Veracity in the Doctor–Patient Relationship
Veracity in the Doctor–Patient Relationship
Abstract and Keywords
This chapter discusses the paternalistic nature of the doctor-patient relationship, and what this means for a physician's attitude towards giving or withholding information from a patient. The ayurvedic treatises advocate honesty as a virtue in the physician, but at the same time recommend that he use deception in certain circumstances. Deception plays a role in preserving patients from harm and ensuring patient compliance. The ayurvedic authors, however, also describe how deception can be used directly as a therapeutic tool. The therapies involved read as extreme interventions, and the moral implications of the use of both deception and violence are discussed at some length.
LAYING OUT A framework of guidelines for professional ethics, Beauchamp and Childress, the authors of Principles of Biomedical Ethics, identify four clusters of moral principles they consider central to biomedical ethics. These are:
1. Respect for autonomy (a norm of respecting the decision-making capacities of autonomous persons)
2. Nonmaleficence (a norm of avoiding the causation of harm)
3. Beneficence (a group of norms for providing benefits and balancing benefits against risks and costs)
4. Justice (a group of norms for distributing benefits, risks, and costs fairly)414
While the principles of nonmaleficence and beneficence are firmly anchored in historical traditions of Western medical ethics (i.e., the medical ethics that has its roots in the Hippocratic medical traditions and those that developed from them), the principle of respect for autonomy marks a fundamental shift in the history of the doctor–patient relationship from medical paternalism to an emphasis on patient's rights. Medical paternalism, the dominant model of the doctor–patient relationship until well into the second half of the twentieth century, is based on the principle that a doctor should act benignly in accordance with his415 conception of the patient's needs for treatment, information, and consultation. This model rejects the notion that a patient has a right to information and hence to autonomy in judgment. In practice, this means that it is up to the doctor's discretion whether he will or will not disclose medical information to a patient or a patient's relatives or guardians, and to what extent he will do so. In a paternalistic doctor– patient relationship, the doctor may opt for comprehensive, accurate, and objective information if he judges his patient fit to receive such information. He may, however, also choose the under or nondisclosure of information, or even give false information, depending on the circumstances. Assuming that (p.125) the doctor-patient relationship is of a fundamentally benign nature, a doctor's well-considered and deliberate choice to give partial or wrong information is perfectly in accord with accepted standards of behavior in the paternalistic model. Speaking untruths, which in other contexts might be seen as morally reprehensible, becomes a correct action of positive moral value.
The Epistemology of Honesty and Lying in the Ayurvedic Classics
In the Suśrutasaṃhitā, the relationship between physician and patient is described as one that requires trust on the side of the patient and benevolence on the side of the physician. Suśruta argues as follows:
A patient may mistrust even his mother, father, children, or relatives but places trust in a doctor. He himself gives himself over, and he does not distrust him. Because of that, the physician ought to protect that patient like a son.416
Suśruta here thus postulates a special relationship between doctor and patient in which the patient's trust is justified by the paternal benevolence of the physician. A patient can trust in a physician because a physician is obliged to be benign. Indeed, according to Suśruta's reasoning, it seems that the very act of trust on the patient's side is what obliges the physician to be worthy of that trust.
As we have seen, the medical treatises standardly characterize a good doctor as someone whose professional knowledge and skills are impeccable. A good patient's key characteristic, on the other hand, is his obedience to the doctor. Obedience to the doctor implies trust in the doctor, while the emphasis on the physician's skills serves to establish the physician as one who deserves this trust. Here, then, it is not a physician's attitude toward the patient that makes him worthy of trust but his qualifications as a doctor.
Once the relationship of one who trusts and one who is worthy of trust is established, the balance of power shifts toward the physician. The patient is now meant to voluntarily submit to the physician's judgment, and in some sense to surrender control over his life to the physician. The doctor knows best—at least if he is a good doctor—and he will decide for the patient what needs to be done, while the patient is expected to comply with the doctor's instructions.
In such a top-down relationship between doctor and patient, information management, including under- and nondisclosure, deception, and lying, is a matter of the doctor's discretion. And, as we will see, that is indeed broadly the idea brought forward by the ayurvedic authors, who in some instances (p.126) advise deception as a legitimate means to shield patients and their relatives from upsetting news; to ensure patient compliance; or even to bring about a certain therapeutic effect. At the same time, however, these authors advocate honesty as a requisite virtue of a good doctor (or a good medical student) in accordance with their general instructions on good conduct (sadvṛtta). Caraka, for example, instructs unequivocally nānṛtaṃ brūyāt, “One should not lie,” in his chapter on good conduct.417
General discussions on honesty and dishonesty are usually part of a larger discourse on righteousness and unrighteousness, good and bad conduct, or healthy and unhealthy behaviors, all of which forms the backdrop against which the medical authors delineate the rules for a physician's conduct. Therefore, before we look more closely at the specifics of the role and use of honesty (and of deception or lying) in the doctor–patient relationship, we will examine the wider epistemology of honesty and lying in the ayurvedic texts. The following passages from the Carakasaṃhitā, Suśrutasaṃhitā, Aṣṭāṅgahṛdayasaṃhitā, and Aṣṭāṅgasaṃgraha were chosen for their use of such keywords as “truth” (satya), falsehood or dishonesty (anṛta), and deception (chadman and upadhā), and their connections with wider contexts.418
A passage from the Carakasaṃhitā (Ca.Vi.3.24) on the origins of disease may serve as the starting point in our exploration of the meaning of honesty and dishonesty in an ayurvedic epistemology. In this passage, set within the chapter on epidemics,419 we are projected into a faraway past that stands at the beginning of the transmission of ayurvedic knowledge, as it is passed on from the sage Punarvasu Ātreya to his disciple Agniveśa. In his lesson, Ātreya places the origins of disease in the time of the transition from the Golden Age (kṛtayuga) to the next, the Silver Age (tretāyuga).420 During this passage from one age to the next, the condition of humans and their behavior and attitudes undergo changes that transform them from perfect beings and paragons of righteousness to increasingly flawed and unrighteous beings. As one vice spawns the next, righteousness wanes and unrighteousness takes hold of the world:
At the beginning of the Golden Age, as [the elements], beginning with earth,421 were full of every good quality, grains with unimaginable properties of savor, potency, postdigestive savor, and specific action arose for those whose nature, qualities, and actions were noble.422 As the Golden Age came to an end, the bodies of some of those prosperous beings became heavy as they consumed too much. In the Golden Age, weariness developed from this heaviness of body, from weariness laziness, from laziness accumulation, from accumulation possession, and from possession greed. Then, in the Silver Age, malice issued from (p.127) greed, lying from malice, and lust, anger, arrogance, hatred, harshness, violence, fear, sorrow, grief, anxiety, distress, and so on from lying. Then, in the Silver Age, a fourth of righteousness disappeared. Because of its disappearance, there was a decrease by a fourth of the amount of rain in the age. And there was a loss of a fourth of the quality of earth and so on. A decline by a fourth of oiliness, purity, savor, potency, post-digestive savor, and specific action in the grains was caused by this loss. After that, people's bodies, not supported as they used to be through diet and lifestyle, which had lost a fourth of quality, and seized by fire and wind, were from now on overpowered by diseases like fever and so on. From that time, living beings gradually suffered a decrease of life span.
