|
 
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| REVIEW ARTICLE |
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| Year : 2019 | Volume
: 14
| Issue : 6 | Page : 97-102 |
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Principals of ethical ayurveda prescription writing in clinical practice: A literature review
Bharat Rathi1, Renu Rathi2
1 Department of Rasashastra and Bhaishajya Kalpana, Mahatma Gandhi Ayurveda College Hospital and Research Centre, Wardha, Maharashtra, India
2 Department of Kaumarbhritya, Mahatma Gandhi Ayurveda College Hospital and Research Centre, Wardha, Maharashtra, India
| Date of Submission | 07-Dec-2019 |
| Date of Acceptance | 27-Dec-2019 |
| Date of Web Publication | 30-Sep-2020 |
Correspondence Address:
Dr. Bharat Rathi
Department of Rasashastra and Bhaishajya Kalpana, Mahatma Gandhi Ayurveda College Hospital and Research Centre, Salod (H), Wardha, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jdmimsu.jdmimsu_213_19
Prescribing Ayurvedic herbs as a medicine for the majority of the ailments is increasing throughout the globe. It is matter of concern that Ayurveda physicians without doing thorough examination of patients as advised by Ayurveda seers are writing lengthy prescriptions, which sometimes leads to severe threats, which is considered unethical according to contemporary rules. In the present study, literature search was done in various Samhitas indicating ethics for prescribing Ayurveda medicines for patients. Ayurveda seers suggested various diagnostic tools before arriving at any diagnosis. They emphasized that an ideal drug or treatment is the one which does not lead to any side effects, while curing a disease. Great caution is warranted while prescribing medicines in children, elderly, and pregnant ladies, and it has been suggested to prescribe disease-specific drugs in limited number of combinations in proper doses with proper adjuvants. Seers also advised that dietary factors, certain habits, and lifestyle factors need to be taken into account while prescription writing.
Keywords: Ayurveda, Dashvidha pariksha, herbal medicine, prescription writing
How to cite this article:
Rathi B, Rathi R. Principals of ethical ayurveda prescription writing in clinical practice: A literature review. J Datta Meghe Inst Med Sci Univ 2019;14, Suppl S2:97-102 |
| Introduction | |  |
In Charak Samhita and Sushruta Samhita, various principles and guidelines are mentioned for ethical prescription writing to make sure the patient's health as a prime concern. According to Sushruta, a person is considered as a physician when he/she completed his/her study and training and achieved proficiency in ayurvedic practice. He/she must be skilled in diagnosis, treatment, Panchakarma (five purificatory procedures), and the effects and side effects of prescribed medicines. A medical professional should be updated periodically by attending and participating in seminars and workshops.[1] A physician must be aware of the conceptual understanding of our science along with allied sciences.[2]
Success in the treatment rests entirely upon four components of therapeutics, namely Vaidya (qualified and skilled physician), Dravya (medicaments), Upasthata (nursing personnel and attendant), and Rogi (patient), commonly known as Chikitsa Chatushpada.[3] Yet, an Ayurveda physician by his/her knowledge, practical skills, and prescribing capacity occupies the supreme position among all and expected that he/she must follow the high standard of ethics in prescription writing led down by Ayurveda seers.[4]
It is a matter of concern that Ayurveda physicians/quacks without doing thorough examination of patients as advised by Ayurveda seers write lengthy prescriptions having multiple ingredient combinations, which sometimes leads to severe threats to the patients. Ayurveda has its own unique comprehensive (pervasive) way of diagnosis and treatment which is thoroughly described in Samhitas. Hence, an attempt is made in this article to describe the various aspects (principles) of ethical prescription writing as described in Ayurveda Samhitas and its significance in clinical practice.
| Materials and Methods | | |
Relevant references were searched concerning roga (disease) and rogipariksha (clinical examination of patient) and chikitsasiddhanta (treatment principles) described in Brihatrayee, namely, Charak Samhita, Sushruta Samhita, and Astanga Hridaya and Laghutrayee, namely, Madhav Nidana, Sharangdhara Samhita, and Bhavprakash and other relevant ayurvedic texts. All the references were reviewed, compiled, analyzed, and discussed thoroughly for the in-depth understanding of the concept of diagnosis and treatment of ayurvedic medicines in clinical practice.
