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The Buddhist Tradition

Religious Beliefs and Healthcare Decisions by Paul David Numrich

uddhism originated as a movement of spiritual Brenunciants who followed Gautama, a prince of the people in northern around 500 B.C.E. (before the , often designated B.C.). Legend recounts that after Siddhartha confront- ed the of old age, illness, and , he Contents renounced his privileged social position to seek spiri- Beliefs Relating to Healthcare 2 tual . Through years spent studying spiritual Overview of 3 practices and practicing disciplined he dis- Religious and covered a kind of transcendent clarity of perspective, The and 4 which is referred to as enlightenment or . The the Patient-Caregiver Relationship prince Siddhartha thereafter became known as the Family, Sexuality, and Procreation 5 (Enlightened One) and Shakyamuni ( of the ). Genetics 6 spread throughout and divided into Organ and Tissue Transplantation 7 three major branches, each with distinctive beliefs, Mental Health 8 practices, and cultural nuances: Buddhism Medical Experimentation 9 in southern and (the modern coun- and Research tries of , , , Laos, Death and Dying 9 , and ), Buddhism in Special Concerns 11 eastern Asia (, , and ), and Buddhism in (mainly ). Each major branch includes various sub-branches and groups; for instance, in China (known as ) and the Dalai ’s Gelugpa in Tibetan Vajrayana Buddhism. A volumi- nous body of scriptures developed among these Part of the “Religious Traditions and Buddhist traditions, including texts of the Buddha’s Healthcare Decisions” handbook series teachings, known as , as well as monastic dis- published by the Park Ridge Center ciplinary rules and commentaries by later religious for the Study of Health, , and Ethics authorities.1

THE PARK RIDGE CENTER In recent times Buddhism has spread outside society, differing both racially and religiously of Asia through population migration and con- from the majority population. Over Buddhism’s versions, today constituting more than 350 mil- 150-year history in America, reception has been lion people worldwide. Perhaps as many as three a mixture of hostility, primarily linked to anti- million Americans now consider themselves Asian sentiment, and fascination, as seen in Buddhists, the majority ethnic-Asian Buddhism’s attractiveness to some segments of immigrants and their descendants. Ethnic-Asian the larger population.2 Buddhists are a double minority in American

BELIEFS RELATING TO HEALTH CARE

uddhism adheres to the basic Indian , The Buddha’s most fundamental insights con- Bone shared with and , that cerned the predicament of human and human existence is part of an ongoing cycle of the way of salvation from it, insights he gained multiple lifetimes (samsara) the circumstances from personal . In his first sermon of which are governed by one’s deeds or actions following enlightenment, called “Setting in (). Death is an inevitable part of existence Motion the Wheel of the Dharma,” the Buddha and subsequent reflects the outcome of laid out the Four Noble : that life is one’s karmic dispositions, which may occur at unsatisfactory, 5 that our own cause life’s the human or another level, such as that of ani- unsatisfactoriness, that there can be cessation or mals or disembodied . Liberation from liberation from life’s unsatisfactoriness (i.e., nir- the cycle of samsara occurs through enlighten- vana), and that there is an Eightfold Path lead- ment, which is also known as nirvana or the ing to this liberation. The Buddha has been Buddha inherent in all living beings. It likened to a great physician who diagnoses the is, however, accessible only from the human underlying human dissatisfaction or “dis-ease” realm of existence. with life—which includes physical illnesses as Nirvana is impossible to explain in ordinary well as mental discomforts—isolates the cause, terms “because human language is too poor to then prescribes the cure. In ways not available express the real nature of the Absolute or to medicine, but compatible with medicine’s Ultimate which is Nirvana.”3 Buddhists concern for alleviating suffering, Buddhism believe that upon death, an enlightened person offers the ultimate remedy for human affliction.6 does not experience rebirth within samsara. All existing things have three characteristics What occurs in such cases cannot be fathomed or “marks.” The first is —change by the unenlightened , other than to say is the only constant, nothing remains that worldly existence comes to an end, along unchanged. Second, and deriving from the first, with all its unsatisfactory aspects. The in nothing contains an unchanging or core. nirvana results in a somewhat dualistic view of Therefore, human beings have no unchanging, reality for Buddhists, who distinguish between essential identity or , and there is no in the conventional realm (the samsaric world) and the Western sense of an almighty and unchang- the ultimate realm (the nirvanic perspective). ing creator who made living in the divine However, Mahayana philosophy pursued the image. The Buddha did recognize the existence conclusion that, actually, “there is not the slight- of “” or spiritual beings above the human est bit of between the two,” since the realm, but they too exhibit the three marks of samsaric world can have only apparent reality in existence. Human beings consist of five aggre- the face of an ultimate nirvana.4 gates, mental and physical strands, factors, or