This particular account of the origin of disease is only found in the Carakasaṃhitā, but it introduces a paradigm that is nearly universal to ayurvedic literature: the connection between human action and health and longevity. From the story it appears that human conduct is a decisive element in the prevention or the propagation of disease: While humans act righteously, health and happiness prevail; when they lapse into unrighteous behavior, a chain reaction is started that ends with the spread of disease and reduced life expectancy. Lying forms a prominent part in Caraka's chain of human frailties, as it calls forth a deluge of negative emotions: lust, anger, arrogance, hatred, harshness, violence, fear, sorrow, grief, anxiety, and distress. From there, the downward spiral seems inevitable, particularly since there is no indication of agency on the part of the humans, that is, that they could choose to act or feel one way or another, righteously or unrighteously, truthfully or falsely. Rather, it seems that their vices are simply a symptom of the inherent character of the age and part of a predestined evolutionary development.
The theme of lacking agency or decision-making capacity is echoed in Suśruta's delineations of personality typologies. Using the Sāṃkhya423 concept of the three guṇas, or qualities, Suśruta categorizes persons as sāttvika (i.e., endowed with qualities associated with goodness, purity and vigor), rājasa (i.e., influenced by the agitating quality of passion), or tāmasa (i.e., affected by the qualities of darkness, ignorance, and illusion).424 Suśruta outlines the human typologies in Śā.1.18 as follows:
The [qualities] associated with goodness [sattva] are benevolence, pleasure in sharing with others, patience, honesty, righteousness, faithfulness, knowledge, intellect, understanding, mindfulness, resolution, and nonattachment. The ones associated with passion [rajas] are much unhappiness, a tendency to wandering around, irresoluteness, egotism, (p.128) falsehood, lack of compassion, deceit, arrogance, excitement, lust, and anger. Those associated with darkness [tamas] are dejection, nihilism, a tendency to unrighteousness, restraint of the intellect, ignorance, stupidity, a tendency to inactivity, and sleepiness.
This definition delineates an asymmetrical dichotomy with all that is associated with sattva on one side and all that is associated with rajas or tamas on the other. This opposition is expressed by the use of negative prefixes (dhṛti/adhṛti, jñāna/ajñāna, āstikya/nāstikya) or of semantically opposed words (satya/ānṛtikatva). Several of the characteristics on each side do not have an opposite on the other, like “pleasure in sharing” (saṃvibhāgarucitā), associated with sattva, or “habit of wandering around” (aṭanaśīlatā), associated with rajas, or “sleepiness” (nidrālutva), associated withtamas. However, without having an exact oppositein the other group, these cases still may be understood to express the qualitative difference between the concepts of sattva and rajas/tamas. It is tempting to order the listed attributes into a framework of good (i.e., belonging to sattva) and bad (i.e., belonging to rajas/tamas) qualities, as this would allow us to interpret honesty as a good quality by virtue of its association with sattva, and dishonesty as a bad quality because of its association with rajas. However, Suśruta's categorization is in itself neutral and does not explicitly state moral judgement. And indeed, in a more elaborate list of typologies (Su.Śā.4.75–94) in which Suśruta specifies seven personality types related to sattva, six related to rajas, and three related to tamas, we find attributes in the latter two categories that need not necessarily be judged negative, such as powerful (aiśvaryavat) and brave (śūra) as markers of the rajas personality. Honesty is not featured in this list as a characteristic of a sattva disposition. Neither are lying or falsehood listed as part of a rajas or tamas disposition here. However, another attribute of the same semantic category is found as a defining characteristic of one of the six rajas temperaments, the “snake's nature” (sarpasattva): being deceitful, or tricky (māyānvita).
In the Carakasaṃhitā (Śā.4.36–40), we find an analogous list of personality typologies, with seven subcategories of the first type, six that are associated with rajas and three associated with tamas. The first typology group parallels Suśruta's sattva category, but Caraka uses the term śuddha, “pure,” instead. According to Ca.Sū.1.57–58, rajas and tamas are the mental parallels (but not correlations) of the bodily doṣas wind, bile, and phlegm:
Wind, bile, and phlegm are called the bodily sum of faults. Both rajas and tamas again are described as the mental sum of faults. The former one is calmed down by medicines depending on divine and rational (p.129) [measures], the mental one by knowledge, discernment, steadfastness, mindfulness, and meditation.425
As H. Scharfe has shown, Caraka generally uses the term doṣa in a negative sense, so that by calling rajas and tamas mental doṣas, he defines them as negative qualities.426 Caraka spells this out even more clearlyin Śā.4.34, where he explains that rajas and tamas spoil the sattva (here used in the sense of “the mind”).427
According to both Caraka and Suśruta, the characteristic tendencies of each personality type become particularly prominent under the influence of intoxicating substances. In line with his general positive/negative categorization of the guṇas, Caraka interprets these tendencies as signs of a superior, inferior, oraverage nature in Cik.24.72–73: “Rain awakens grain and fire shows the nature of gold, but wine does both to all beings. As fire shows the kinds [of gold] to be superior, inferior or average, wine shows the nature of beings to be superior, inferior, or average.” This passage is followed by remarks on the typological characteristics of drinking partners, which allows the reader to conclude that Caraka is referring to the respective qualities of each personality type when he classifies persons as superior, inferior, or average.