Review findings
The patient is a human who approaches to a physician under multiple emotional involvement such as fear, hope, and seeking relief and assurance from a physician to get rid of his/her sufferings. Considering this fact, a physician should be an attentive listener, a nonverbal communicator, and should be friendly, emphatical, and articulate.[5] Hence, a physician should try to comprehend the nature of disease and the site of its manifestation and etiological factors and should only then initiate the treatment. A physician who so initiates the treatment after having full knowledge with regard to scriptural instructions would never fail in his/her attempt to cure the disease.[6] Acharya Charaka has indicated that the patient must be examined thoroughly to obtain the knowledge of pathogenetic factors, namely Agni (digestive capacity), Bala (strength), and intensity of morbidity, and then only he/she can initiate appropriate therapy.[7] According to him, if a physician is not able to name a particular disease, he/she should not feel ashamed on that account because it is not always possible to name all types of diseases in definite terms.[8]
The following diagnostic tools are described by various Acharyas for the diagnosis of disease, which is the prerequisite for the effective administration of the principles of therapeutics (drug therapy).
Trividh pariksha (threefold examination)
Suggested by Acharya Vagbhata, it includes Darshanapariksha (inspection), Sparshanapariksha (palpation), and Prashnapariksha (interrogation).[9] Charaka has suggested three types of evidence-based examination. The learned physician, desirous of diagnosing a disease properly, should know about the disease from an authoritative person (Aptopdesh). He/she should also study the disease by direct evidence (Pratyaksha) and by applying logic (Anuman). Thus, by examining the disease from all aspects and taking into consideration all the possibilities, the physician should employ the therapy.[10]
Nidanapanchak
Acharya Madhava described five means for the diagnosis and prognosis of a disease commonly known as NidanaPanchak, namely, Nidan a (etiological factors), Purvarupa (prodromal features), Rupa (clinical features), Upasaya (therapeutic trial), and Samprapti (mode of manifestations of disease/pathogenesis).[11]
Astavidha pariksha (eightfold clinical examination)
Astavidhapariksha was described by Yog Ratnakar where he has advised to examine eight means thoroughly to arrive at a correct diagnosis. They are Nadi (pulse), Mutra (urine), Mala (stool), Jivha (tongue), Shabda (speech and sound), Sparsha (tactile), Drik (Eye), and Akriti (physique).[12]
Dashvidha pariksha (tenfold examination)
According to the strength of the illness, therapeutic measures are applied, hence Charaka has opinioned that the patient should be examined in respect of Prakriti (body constitution), Vikriti (morbidity), Sara (excellence of dhatus), Samhanan (compactness of organ), Pramana (measurement of the organs of the body), Satmya (compatibility), Satva (mental strength), Aaharshakti (power of intake and digestion of food), Vyayamshakti (power of performing work), and Vaya (aging).[7] Along with these ten elements of diagnosis, the knowledge of Updrava (complications) is also helpful in confirming the diagnosis of the diseases.[11]
Treatment principles
Since ancient times, ayurvedic medicines have been evolved with two objectives: the first one is for the preservation of health of a healthy person and second for the treatment of a sick person by maintaining the balance of deranged Doshas. Thus, ayurvedic medicine is essentially promotive and preventive in its approach. However, it also provides a comprehensive system of curative medicine for the treatment by adopting a unique holistic approach.[13] Ayurveda strongly believes that disease is nothing but the state of imbalance of doshas and treatment is the collective approach and co-ordination of physician, medicine, nursing personnel, and patient. Together, it leads to the establishment of an equilibrium of abnormal Doshas, Dhatus, and Malas (biowaste products).[14] Hence, a physician once having diagnosed the condition of a patient should prescribe the drug and its dose judiciously to attain success in the treatment. Sushruta emphasizes that an ideal therapy is the one which while curing disease does not provoke the manifestation of another disease.[15]
Here are the specified guidelines mentioned by Ayurveda seers to prescribe the drugs for the effective therapeutic management.
Nidan parivarjanam (abstinence of causative and provocative factors) is the very foremost and important principle of ayurvedic therapy. Intake of dietary substances is (Pathyasevan) beneficial to the body, therefore abstinence of etiological factors such as diet, lifestyle, and specific habits and use of substances agreeable to the body is the ideal line of management.[16] It also encompasses the idea to refrain from precipitating or aggravating factors of the disease.