2 THE BUDDHIST TRADITION: RELIGIOUS BELIEFS AND HEALTHCARE DECISIONS aspects that include the body and consciousness. ple] is not obsessed with the idea that ‘I am the The third mark of existence, unsatisfactoriness, body’ or ‘The body is mine.’ As he is not derives from the other two marks: as we attempt obsessed with these ideas, his body changes and to grasp onto that which changes continuously, alters, but he does not fall into sorrow, lamenta- ever seeking permanence in a sea of imperma- tion, pain, distress, or despair over its change nency, we create dissatisfaction in ourselves. As and alteration.”8 noted above, the explain how Buddhist tradition and iconography include to overcome this dilemma. celestial Buddhas, which are not to be confused Ancient portray the Buddha with the historical , and bod- and other enlightened notables as exhibiting hisattvas, beings that postpone their own final great mental composure under circumstances of enlightenment in order to facilitate enlighten- physical pain, even suppressing bodily illnesses ment in others. These beings carry implications in some cases. Such notables offer an ideal even for health, healing, and general well-being. Faith though the vast majority of Buddhists in all in Bhaishajya- (Master of Healing) Buddha, periods would not consider themselves capable for instance, is considered efficacious in times of of reaching such a state of enlightenment in illness and in overcoming negative effects of their lifetime. For any patient, regardless karma at death. The of the level of spiritual attainment, the textual Avalokiteshvara’s very name invokes notions of tradition encourages cultivation of a wholesome celestial care: the Who Looks Down (with mindset through contemplation of the dharma ), known in China in female form as and consideration of one’s own spiritual . Kuan-yin, which translates to the One Who These activities are portrayed as having healing Regards Cries or the One Who Hears . efficacy. The texts also distinguish two types of Many Buddhists seek the services of Buddhist pain, physical and mental, explaining that when trained in ancient Indian medical prac- a person suffering from the former adds the lat- tices known as . According to some ter, it is as if that person were shot with two scholars, Buddhist monastic practitioners played arrows instead of just one.7 Thus the Buddha a key role in the historical development of taught his monastic followers to distinguish Ayurvedic medicine, although it is usually asso- between the two: “You should train yourself: ciated with Hinduism.9 Buddhist monks also Even though I may be sick in body, my mind receive training in the use of special vers- be free of sickness. . . . [A Buddhist disci- es that carry protective and healing properties.10

OVERVIEW OF RELIGIOUS MORALITY AND ETHICS

he Fourth Noble Truth taught by the Buddha duct, not to tell falsehoods, and not to take Tdelineates the Eightfold Path to liberation. intoxicants that cause careless behavior.11 Some This path is often symbolized as a wheel with consider the principle of non-harm to living eight spokes. By cultivating each spoke, a person beings, encapsulated in the first precept, to be approaches the enlightened hub of the wheel, the of .12 The behavior of that is, nirvana. Three spokes comprise the ethi- Buddhist monks and is governed by cal aspect of the path: right speech, right action, numerous additional precepts and monastic dis- and right livelihood. Under right action we find ciplinary rules. The renunciant lifestyle of the the , the basic moral commitments Buddha and his monastic community continues incumbent upon all Buddhists: not to destroy to provide a powerful ethical ideal for many life, not to steal, not to engage in sexual miscon- Buddhist , groups, and cultures.