Suśruta discusses the different reactions typologically different persons display when under the influence of alcoholic or intoxicating beverages (madya) in Sū.45.207–209, warning that persons of predominantly rajas or tamas disposition would be disagreeable drinking partners and should be shunned, if possible. According to Su.Sū.45.209, persons influenced most strongly by the qualities of tamas would, among other things, speak untruths when intoxicated: “And in a person affected by the quality of darkness [tamas], intoxication would cause uncleanliness, sleep, envy, intercourse with women who should not be approached, wantonness, and lying.” Note that in Suśruta's general introduction to the personality types, he lists speaking falsehoods as a characteristic of rajas personalities rather than of tamas personalities.
Though Caraka and Suśruta have somewhat different interpretations of the meaning and functions of the guṇas, they share the fundamental notion that the guṇas determine how a person thinks, feels, and acts. Unfortunately, they don’t explain how exactly a person comes to have his or her personality type or predominance of one psychological quality—whether they are “genetically” preordained constitutions, determined at conception or birth; or something a person acquires and thus can change during lifetime through lifestyle or mental discipline. Caraka, however, does suggest in Sū.1.57 that mental faults can be remedied through knowledge, discernment, steadfastness, mindfulness, and meditation, and thus advocates agency and choice (p.130) rather than complete predetermination of human emotion and action. Accordingly, a person of a rajas constitution may have an initial tendency or impulse toward lying but can choose not to lie, thereby diminishing the tendency itself.
Human agency and choice are central to ancient Indian medicine, which relies on a person's ability to choose a certain lifestyle, or to act on medical advice (incurable diseases and natural death being the exceptions to this rule, and the only circumstances in which a physician—and any human—must accept defeat). A human's options for actively seeking health and happiness and avoiding the opposite are laid out at length in the context of daily and seasonal regimen (a feature found in most of the ayurvedic classics), as well as in other contexts. The possibility of choice is expressed through the use of the optative in these passages. A person “should” or “ought to” (or “should not” or “mustn’t”) think, say, or do something, which clearly indicates that any of these activities is a matter of choice. Suśruta (Cik.24.90), for example, gives the following instructions in his chapter on healthy conduct (svasthavṛtta):
One should not speak what is hated by the king, harsh, slanderous, and untrue, nor should one blame gods, brahmins, and ancestors, or serve those who are hated by the king, insane, fallen [from their class], low, and inferior.
The choice implied by the use of the optative verbal mood is not necessarily a moral one, but may be quite utilitarian and meant to bring about more or less tangible results. A number of effects are on offer: happiness, wealth, and pleasure, or—perhaps more appropriate to a medical context—health and longevity. At the beginning of Cikitsāsthāna 44, Suśruta notes specifically that the chapter's instructions are about accomplishing health, indicating that any categorization of what should be done or ought not to be done is first of all based on its implication for health.
A passage in the Carakasaṃhitā (Śā.2.46) confirms the connection between conduct and health:
A man who resorts to a wholesome diet and lifestyle, who examines [everything] closely, who is not attached to the objects of the senses, who is liberal and impartial, to whom truth is paramount, who is forbearing, and who is devoted to those who are accomplished becomes free from disease.428
There are two ways of interpreting this passage. One is that good conduct (i.e., resorting to a wholesome diet, being honest, etc.) leads to or even guarantees health. The other is that the described conduct or lifestyle is not good per (p.131) se in a moral sense but good in that it is useful for attaining or maintaining health. A similar passage in the Aṣṭāṅgahṛdayasaṃhitā (Śā.3.120) connects good conduct with the prolongation of life. Here, there is a slight shift in emphasis from utilitarianism to a more moral perspective, as Vāgbhaṭa writes that the outlined conduct is a way to prolong a virtuous life, rather than just to prolong life in general: “Charity, good conduct, compassion, truthfulness, celibacy, gratitude, rejuvenative therapies and benevolence form the group that prolong a virtuous life.” A different connection between health and conduct is delineated by Caraka in his chapter on the nonsuppression of urges (na vegān dhāraṇīyam adhyāya, Ca.Sū.7.26–30), where he defines certain mental or physical actions as urges and explains that how one deals with such impulses has a direct impact on health:
However, one who desires well-being both in this world and in the next should check those urges of blameworthy recklessness in the actions of mind, speech, and body.429 A wise person should restrain the urges of greed, grief, fear, anger, and arrogance, of shamelessness, envy, excessive passion, and desire. One should check the urge to speak harshly, excessively, treacherously, falsely, and untimely when it arises. One should restrain urges to [commit] any bodily practice connected with hurting another, like illicit intercourse, theft, violence, and so on. Aman who is virtuous in word because he is faultless in the actions of mind, speech, and body is happy and enjoys and accumulates righteousness, wealth, and pleasure.
Again, the aim is well–being, as well as happiness, wealth, and pleasure. Lying is here described as an urge of “blameworthy recklessness,” clearly defining it as a negative action that has a definite detrimental effect on health as well as on other aspects of life: It is an urge (and as such innate to every human) that should be suppressed.