According to Charaka, ayurvedic physicians must follow Yutkivyapasrayachikitsa (rational therapy) through proper Aahara (diet) and aushadhi (drugs) to pacify the disease. It shares the major part of ayurvedic therapeutics and is practiced in the doctrine of Samanya and Visesa, i.e., homologous versus heterologous.[17],[18],[19] The same treatment principle is reflected in TrividhChikitsa mentioned by Vagbhata as Hetuviprita (opposite to etiology), Vyadhiviparita (opposite to disease), and Ubhayviparita (mixed approach).[20] He also added that Basti (enemata), Virechana (purgesions), and Vamana (emesis) are best therapies and tail (oils), Ghrita (ghee), and Madhu (honey) are the best medicines for mitigating Vata,Pitta, and Kapha, respectively.[21]
Acharya Sushruta has mentioned four types of treatment which include Samshamana (palliative therapy), Samshodhana (biopurificatory therapy), Aahara (dietetic regimen), and Acara (good conduct).[22] Sushruta described VyadhiKriyakala which gives an idea about the consecutive stages of the disease and accordingly preventive measures to overcome further complications.[23] Sushruta in Chikitsasthana asserted the treatment principle which according to him maintains the homeostasis of doshas. According to him, doshas which are diminished should be nourished, those aggravated must be mitigated or pacified, and greatly exacerbated doshas should be expelled out of the body through purificatory procedures. The equilibrium state of doshas should be protected.[24] If treated at this stage, further progression of the disease is halted and disease gets cure early.
According to Charaka, there is nothing in the world which does not have therapeutic value, unless it is used in apt condition.[25] Fifty Mahakashaya[26] (decoctions), 37 Dravyagana[27] (classification of herbal drugs according to therapeutic value), and Agryasamgraha[28] (single herbal drug therapy) are the rich source of drugs mentioned in Brihatrayee. Moreover, Brihatrayee hold commendable knowledge on therapeutic applications of nearly about 500 herbal drugs and equally herbal and herbomineral formulations which are described in various chapters.[29] Physicians can wisely choose appropriate drug and formulation according to the patient's condition.
Aushadhi matra (dosages) and Anupana (adjuvant) – Ayurvedic classics specify the general dosages for the different dosage forms. Ayurveda seers emphasized that drugs should be used neither in excess nor in low dosage, but they should be prescribed appropriately keeping in view the strength of the disease and strength of the drug.[30] According to Sharangdhara, dose fixation of a drug depends on Kala (season), Agni (digestion capacity), Vaya (age), Bala (strength of person and disease), Prakriti (body constituents), and Doshas and Desh (climate and body part afflicted). There is no fixed dose of a drug because drug dose does not only depend on the status of disease, but also depend on the intelligentia of the physician.[31] Shusruta has warned the physician to take utmost care while prescribing a medicine to children. He advised to prescribe the disease-specific medicines in children in smaller doses.[32] Anupana is usually an adjuvant or fluid vehicle for the internal administration of medicaments. Ayurveda seers have advised anupana intake keeping in mind the disease condition, medicine given, and the strength of the person who consumes it. In general, anupanas are decided according to the dosha predominance.[33]
Aushadha Sevan Kala (Time of drug administration) – Ayurveda science always believed that there will be rhythmic changes in the predominance of doshas with time.[34] All the classics have explained the specific time for consumption of medicine for better treatment outcomes. Ayurvedic Acharyas (Charaka, Sushruta, and Vagbhata) have described ten times of drug administration, while in Astanga Samgraha, 11 times have been described. Acharya Sharangadhara and Bhavprakash have described five different times for the intake of ayurvedic medicines.[35] Thus, the concept of Aushadhakala is based on the fact that if the medicine given to the patient concedes with the time of the doshas, then the administered medicine will be more effective. The concept of Aushadhasevenkala is accepted in modern science as chronopharmaceutics and is being introduced into mainstream medical practice.
