Dagmar Wujastyk. Well-Mannered Medicine: Medical Ethics and Etiquette in Classical Ayurveda. New York: Oxford University Press, 2012. vi + 238 pp. $99.00 (cloth), ISBN 978-0-19-985626-8; $35.00 (paper), ISBN 978-0-19-985996-2.
Reviewed by Daud Ali (University of Pennsylvania)
Published on H-Asia (March, 2014)
Commissioned by Sumit Guha
Well-Mannered Medicine represents the first serious and sustained study of ethics and etiquette within the classical ayurvedic tradition, and is a welcome addition to the growing scholarship on medicine and medical practice in early India. Overall, the book is a well-researched, systematically presented, and clearly and economically written monograph. It begins with an introduction that sets the parameters of the study, raises some general questions, introduces the various ayurvedic texts that it draws upon, and reviews the rather scant scholarship relevant to the ethics of medical practice in early India. Here the author defines ethics as the “principles of right and wrong ... accepted by an individual or social group” and etiquette as rules of behavior based on “custom and convention ... rather than moral principles” (p. 3). The question is posed as to whether it is possible to speak of a distinct and autonomous ayurvedic medical ethics as opposed to the more general principles of social ethics evident in contemporary “Brahmanical” sources, a problem which in the end the author concedes is very difficult to decide. With the apparent absence of any sustained discussion of morality itself within ayurveda, the study becomes one of reconstructing the “embedded ethics” of medical practice.
To this end, Wujastyk treats a number of subjects in a refreshingly systematic manner. She begins each chapter by introducing the topic and its relevance and then presents the evidence of the sources, often in the form of extended passages from the original texts, followed by analysis and conclusions. A notable feature of the monograph is the provision of the original Sanskrit text for all translated passages presented in the chapters of the book in a series of appendices correlated with each chapter. This retains the flow of the argument and prose within the argument without sacrificing the discerning reader’s need to peruse the original texts of the passages presented and analyzed. The chapters deal with a broad range of topics central to ayurvedic knowledge: from the most general (the so-called pillars of ayurvedic treatment, including the qualities of the physician) to those relating to his training, peer associations, and benefits, as well as those relating to the doctor-patient relationship. It is the chapters on this latter topic that conform most readily to what is understood as “medical ethics” today. These include chapters on when a doctor should and shouldn’t begin treating a patient, truthfulness in the doctor-patient relationship, and what the author calls “ethical elisions.” Wujastyk finds in her texts, particularly those treating the issue of veracity—and specifically their position that the doctor may hide the truth from a patient if doing so is in her or his greater interests—a strong inclination toward what is now termed “medical paternalism,” an ethical regime in which the physician should act benignly in the greater interests of the patient’s well-being without regard for the patient’s autonomy (as a subject with rights). Such a definition, obviously conceived from within the regime of patient rights, is seen to characterize most traditional (including European) medical systems. Wujastyk sees it as the “backbone” of ayurvedic medical ethics.
This characterization at one level does point to distinctive elements of what is deemed to be the “traditional” medicine in India, but tends to do so largely from the vantage point of modern medicine and the rights-regimes of modern societies. This is perhaps the only problem of the book, one more of theoretical perspective than evidence and analysis This is nowhere more evident than in the chapter entitled “Ethical Elisions,” treating issues that “one might expect in a study of medical ethics” but which in fact find “little or even no mention in the classical ayurvedic treatises” (p. 142). The discussion that follows, drawing on oblique and minor references to subjects like euthanasia, abortion, and contraception from a wide variety of texts, may succeed in telling us what little classical medical sources have to say on matters of contemporary significance, but they scarcely illuminate the ethical world of ayurveda itself. The conclusion that these silences constitute “elisions” presumes the transhistorical universality of modern, rights-based ethical systems. If matters like euthanasia and abortion were of little concern to the treatises, we might legitimately ask what ethical problems were of significance—and merited extended discussion, debate, and reflection on the part of the authors of the treatises. Here the earlier chapters of the book, which deal with topics that the medical sources elaborate in typical but highly revealing śāstric patterns, hold considerable promise, and more searching analyses of these passages would be a fruitful direction for further research. A key problem here is likely to be one recognition: that concerns that may not seem to us today as properly “ethical” (etiquette, for instance), might very well have been issues of considerable ethical importance to the authors of these texts. The “recuperation” of such ethical domains has, as Jeffrey Minson has pointed out, been greatly advanced in European philosophy and sociology by scholars like Norbert Elias and Michel Foucault—scholars whose focus on practice and selfhood has pointed to serious limitations in the post-Kantian ethics organized around concepts like autonomy and universalism.
My own limited work on courtly ethics in medieval India has argued for the centrality of the metaconcept of “virtue” (guṇa) in both the formation and action of ethical subjects. While such an orientation may not be entirely relevant in the ayurvedic context, in at least one case treated by Wujastyk—that of the problem of dishonesty and truthfulness—I think it provides some insight. From a virtue-based ethics, the divergence between dictums toward truthfulness and recommendations of lying presents less of a problem of ethical contradiction in the manner treated by the author, who after a segue on the “epistemology” of honesty concludes that the doctor must temporarily abrogate the exhortation to truth for the higher good of the patient’s well being. A virtue-based approach would see the problem as one of what I would call “disposition”—how one should manipulate and hierarchize the distinct but overlapping virtues of beneficence and honesty. It is precisely the skill in deploying these virtues which the treatises seek to give advice upon and which marks the superior physician. While it might seem that these two interpretations amount to much the same thing, their consequences both for the ethical individual as well as the larger systems of medical and social ethics, are quite distinct, and significant. It remains to be seen how the dynamics of a virtue-based ethics might play out in the context of doctor and patient relationships, where other ethical frameworks undoubtedly came into play. Such a perspective might also relieve the author’s anxiety regarding the relative distinctiveness of ayurvedic ethics. Can we not see the ethics of medicine at the conjuncture of different ethical strands within the societies that produced them? These more systemic questions, however, are perhaps too much to ask from the very first useful monograph on the subject of medical ethics and hardly detract from the important contribution that this book makes to the field.
If there is additional discussion of this review, you may access it through the network, at: https://networks.h-net.org/h-asia.
Daud Ali. Review of Wujastyk, Dagmar, Well-Mannered Medicine: Medical Ethics and Etiquette in Classical Ayurveda.
H-Asia, H-Net Reviews.
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