To summarize: From the above excerpts, it is clear that the ayurvedic authors understand honesty to be a virtue: a righteous behavior that is useful for maintaining both an individual's and society's health and happiness. Agood person is characterized by his adherence to the truth or, more generally, by his honest character. Such a person is likely to have a sattva personality, which makes him a superior being altogether. Dishonesty, on the other hand, is associated with the opposite qualities. It leads to a number of negative and hurtful emotions in the first instance, and has negative implications for the health of the individual and that of society. Lying is a characteristic of tamas or rajas personalities and as such generally an undesirable behavior. In discussions on (p.132) good conduct, instructions on honesty and dishonesty are unequivocal: one should not lie!
Finally, Caraka's definition of lying as an urge of blameworthy recklessness—probably the strongest statement one can find in the medical classics on this topic—leaves no doubt about whether lying is an unacceptable action. The reasons for its unacceptability may lie in practical consideration rather than in morality, but it is a clear and unambiguous social rule nevertheless.
And yet, as we have indicated in the introduction to this chapter, the medical authors do allow for circumstances in which it would be permissable or even desirable for a physician to lie to his patient. What seemed an absolute rule becomes less absolute and somewhat blurred when applied to the doctor-patient relationship. Here, as we will see in the following section, the concept of honesty pertains to a physician's character rather than to his actions, while truth itself is a qualifiable concept.
A Physician's Honesty: Truth, But Not the Whole Truth
There are several contexts in which a physician's honesty is discussed in the medical classics. One of these is the medical student's initiation, descriptions of which are found in the Suśrutasaṃhitā, the Carakasaṃhitā, the Aṣṭāṇgahṛdayasaṃhitā, the Aṣṭāṇgasaṃgraha and the Kāśyapasaṃhitā, as been discussed in Chapter 2. Suśruta gives particular emphasis to the virtue of honesty in his version of the initiation, calling the student to abandon untruth, and to be totally devoted to truth as part of his studentship.430
Caraka mentions honesty twice in his version of the medical student's initiation in Vimānasthāna 8.13. The first instance parallels Suśruta’a passage, relating to a medical student's behavior during his apprenticeship and describing the spartan habits he should adopt while studying with his teacher: “You should lead the austere life of a student, wearing a beard, speaking the truth, not eating meat, resorting to that which is pure, [and] unselfish, and not carrying weapons.”431 The second pertains to the medical student's behavior once he is a practising physician. He then should “speak gently, purely, justly, joyfully, in a wholesome manner, truthfully, affectionately, and moderately.”432
In the Kāśyapasaṃhitā (Vi.2[?].4), truthfulness is listed as one of the desired qualities of a pupil, but it is not mentioned in the same chapter's description of the method of practice. Finally, the Aṣṭāṇgasaṃgraha's summary of the student's initiation (Sū.2.1–7) makes no mention at all of honesty or dishonesty as a virtue required of the student or the practicing physician. (p.133)
As we have seen, Caraka is alone in demanding honesty of the practicing physician. However, the rule to “speak truthfully” is apparently not absolute, as it is followed by conflicting advice concerning communication with patients in the very same passage: “And even if you know that the life span 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.”433 This would seem to imply that Caraka differentiates between lying and withholding the truth. “Speaking truthfully” then means telling the truth, but not necessarily the whole truth. The validity of this concept of truthfulness, however, rests on a crucial assumption: When Caraka advises not to tell all that is to tell, he specifies that the disclosure of information should be subject to the potential damage a patient might suffer from hearing it. This reflects a fundamental paradigm of medical paternalism: beneficence, according to which the consideration of a patient's well-being is central to any communication or interaction between doctor and patient. Under the rules of paternal beneficence, not telling the whole truth in order to shield a patient from harm represents the ethically correct choice of action.
Ensuring Patient Compliance
In the following section, I would like to discuss a more active use of deception or untruth by the doctor as part of his therapeutic method. In the introduction to this chapter, I have stated that the medical authors propose deception as an appropriate course of action to facilitate medical treatment by ensuring patient compliance. A passage from Caraka's Cikitsāsthāna—the section on therapeutics—gives an example of how deception may be used by a physician to make sure that patients get the treatment they need. This passage has already been commented on by Francis Zimmermann in his landmark publication The Jungle and the Aroma of Meats, where he discusses it in the context of the tension in the ayurvedic classics between a therapeutic system of purity, based on nonviolence, abstinence, and vegetarianism, and a therapeutic system of force and virility, in which a certain amount of violence exists through the use of meat, purging, and so on. Counter to what one might expect from texts that position themselves within a brahmanic context, now widely associated with vegetarianism,434 the early classical medical treatises present the use of meat, either as part of diet, or as part of a medicinal preparation quite casually and do not discuss it at all as an ethical issue vis-à-vis vegetarianism or other food rules.435
Ca.Cik.8. is about therapies against consumption or wasting disease, and the passage that is relevant to our discussion provides the reader with (p.134) a list of meats that are declared particularly nourishing and strengthening for those who are emaciated and worn out. The catch is that what is considered the most nourishing type of meat by Caraka—the meat of meat-eaters (māṃsādamāṃsa)—seems to have also been regarded as an unacceptable food by his contemporaries. Thus, Caraka warns the reader that patients may refuse to eat this meat or may vomit when told what it was. To avoid this, he advises the physician to deceive the patient by presenting the carnivore's meat as the meat of a more acceptable animal and provides a list of replacement names:
One who knows the rules should give those who are dehydrated and whose flesh is wasting the prepared meat of meat-eaters, which is particularly nourishing. To one who is dehydrated, he should give peacock and other [meats] under the name of peacock: 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. 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 and hyenas, tigers, and meat-eaters of such a kind under the name of antelope. To increase flesh, the doctor should give the seasoned436 meat of elephant, rhinoceros, and horse in the name of buffalo. Valued for [its] pungent, hot, and light [properties], the meat of particular kinds of beasts and birds whose bodies are abundantly covered in meat is the best provider of flesh.