| Discussion | | |
Rationale of diagnostic tools
Inspection is an active process. It is done with the eye and the intellect. Even as the physician starts interrogating the patient, the inspection begins through active observation. Through inspection, physicians get aware of the color, gait, built, wasting, strength of muscles, and features of life (ayulakshana).[36] Touch in healthy and diseased states is assessed through palpation. By touching with palmer surface of the hand, the physician can feel tactile perceptions such as softness (mardava), hardness (kathinya), and coldness (shaitya) in diseases such as fever, tumor, abscess, and edema.[37] Interrogation is the beginning of a doctor–patient relationship. Getting a proper history from the patient largely depends on his/her faith in the doctor. Therefore, the doctor must put the patient at ease by his/her caring and friendly attitude and should encourage the patient to talk freely. As per Sushruta, the various information related to the patient required for reaching the diagnosis of a disease must be obtained by interrogating the patient.[38]
When the sensory organs meet with their respective sensory objects along with mind, there is a direct perception of the respective things. This is known as Pratyakshapramana (direct evidence).[39] Direct disease evidence could be obtained by direct examination of the patient with the help of sensory organs.[40] Inference (Anumana) refers to the logic based on rational.[41] Inference can be derived on the basis of earlier direct evidences, for example, appetite is referred by observing the digestive capacity, strength is referred by the exercise capacity, and bad prognosis is inferred by fatal signs.[42] A person who is devoid of all ill feelings on account of the wisdom he/she gained and who imparts the wisdom always is referred as Aapta.[43] The authoritative person or books which are known as Aapta provide unbiased knowledge and guidance by giving information on the etiology, site of pathology, specific clinical features, etc., like our teacher.[44]Yukti refers to the method to be used rationally wherever it is required.[45]
Yogratnakar advised to examine the patient by eight means for a better understanding of the pathogenesis of the disease and treatment modalities. Charaka has the opinion that the patient is the true element of examination. Patients should be examined on ten factors to assess the life span, strength of the morbid doshas, and strength of the illness. If a physician without examining the patient intensely prescribes potent drugs, it may threaten the life of the patient. Weak patients are incapable of resisting strong therapies such as medicaments dominating in Agni and Vayumahabhutas. Hence, physicians should treat the weak patient with mild and unharmful drugs.[7]
Each of the above factors mentioned by all acharyas as an examination tools have a potential role in the determination of strength and intensity of the disease and prediction about the diagnosis certain medicaments, dose, and anupana required for the patient. Vagbhata is confident by saying that the physician who minutely examine the patients and determine the condition of ten factors never go wrong in doing treatment.[46]
Rationale of Nidana Panchaka
The factor which confirms the diagnosis of disease is known as Nidana. It leads to the development as well as the diagnosis of a disease. When it leads to the development of a disease, it is referred as hetu or Vyadhijanaknidana and when it helps in diagnosis after taking into consideration the etiology, prodromal and clinical features, pathogenesis, etc., it is referred as Vyadhibodhakanidana.[47] Based on the particular etiological factor, future disease can be predicted. It also gives an idea about the prognosis of the disease. If the disease is caused by all the etiological factors, then it carries a bad prognosis.[48] Features indicating the future disease are called Purvarupa.[49] If the morbidity of the doshas is eliminated during the phase of prodromal features, they do not lead to the advanced stage. Manifestation of disease is termed as Rupa. Disease is also called syndrome as it includes many clinical features in it. When such a syndrome is well established, it leads to the diagnosis of a particular disease. Clinical features are helpful to the physician for the differential diagnosis of the diseases. It also provides a general idea about the site of pathology. Upashaya refers to the beneficial effects of diet, lifestyle, and medicine in minimizing the intensity of illness and thereby in diagnosing a disease in doubtful conditions.[50] Contrary to this, no alteration in disease status or further deterioration with the intended administration of diet, lifestyle, and medicine, is Anupshaya.[51]
Samprapti refers to the process of pathogenesis of disease, which explains how the doshas get vitiated, how they spread in the body, and how they get accumulated to produce a pathology.[52] If the morbidity of the doshas is eliminated in the initial stages, then it does not proceed to advanced stages and treatment becomes easy. As the pathology advances, treatment becomes difficult. Prodromal features give an idea about the sthansanshray stage of the disease. Hence, the knowledge of stages of pathogenesis is essential. Thus, Nidanapanchaka helps the physician to execute the therapeutic measures to be employed at various stages of the disease. For the same purpose, Sushruta described VyadhiKriyakala which gives an idea about the consecutive stages of the development of the disease and accordingly preventive measures to overcome further complications.[23]Upadrava refers to the secondary disease developed as a complication of the primary disease. Thus, complication depends on the existence of primary disease. As the primary disease gets relieved, the complication also gets treated.[53]
Rationale of Samana and Shodhan therapy
The therapeutic measures which neither eliminate nor vitiate the doshas but normalize the vitiated doshas are called SamanaChikitsa or palliative treatment. It can be applied by seven ways, namely Pachana (digestant), Dipana (appetizers), Kshudha (withstanding hunger), Pipasa (withstanding thirst), Vyayama (exercise), Aatapa (exposure to sunlight), and Vayusevan (exposure to breeze).[54] Thus, Aahara and Pathyasevan are given due importance in the Samana aspect of ayurvedic cure.
