to rule.
The flesh of one whose mind is pure grows
through meat."
And in the commentary, which was written about
2,000 years later, the commentary says,
"The meats of lions etc. are given under disguise,
thus 'of one whose mind is pure'.
"
I think that is a sort of argument in favor
of intentionality.
So this clears the patient of guilt, the guilt
of having taken an impure substance.
What about the physician?
Does this implicate the physician in committing
an offense?
First by handling impure stuffs, and then
by maybe committing a bad deed by giving it
to patients.
Well, unfortunately, the texts actually don't
discuss this at all.
We do, however, have a comment, again by Chakrapanidatta,
--- and here I've got a different print edition
of Charaka's collection because it includes
Chakrapanidatta's commentary on the Ayurveda
Dipika, Light on Ayurveda.
There Chakarapanidatta says that the rules
of Ayurveda do not teach the achievement of
righteousness, rather they teach the achievement
of health.
Now, I've got to say I don't actually agree
with Chakrapanidatta because there are these
whole sections on ethics and etiquette and
good conduct and on a virtuous life,
so I think Ayurveda, does indeed, teach a
virtuous life.
Perhaps we can understand this as what the
main aim of the physician should be, his dharma
as it were, namely to cure, or at least to
help, the patient.
Coming back to the topic of honesty though,
Chakrapanidatta has has asked a further, very
relevant, question.
I quoted Charaka before in the section on
good conduct, Charaka said do not tell a lie,
and Chakrapanidatta asked, well, before you
said do not tell a lie,
here you say we should lie about the meats,
so isn't that a contradiction?
He answers his own question by saying that
it is not a contradiction since the guilt
of speaking falsehood is incurred by speaking
an untruth that results in harming another,
but not by speaking untruly for the sake of
another's life.
In other words, truth, or rather, untruth
can be morally qualified.
It's only a vice when used to harm others,
it is acceptable when used for a good cause.
The underlying principle here is that whatever
needs to be done to ensure patient compliance,
to ensure that the patients get the treatment
they need, to ensure the success of the therapy,
may, or indeed, ought to be done.
The goal justifies the means.
We've come to the third circumstance where
the physician should use deception, or should
lie.
This is about bringing about a certain therapeutic
effect.
The context is treatment against a certain
type of madness, which is interpreted or categorized
as being, pittika,
that is associated with a humoural imbalance,
in this case the humor, pitta, or bile.
Charaka prescribes certain ways of interacting
with the patient that is part of the therapy.
Now this is a bit of a shocking read when
you read this, and I should point out that
this is not typical for Ayurvedic therapy.
This is extreme therapy used in one specific
case, in this kind of madness, about which
we might actually hear more in the next talk
by Fred Smith.
So here the prescription goes as follows,
" A friend should encourage him with words
of religious merit and wealth or, or tell
him of the death of a beloved one, or show
him surprising things.
Or, after he has been fettered and oiled with
mustard oil, one should lay him down stretched
out on the back in the sun.
--- Now, that would have been very painful.
Mustard oil really stings the skin.
Being put in the sun you would have a very
strong burning sensation, this would not be
pleasant.
"Or one should touch him with Velvet bean,
--- Velvet bean has irritant bristles, it's
like being touched by stinging nettles.
"or with heated metal, oil or water."
--- I think that needs no explanation.
"Or, having struck him with whips, one should
confine him firmly fettered in a deserted
house, for thus his confused mind comes to
rest."
The next section is a bit more relevant to
the topic of honesty.
It goes on,
"One should scare him with a snake whose fangs
have been extracted, or with tamed lions and
elephants, or with robbers or enemies holding
knives, or otherwise, royal officers"
--- Policemen
" should take the well restrained patient
outside and should scare him, threatening
to kill him on the king's order.
For the fear of one's life is thought to exceed
fears of bodily pain."
--- So this is the better treatment, hurting
him is good, scaring him his better.
"Through this his disordered mind comes to
rest."
Several other treatises describe similar treatments
and this is the accepted therapy for people
suffering from pittika unmada, pitta induced
madness.
What is happening in these treatments?
Now, apart from the initial suggestion that
a friend should encourage him with words of
religious merit and wealth,
they're all characterized by various degrees
of violence to the patient.
A low level of violence lies in the telling
of sad news.
These may be quite untrue but, true or not,
are intended to let the patient experience
anguish or strong grief.
Whipping, burning, fettering, isolating the
patient are more marked displays of violence
and the idea is to induce fear.
Fear for his life, probably.
However, the central method of treatment is
the use of threat.
Each threat, of being bitten by a snake, attacked
by lions or elephants, assaulted by robbers
or enemies, or executed by royal officers
on the king's orders,
is aimed at making the patient fear for his
life.
However, Charaka indicates quite clearly that
the threats are just that, at no time is the
patient's life actually in danger.
The fangs of the snake have been removed.
The elephants and lions are tamed.
You kind of wonder where they got those lions.
Probably robbers and enemies would not have
been at the physician's disposal or either
royal officers, so there's play acting.
As there is no true intention of harming the
patient, the threat, is therefore, an act
of deception.
The treatment's success relies on the contrasting
perspectives of the participants in this medical
drama have.
So whether the doctor or carer or royal officer
does not intend to actually commit the violent
act or to let it happen, to let harm come
to the patient,
it is crucial that the patient believes that
he does.
The violent fear that the patient experiences
is his therapy and therefore deception is
used as a therapeutic tool.
I'll come to the end.
I'll just quickly summarize again.
Honesty is really central to Ayurvedic ethics.
It's a good thing.
It's good conduct.
It has repercussions for the individual, for
society, for the environment at large.
And yet, there are certain circumstances in
which the physician really must lie, or at
least, withhold the truth in the context,
to shield the patient from harm, in the context
of giving him upsetting news,
to ensure patient compliance, making sure
the patient gets the treatment he or she needs,
and then, in the end, used as a therapeutic
tool so deception itself is the thing that
will make the patient better.
Perhaps, we can reformulate Charaka's dictum,
'one should not tell lies',
to you should not tell lies unless they are
therapeutic.
Thank you.