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.
This practical advice is echoed by Vāgbhaṭa in Ah.Cik.5.7:
[The meat of] vultures and birds of prey, donkeys, and camels is wholesome when prepared so as to be unrecognizable; when recognized, it is abhorred and therefore [would cause] vomiting instead of strength and vigor.
(p.135) Note how neither Caraka nor Vāgbhaṭa mentions beef, which is now the kind of meat an orthodox Hindu and particularly a brahmin would absolutely avoid.437
Suśruta also devotes a similar passage to the treatment of consumption, which he calls śoṣa rather than rājayakṣma. Su.Utt.41.35–36 and 39 have direct reference to the preparation of carnivores, as well as of some other animals. While Suśruta here does not, like Caraka, advise the physician to give particular meats under other names, he does hint at using deception when giving certain meats in Utt.41.35: “One should give [the meat of] crows, owls, mongooses, cats, earthworms, beasts of prey, hole-dwellers and moles, and vultures under various pretexts, fried in mustard oil with rock salt.” Suśruta has more to say about the meat of meat-eaters in Cik.1.82cd-83ab, where he discusses it in the context of treating patients with wounds. Here, the meat of meat-eaters is said to promote the growth of flesh—probably for covering deep wounds: “A man should eat meats of meat-eaters according to rule. The flesh of one whose mind is pure grows through meat.” Ḍalhaṇa, Suśruta's commentator, specifies meat-eaters such as lions and so on. He also explains “one whose mind is pure” (viśuddhamanas) as “one whose mind is not beset by sorrow, anger, and so on” but adds that the commentator Jejjaṭa interprets viśuddhamanas differently: “The meats of lions and so on are given under disguise, thus ‘of one whose mind is pure.’ ”438 Jejjaṭa's comment, as quoted by Ḍalhaṇa, links Suśruta's passage on the treatment of wounds and Caraka's passage on the treatment of rājayakṣma by bringing terms into context that are not actually common to these passages (i.e., viśuddhamanas occurs only in the Suśrutasaṃhitā, and chadmopahita only in the Carakasaṃhitā).439
When Caraka writes that one should give patients meats under false names, he explains that persons will not want to eat something that they are not used to (anabhyāsa). Caraka's commentator Cakrapāṇidatta brings this matter to a more complex level, when he glosses anabhyāsa, “lack of habit,” with abhakṣyatva, “not to be eaten,” a technical term found in reference to food laws of brahmanic law literature.440 And indeed, most of Caraka's items fall into the categories of forbidden foods found in Manu's Dharmaśāstra. Manu's categories also include animals that are not meat-eaters. This could explain why Caraka mentions horses and elephants in a list otherwise consisting of carnivores.441 Caraka's list of meats also corresponds to a list found in the rules of discipline for Buddhist monks in the Pāli Canon (Vinayapiṭaka, Suttavibhaṅga, Pacittiya 8.4). If the meats listed by Caraka were subject to food laws his contemporaries generally adhered to, their use in therapy would have serious ethical implications. Patients might, for example, consider themselves irredeemably spiritually tainted by the use of such substances—or they might (p.136) understand it as a minor misdemeanor, easily expiated. Intentionality might play a role in establishing whether an offense was committed: It might make a difference that the patients did not know what they were taking.442 Finally, the physician might be considered tainted by administering impure food, either through being in contact with it or by committing a bad deed through making someone else take such a food. This discussion goes beyond either Caraka's or Cakrapāṇidatta's treatment of the subject.443 This omission is somewhat surprising, given that diet is such a central concern in Ayurveda. An acknowledgment and debate of existing food laws would therefore prima facie seem a necessity. Yet Caraka's prescriptive menu of meats not only runs completely counter to brahmanic prohibitions but does this quite casually. What made such a cavalier attitude possible? It is conceivable that the religious food rules mentioned were simply of no particular importance to the society Caraka (or later Cakrapāṇidatta) lived and worked in.
A comment made by Cakrapāṇidatta in a different context (at Ca.Sū.8.29) may give a clue to why religious prohibitions may have been disregarded by Caraka: “For the rules of ayurveda do not teach the achievement of righteousness. Rather, they teach the achievement of health.”444 However, the medical authors, and Caraka among them, do on many occasions display both a knowledge of and, more important, agreement with brahmanic customs,445 and the correspondence of Caraka's list of foods to foods forbidden by Manu (or by the Buddhist Canon) is too extensive to be coincidental. Perhaps the question is which came first: the custom not to eat certain foods (and remember, it is that the meats are “uncustomary,” anabhyāsa, that Caraka refers to) or the brahmanic (or Buddhist) prohibition? Unfortunately, this question cannot be answered here, so we are left only with the observation that it does not seem Caraka's intention to link his choice of prescribed meats with religious significance or deeper meaning.
To return to the initial topic of deception, it should be noted that the passage in Caraka's Cikitsāsthāna 8 is not composed as an ethical discourse in general. While it indicates that a physician may need to make allowances for a patient's attitude or feelings toward a substance—a concern that is rarely expressed in the medical texts—it does not present this as an ethical dilemma for the physician, but simply as a matter for practical consideration. Caraka is not asking moral questions about truthfulness or whether a physician should give a substance to patients that they object to. He simply promotes deception as a tool to ensure patient compliance. However, Caraka's commentator Cakrapāṇidatta questions the moral implications of Caraka's practical advice and compares it with a statement Caraka makes in a passage on good conduct (sadvṛtta) in another part of his work (Ca.Sū.8.19). There, Caraka states (p.137) “one should not tell a lie” (nānṛtaṃ brūyāt), which leads Cakrapāṇidatta to ask whether this does not contradict what is said in Cikitsāsthāna 8.19: that one should use deception (upadhā) in saying that one animal's meat is that of another. He answers his own question as follows:
“One should not lie” should not be seen as a contradiction to the advice about speaking falsely beginning with “crows by the name of partridge” and so on in the context of royal consumption, since the guilt of speaking falsehood is incurred by speaking untruth that results in harming another, but not by speaking untruly for the sake of another's life.446
In other words, truth, or rather untruth, can be morally qualified. It is only a vice when used to harm others, and is acceptable when used for a good cause. Thus, tricking a patient into using a substance that is medically efficacious, albeit generally considered disgusting, is an act not of vice but of virtue. The underlying principle here is that whatever needs to be done to ensure patient compliance—always a key factor for the success of any therapy—may, orindeed should, be done.