Samshodhana or shodhana therapy is an important and viable branch of Ayurveda. According to Ayurveda, the human body comprises innumerable channels (i.e., strotamsi), through which nutritional components and excretory waste products flow for proper functioning of the body, and it is essential to keep these channels intact. If they are blocked by Ama (impaired digestion) and other malas, then they can interact with doshas and Dusayas (vitiated tissues and waste products) of a particular site for a particular disease. Hence, it is mandatory to keep these channels clear and competent. Ancient seers described a number of therapeutic procedures to clean the body channels. These procedures are termed as shodhana therapy or Panchakarmas. They are Vaman (emesis), Virecana (purgation), Basti (oil and decoction enemas), Nasya (nasal insufflation), and Raktamokshana (bloodletting). Thus, by applying these purificatory measures, the body channels become clean and competent. It has been claimed that this therapy affords a permanent cure.[55] Symptoms of morbid doshas result due to accumulation of doshas in their respective site. If a physician can identify these features at an early stage of accumulation, then the morbid doshas can be eliminated in the initial stages, preventing further progression of the disease. In advance stage, the disease becomes more virulent.
Anupana provides a medium of administration with acceptability and palatability. It also helps in quick absorption and assimilation of the medicines. Sometimes, Anupanas are also used to produce an antidotal effect.
Rationale of Ahara and Pathya – Apathya (ayurvedic dietetics)
Diet and lifestyle are extremely important for the nourishment of the body and management of diseases. The extent of dietary intake depends on digestive capacity, i.e., Agnibala. That is why small quantity and easily digestible food is advised to the patient. Similar to body, diet is also made up of five basic elements, i.e., Panchamahabhuta. Diet poses all six rasas (tests), which promotes specific diversified effect of nourishment on the body. Diet deficient in any of the five basic elements/six tastes may lead to nutritional deficiency state and causes diseases in the due course of time. In this context, not only physical components of a diet are important, but accurate planning, mixing of food articles, method of preparation, quantity, method of ingestion of food, and above all good mental states are also extremely important. This is the underlying fact behind the principles of “AstavidhaAaharaVesesayatana” (dietary rules) described by Charaka[56] and “DwadasaAasanaVicara” (12 considerations during food intake) described by Sushruta[57] in ayurvedic lexicons.
Thus, disease should be diagnosed first and then rational therapeutic measures should be employed. Physician, who starts the treatment without diagnosing a disease, succeeds by chance even if he/she is an expert in medicine.[58]
| Conclusion | | |
Writing a prescription is an essential component of ayurvedic practice. In the context of Ayurveda, a prescription is a document which brings a co-ordination between physician, patient, and attendant. It also provides instructions to pharmacists and guidelines to patients. A written prescription is a health-care plan executed by a physician in the form of instructions that administrate the arrangement of care for an individual patient.
From the literature search, it is evident that exemplary medical ethics have been maintained by Ayurveda seers for diagnosis and therapeutic management, and it is expected that the present-generation Ayurveda physician follow the high standard ethics with the same zest and zeal. Patients must be examined thoroughly with the diagnostic tools to identify the status of pathogenetic factors. Prescribe only the drugs that will serve the patient's need and avoid multi-ingredient polyhedral combinations in one prescription. Drugs in prescription should be disease specific, palatable, and minimal in dose and frequency with proper anupana. Dietary instructions (pathya) and lifestyle modifications are to be reflected in the prescription, which will help to check further progression of the disease. This will reduce the economical burden on patients and boost the physician–patient compliance and provide encouraging support to herbal clinical practice.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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