India’s Dwindling Healthcare Needs Funds, Not a ‘Charak Shapath'

(This article was published on 16 February 2022, and is being republished in the backdrop of the Dean of the Madurai Medical College being removed from the post by the Tamil Nadu government after first-year students were made to take the ‘Maharshi Charak Shapath (oath)’ instead of the Hippocratic oath at their induction ceremony on 30 April.)

“What is in a name? That which we call a rose by any other name would smell as sweet,” these famous lines from Shakespeare’s Romeo & Juliet in the context of the Charak Shapath vs the Hippocratic oath controversy, raises several questions.

Are these two oaths the same or similar? The brief answer to that is no, at least going by the versions of the Charak Shapath published by professors of Ayurveda in known Ayurvedic journals. There is no official version of the proposed oath of the National Medical Commission (NMC), from where the controversy seems to have emerged following the purported minutes of a meeting of the NMS’s Undergraduate Board held on 7 February. The meeting stated that the Hippocratic Oath will be replaced by the Maharishi Charak Shapath.

The Physicians’ Pledge

As far as names go, it is not the Hippocratic Oath that is taken by most medical students. The ‘original’ Hippocratic oath is from a 2,500-year-old text called the Corpus of Hippocrates, from Greece. The pledges taken now are mostly versions of the physicians’ pledge of the World Medical Association (WMA), of which the Indian Medical Association (IMA) is a part. The pledge was published in 1948 at the Declaration of Geneva (which is the human rights declaration of the world) post the atrocities of the second world war. It has been amended five times over the last seven decades, (the last in 2017) to keep it relevant to the present context of healthcare and society.

The pledge was developed to codify and emphasise the ethical values that should be inherent in the practice of medicine, and which had been abandoned by some physicians during and preceding the second world war. Physicians had been involved in the torture, incarceration and eugenic studies of millions of people, particularly in the concentration camps of Nazi Germany. Hence, the emphasis and importance of these lines in the pledge, “I WILL MAINTAIN the utmost respect for human life. I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat. I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient.”

Inherent Casteism

The Charak Shapath, possibly about the same antiquity as the Hippocratic corpus, starts with these lines: “The teacher then should instruct the disciple in the presence of the sacred fire, Brahmanas [Brahmins] and physicians.” It goes on to say that, “….thou shalt pray for the welfare of all creatures beginning with the cows and Brahmanas.” This is according to a translation by Professor AVR Murthy, Dean & Medical Superintendent of Atreya Ayurveda Medical College, Bangalore, published in the Journal of Vishwa Ayurved Parishad, November-December 2018. The reference to caste in relation to transmission of knowledge and medical training would be unacceptable in this day and age.

Even the ‘modified’ version doing the rounds cannot escape its casteism. It starts with, “O Dwij [twice born]! Facing the east in the presence of holy fire…” As is well-known, the term ‘twice-born’ is used to exclude Dalits & Shudras. The authors of this “modern” version resort to verbal contortions in an attempt to explain away their obvious caste bias in a footnote.

There are multiple aspects of the Charak Shapath that are not only dated but show serious prejudice. The Charak Shapath expects the physician (assumed to be male) not to treat, “those who are extremely abnormal, wicked, and of miserable character and conduct”, and similarly “women who are unattended by their husbands or guardians”. Though the ‘modified’ versions leave out most of this, it carries the part about women almost unaltered.

The regressive ideological basis of these lines comes as a shock. These values go against the present ethics of medicine, the physicians’ pledge of the WMA/NMC and the basic ideas of humanity and human rights. There are clear protocols already in place about a male doctor examining a female patient, wherein the presence of another woman is essential, be it medical staff or a woman accompanying, if not the husband, and definitely not a mandatory male “chaperone”.

The Student-Teacher Relationship

The Charak Shapath’s understanding and expectations of the student-teacher relationship are also extremely dated, hierarchical and demeaning. Sample this from a version, “Thou shalt dedicate thyself to me and regard me as thy chief. Thou shalt be subject to me and conduct thyself forever for my welfare and pleasure. Thou shalt serve and dwell with me like a son or a slave or a supplicant.”

One of the ‘modified’ versions is just marginally better, stating “During the period of my study … [I shall submit] myself to my Guru [teacher] with complete dedicated feeling. I shall act like a son/daughter for his/her welfare and happiness”. Compare this to the WMA pledge, “I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due [emphasis mine].”

Allegiance to Powers That Be

Of course, the two pledges have some similarities, like those about being dedicated to alleviating the patient’s suffering and a strong commitment to caring, accumulation and sharing of knowledge and confidentiality about the patient’s condition.

Another part of the Charak Shapath that is of significance in the present context is its pledge of allegiance to the powers that be. “No persons, who are hated by the king or who are haters of the king or who are hated by the public or who are haters of the public, shall receive treatment.”

In contrast, the modern day physician is expected to stand up to authority if it goes against humanitarian values, and not to abide or participate in it, as the WMA/NMC pledge emphasises. “I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat” – this part of the pledge was important in the Geneva declaration, as many physicians were culpable in the Nazi-led massacres and torture of Jews, Roma and other ethnic groups. This is of particular relevance in the current social climate of bigotry, hatred and violence against various communities in India and across the world.

Medical Education is in a Race to the Bottom

This brings us to the question: what if the Charak Shapath is updated to the present context? The answer to that is, there is already a well-drafted pledge that is not credited to a God or person; it is simply called ‘The Physician’s Pledge’. It was drafted by the WMA, which comprised doctors’ associations from countries across the world, including the IMA, which had participated in the drafting. Thus, it is hardly ‘foreign’.

A similar “declaration” is part of the Ethics Regulations adopted by the NMC. If anything, NMC ought to push medical colleges to use the declaration and drop the term “Hippocratic oath”. Moreover, if the pledge has to be changed, there has to be a detailed and appropriate process according to the rules of the NMC, about how to go about it. It cannot be just announced by one part of the NMC.

Is changing the name of the pledge the most important issue plaguing medicine and healthcare in India? After all, pledge or no pledge, our healthcare system is plagued by corruption and profiteering. Our healthcare indices remain at the bottom of the pile, even among lower-middle-income countries.

There is no attempt to increase investment in public healthcare. Medical education is in a race to the bottom in terms of quality, and a race to the top in terms of cost.

Expensive private medical education is an extreme form of “reservation” for the rich, which leads to the “production” of doctors who view the practice of medicine as a “return on investment”, or ‘ROI’, a favourite term for corporate hospitals. Is this not contrary to the very ethos and ethics of medicine? Does this not lead to inaccessibility and indebtedness due to healthcare costs?

Rather than addressing these real issues and challenges in India’s medical education, ethics and delivery of healthcare, a distraction in the form of a different pledge is being created.

(Dr Sumit Ray is a senior consultant in critical care medicine. This is an opinion article and the views expressed are the author's own. The Quint neither endorses nor is responsible for them.)