We have seen how ayurvedic authors advise deception as a legitimate means to shield patients and their relatives from upsetting news, as well as to ensure patient compliance. I will now explore a third possibility: the use of deception as a tool to bring about a certain therapeutic effect.
Deception as a Therapeutic Tool
In Cikitsāsthāna 9, Caraka describes various types of madness (unmāda) and their treatment. For patients who suffer from madness categorized as paittika—associated with the humor, pitta, or bile—Caraka prescribes the following ways of interacting with the patient as part of the therapy:
Or a friend should encourage him with words of religious merit and wealth, or tell him of the death of a beloved one, or show him startling 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. Or one should touch him with velvet bean [kapikacchu],447 or with heated metal, oil, or water. Or, having struck him with whips, one should confine him firmly fettered in a deserted house, for his confused mind thus comes to rest. One should scare him with a snake whose fangs have been extracted, or with tamed lions448 and elephants, or with robbers or enemies holding knives. Or otherwise, royal officers should take the well-restrained [patient] outside and should scare him, threatening to (p.138) kill him on the king's order.449 For the fear for one's life is thought to exceed fears of bodily pain. Through this his disordered mind comes to rest.450
Ah.Utt.6.48–51, As.Utt.9.54–57, and Bhāv.Madh.8.22.39–42 copy Caraka's instructions, quoting him nearly verbatim, the former two with one variant reading each at the same place: Caraka's trāsayeyur (“they should scare”) in Cik.9.83 is replaced with bhāpayeyur, “they should intimidate,” in the Aṣṭāṅgahṛdayasaṃhitā, and again with another word in the Aṣṭāṅgasaṃgraha: bheṣayeyur, “they should make fear.” This scenario points to such treatments taking place in a courtly setting, or at least in proximity to it. This is indicated not only by the role royal officers (or persons disguising as such) play in it but also by the use of such animals as lions and elephants. These, and the lion in particular, would hardly have been easily available to normal citizens.451
However, the treatments themselves stand in striking contrast to privileges one might associate with a courtly setting, as—apart from the initial suggestion that “a friend should encourage him with words of religious merit and wealth”—they are 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 probably intended to let the patient experience anguish or strong grief. Whipping, burning, fettering, and isolating the patient are more marked displays of violence. 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, Caraka indicates fairly clearly that these threats are just that: the patient is at no time in real danger of losing his life. After all, the snake's fangs should have been removed and the lions and elephants should be tame. As for the robbers and enemies, it is very unlikely that true criminals were at the physician's disposal, so that we can safely assume that some chosen persons were to playact, pretending to be robbers with the intention of assaulting the patient with knives. The same goes for the execution threats of the royal officers, whether real or not. As there is no true intention of seriously harming the patient, the threat is in fact an act of deception. The treatment's success relies on the contrasting perspectives the participants in this medical drama have: While the doctor/carer/royal officer does not intend to actually commit the violent act or to let it happen, it is crucial that the patient believes he does. The violent fear that the patient experiences is what is meant to ultimately set his mind (which, as we must remember, is disturbed, as he is mentally ill) to rest. However, the actual mental processes that bring on this change are unfortunately not (p.139) explained by Caraka, who merely points out that the fear for one's life is an extremely powerful emotion, stronger even than the fear of bodily pain.
Similar treatments are described by Suśruta in Utt.62.17–21b:
One should show him startling things, or tell him about the death of one dear to him. One should intimidate him with men of fearful appearance, with tamed elephants and poisonless snakes. Or one should then beat him with whips, after he has been fettered with chains. Or, having restrained him, one should frighten the well-guarded one with a grass-fire. Or else one should threaten him with water, or one should pretend [to threaten him] with blows with a rope. And a strong man should guard him, and make him stand overnight in water. One should pierce him with a pointed tool [āra/ā, awl], [but] one should avoid injuring the vital points [marman]. Having entered a house, one should set that house on fire, protecting him. Or one should constantly keep him in a covered and waterless pit well.
Suśruta's suggestions for treatment are an even more startling read than Caraka's, though the basic principle is the same: deceiving the patient into believing that his life is under threat. Again, the rough and violent treatments are meant to frighten the patient but never to seriously endanger him. Interestingly, just a few sentences before (Uttaratantra 62.12), Suśruta describes how the fear for one's life, but also the loss of what is dear to one, can be the very causes of madness.452 Generally speaking, Suśruta's section on madness (unmāda) seems somewhat less structured than Caraka's treatment of the subject, which first gives the symptoms of each type of madness, followed by their remedies. While it is clear from Caraka's description that these particular fear-inducing treatments are meant for patients with paittika madness, this is not clearly categorized in the Suśrutasaṃhitā, indicating that these treatments may not have been fully understood in the latter tradition.
To conclude, in the ayurvedic classics, honesty is described as one of the qualities that define good conduct. For the medical authors, good conduct is not solely a matter of etiquette and social rules; it is part of a metaphysics that understands individual human behavior as having far-reaching consequences for the individual, for society, and for the environment at large. Bad conduct is seen as one of the root causes of illness and unhappiness in the individual, and it has similarly serious implications for human society as a whole. The medical classics offer clear categorizations of behaviors or actions as good or as bad, or rather as “to be done” or “not to be done,” each respectively associated (p.140) with health and happiness, or illness and misery. However, the classification of actions and behaviors does not necessarily translate into a moral characterization of the human beings displaying them. A certain tension is created by the medical authors between an idea of human beings as on the one hand creatures able to make moral decisions and to act on them and on the other as beings displaying tendencies to certain behaviors that are part of their nature. The former model makes humans active agents in a moral universe; the latter model places human action outside moral judgement. The question of how accountable human beings are for their actions remains somewhat unresolved by the medical authors, though the prevalent tendency displayed by them does seem to favor human agency. In fact, Caraka's admonition “one should not lie,” as indeed all of the advice given in the medical texts’ chapters on good conduct, only makes sense in the context of human agency. However, even if the premise of human agency with its potential for moral choice is accepted by the medical authors, their emphasis is never on abstract moral goals, but on the more tangible achievement of health and longevity.
Advice on good conduct in general is echoed by the medical authors’ descriptions of desirable characteristics in a medical student. Several of the medical classics describe how in the medical student's initiation ceremony, the student is called on to be honest and to abandon untruth. This rule may pertain mainly to the student's behavior toward his teacher during his apprenticeship, but it is also described as a necessary behavior for the practicing physician “who wishes for success and wealth and the attainment of fame and heaven after death.”453
Such advice is, however, contradicted, or at least somewhat reinterpreted, in the course of action proposed by Caraka in the case of a patient's imminent death. Here, he advises the physician not to tell the patient or his relatives the whole truth about the patient's condition if he considers it too upsetting for the patient. This introduces the first of the three contexts in which a physician's actions may break the general requirement of honesty, while remaining ethically correct. In the second context, physicians are advised to administer certain efficacious but disgusting meats disguised as more acceptable foods to patients. In the third context, deception is used to shock the patient into believing his life is at stake and thus to bring about the necessary changes in the patient's mental state. The role of dishonesty is different in each context. In the first, dishonesty is used to shield the patient from upsetting news. In the second, dishonesty is used to ensure patient compliance with the physician's prescription. In the third, deception is a central part of the therapeutic process: it is used as a medical tool, as it were. Each use of deception ultimately relies on the fundamental assumption that the physician has both a full understanding (p.141) of the medical situation and bears the patient's best interests in mind. Thus, the doctor–patient relationship in Ayurveda is shown to be essentially paternalistic.
As a final observation, it needs to be pointed out that while the chosen excerpts from the medical texts display a certain amount of reference to the topic of honesty and deception in the doctor–patient relationship, the classical texts lack ethical metadiscussion of this topic entirely. Only the commentators—and particularly Caraka's commentator Cakrapāṇidatta—actually problematize the ethical dilemmas facing physicians in some of the situations depicted in the classics.
(415.) For the sake of brevity, I will refer to the doctor as “he.”
(416.) Su.Sū.25.43–44. This passage is oddly placed within a chapter on the eight types of surgical operations, where it does not at all fit in with the general context. For a similar statement about the doctor-patient relationship see As.Utt.50.189: “A diligent physician should protect all patients who are suffering as he would his own children, keeping in mind knowledge and virtue.”
(417.) Ca.Sū.8.19. (p.215)
(418.) Word searches for the same keywords were also conducted in the Mādhavanidāna, the Bhāvaprakāśa, and the Śārṅgadharasaṃhitā but did not bring up any relevant results.
(420.) The translation of kṛtayuga as “Golden Age” is not literal but follows the common modern usage of the concept of the Golden Age, i.e., a utopian period of peace, prosperity and happiness in the beginnings of humanity. Similarly, tretāyuga is translated as “Silver Age,” i.e., a period regarded as notable but inferior to the Golden Age.
(421.) I.e., the five elements (mahābhūta) ether, air, fire, water, and earth.
(422.) The concepts of savor, potency, postdigestive savor, and specific action (rasa, vīrya, vipāka, and prabhāva) are used to explain the effects of drugs. Caraka defines these concepts in Sūtrasthāna 26. See also Meulenbeld (1987) for a discussion of their meanings.
(423.) Sāṃkhya is one of the six orthodox schools of classical Indian philosophy.
(425.) Cakrapāṇidatta glosses daiva, “divine,” with adṛṣṭa, “invisible,” “not experienced,” or “that which is beyond the reach of observation or consciousness,” and explains that such remedies would include the use of powerful auspicious amulets or charms, etc.
(426.) See by contrast Benner (2005a) on Ah.Sū.11.2 on the positive interpretation of the doṣas as an essential part of the body. See also Scharfe (1999) for an overview of the differences and similarities regarding the understanding of the concept of the doṣas in the medical classics and other Indian literature.
(428.) This passage is quoted nearly verbatim inAh.Sū.4.36, merely exchanging nara, “a man,” for nityam, “always.” A similar passage in the chapter on “daily regimen”(dinācārya) in As.Sū.3.82–86a omits any mention of truthfulness, though it does not seem to abbreviate otherwise, but rather to extend explanations of a good person's behavior.
(429.) Cakrapāṇidatta comments sahasā ātmaśaktim anālocyam kriyata iti sāhasaṃ, tat tu gajābhimukhadhāvanādi, “Recklessness is acting in an unpremeditated manner without having considered one's own strength, like running towards an elephant etc.”
(433.) Part of Ca.Vi.8.13.
(434.) Though note, for example, the list of forbidden foods and the chapter on eating meat in Manu's Dharmaśāstra, a major work on religious law roughly dated to between the last two centuries BCE and the first two centuries CE. Here, Manu states: “He may eat meat when it is sacrificially consecrated, at the behest of Brahmins, when he is ritually commissioned according to rule, and when his life is at risk”(Olivelle, 2005, 139). The last part of this statement is particularly important for the medicinal use of meat.
(435.) The use of meat does, however, become an issue for the later commentators, such as Cakrapāṇidatta. See Zimmermann (1999 , 192–193) and Wujastyk (2004b) for Cakrapāṇidatta's discussion of the tension between the use of meat and the ethical goal of nonviolence. It is, however, only in the Kalyāṇakāraka, a Jain medical work by Ugrāditya dated to c. the ninth century (Meulenbeld, 1999–2002, IIA, 155), that vegetarianism becomes the central focus of ethical argument. Here, animal products that can only be obtained through killing or harming an animal are replaced by vegetable or mineral substances, or by other animal products such as hair, nails, excrement, etc.
(436.) Read vesavāra, “particular condiment or kind of seasoning,” for veśavāra.
(437.) On the changing customs regarding the eating of beef by Hindus see K.T. Achaya 1998; 16–18. On the use of beef in medicine and the implications of its use for the status of physicians in ancient India, see D. Chattopadhyaya 1977, 380–387.
(438.) Vyāghrādīnām ity arthaḥ. viśuddhamanasaḥ śokakrodhādy anabhibhūtamanasa ity arthaḥ; jejjaṭas tu vyāghrādīnām māṃsāni chadmopahitāni, evaṃ viśuddhamanasa iti vyākhyānayati.
(439.) This quotation is also interesting for the reason that it represents a section of Jejjaṭa's commentarial work that is otherwise not available to us at present. It is not clear whether Ḍalhaṇa's quotation of Jejjaṭa stems from the latter's commentary on Caraka, or the one on Suśruta. According to K. Zysk (personal communication by email, Nov. 14, 2006), we don’t have the manuscript of Jejjaṭa's commentary on Ca.Cik.8.149–157. Meulenbeld in IA, 385, writes: “Jejjaṭa commented on both Caraka- and Suśrutasaṃhitā. His commentary on the latter treatise has partly been preserved, but its title is unknown.” And in note 360 of IB, 507, Meulenbeld adds: “A single MS, containing part of the commentary on the Uttaratantra, is known (NCC VII, 317; STMI 89).”
(440.) Patrick Olivelle, in his translation of Manu's Dharmaśāstra, notes that “Dharma literature makes a clear distinction between abhakṣya, foods forbidden because of their very nature, and abhojya, foods that have become unfit for a variety of reasons” (Olivelle, 2005, 278, note 5.5).
(441.) Manu's list of forbidden foods is found in chapter 5. It includes carnivorous birds (5.11), animals that wander alone (5.17), and animals with five nails (p.217) (pañcanākha, 5.17–18). Interestingly the rhinoceros, despite being categorized as having five nails and wandering alone, may be eaten. The camel is specifically mentioned as a forbidden food (see Olivelle 2005, 138–139). Zimmermann (1999, 243, note 45), referring to Bhāgavata Purāṇa III, 10, 20–24, lists the pañcanākha animals as follows: dog, jackal, wolf, tiger, cat, hare, porcupine, lion, monkey, elephant, tortoise, lizard, and makara (a kind of sea monster). Further, Manu notes in chapter 11, 157, that “The hot-arduous penance is the purification for eating the meat of carnivorous animals, pigs, camels, cocks, humans, crows or donkeys,” thus firmly placing carnivores into the list of forbidden foods (Olivelle, 2005, 223).
(442.) This, incidentally, may be what Jejjaṭa (via Ḍalhaṇa) on Su.Ci.1.82bc–83ab is hinting at when he comments that the mind remains pure because the meats are given under disguise.
(443.) Commenting on another passage, Cakrapāṇidatta discusses the question whether the physician commits an act of cruelty by recommending meat. First, Cakrapāṇidatta argues that “the masters of ayurveda do not actually recommend meat: they merely say that meat can be good for you in certain circumstances” (Wujastyk, 2004b, 836). Second, he states that the responsibility for eating meat lies with the eater, not with the doctor who recommends it (Wujastyk, 2004b, 836). However, Cakrapāṇidatta's general statements about the use of meat do not include a discussion about food categorization in a religious sense and also do not answer the question about liability in the case of a physician giving a patient something that the latter would not accept if he knew what it was.
(445.) See, for example, Benner 2009 on brahmanic fertility rituals in the Aṣṭāṅgahṛdayasaṃhitā. Zysk (2000) writes comprehensively about the use of brah-manic material in the medical texts, as does Chattopadhyaya (1977).
(446.) Cakrapāṇidatta on Ca.Sū.8.19: nānṛtaṃ brūyād ity asya rājayakṣmaṇi ‘kākāṃs tittiriśabdena’ ityādy ayathābhāṣaṇopadeśena virodho na vācyaḥ, yataḥ parāpakāraphalam asatyabhāṣaṇam anṛtavyāhāradoṣeṇa spṛśyate, na tu parasya jīvanārtham anyathābhāṣaṇam. See also Zimmermann's translation, it cannot be said that there is any contradiction[,] for false speech is only affected by the vice of lying when its effect is to harm others, and is in this case it is in order to save another's life that one does not speak the truth.” (Zimmermann, 1999 , 178).
(447.) This plant is a climber with pods that are covered with irritant bristles. See http://envis.frlht.org/plant_details.php?disp_id=1471.
(448.) Cakrapāṇidatta glosses siṃha with vyāghra, thus interpreting it as as a tiger rather than as the nonnative lion.
(449.) Cakrapāṇidatta specifies that “outside” means outside the village.
(p.218) (450.) Ca.Cik.9.79–84. This section is also described and discussed by Smith (2006, 538). Smith elsewhere (2006, 477) makes note of Caraka's categorization of madness by accountable pathological factors and madness by unaccountable invasive entities, the latter being the focus of Smith's study.
(451.) Zimmermann points this out in his discussion of the carnivore's meats that are given under disguise by the physician in Ca.Cik.8.149–157: “Fantastical prescriptions, I admit, if only because they presuppose a wholee conomic infrastructure capable of producing on demand lions, bears, hyenas, tigers, and other game—in short, a royal existence!” (Zimmermann 1999 , 176).
(452.) The same passage appears in Mādh. 20.14–15.