THE PARK RIDGE CENTER 3 Other Buddhist virtues and ethical insights sublime states will root out the fundamental impinge upon healthcare issues. Following the causes of actions in human beings, namely, example of Gautama Buddha himself, Buddhists ignorance and delusion. seek to embody and compassion in their In Buddhist ethical discourse, great emphasis own lives. A traditional subject for meditation is placed upon intent. In many circumstances, a with clear ethical connotations is the four “sub- person may not be held culpable for the tragic lime states”: loving-kindness, compassion, sym- consequences of an act performed with pure pathetic joy, and . Cultivation of these motivations.

THE INDIVIDUAL AND THE PATIENT-CAREGIVER RELATIONSHIP

lthough classical Buddhism did not develop CLINICAL ISSUES Athe modern concept of individual human rights, the notion that all persons possess the Self-determination and informed consent potential for enlightenment nevertheless offers The ancient Buddhist monastic codes offer Buddhist grounding for respect of the individ- ethical principles relevant to issues of patient ual’s inherent worth and dignity. Buddhist choice and consent. A person lacking teachings about ethical duties imply individual of what is occurring, whether through mental rights for the beneficiaries of one’s dutiful disruption or extreme physical pain, is not con- actions.13 sidered morally culpable for their actions. Also, The Buddha’s compassionate behavior as the intention underlying an action can some- attested in the ancient texts offers a model for times absolve a person of wrongdoing, as in Buddhist caregivers, both healthcare profession- cases of accidental death.15 Applying these stan- als and others. One day the Buddha and his dards, patients must have the capacity for full beloved disciple, Ananda, happened upon a knowledge of the situation to be considered suffering from acute dysentery. The two capable of giving consent, and the intentions of attended to the ill monk’s physical needs, all parties involved—patient, relatives, medical bathing him in warm water, after which the staff, researchers, healthcare administrators, and Buddha taught other monks that “He who others—must be weighed in the decision-making attends on the sick attends on me.” Another process. time the Buddha showed similar compassionate care to a monk with a repulsive affliction that Truth-telling and confidentiality had turned other monks away. The notion of right speech and the precept The Buddha also taught that a good nurse prohibiting falsehoods pertain here. Lying and should be knowledgeable of both medical proce- certain forms of speech can harm others; break- dures and the needs of the patient, and should ing the trust of confidentiality can lead to harm- perform tasks out of a sense of service rather than ful gossiping or idle chatter, expressly forbidden for the sake of salary alone. Loving-kindness and by Buddhist tradition. compassion should be guiding virtues. Moreover, Withholding the truth in certain cases may be the Buddha expected nurses to attend to a acceptable, for instance, when dealing with patient’s mental state by imparting spiritual guid- Buddhists from cultures that subsume an indi- ance through the truths of the dharma. On the vidual’s right to the truth about their condition patient’s part, the Buddha expected honest disclo- to the impact of disclosure on the general well- sure of the nature of the illness, cooperation with being of the family. the treatment plan, and forbearance of pain.14

4 THE BUDDHIST TRADITION: RELIGIOUS BELIEFS AND HEALTHCARE DECISIONS Proxy decision-making agent. These can insure follow-through on Casey Frank, a Zen Buddhist attorney in the specifically Buddhist wishes, as in treatment of bioethics field, advises Buddhists to prepare the body following death (see below under advance directives and to appoint a healthcare Death and Dying).16

FAMILY, SEXUALITY, AND PROCREATION

he Buddha established a community of full CLINICAL ISSUES Ttime renunciant followers, thus valorizing a celibate lifestyle for the unencumbered pursuit Contraception of spiritual progress. Although most Buddhists Buddhism has permitted natural contracep- marry and raise a family, they typically value tive methods like rhythm and withdrawal since renunciant ideals even in Asian cultures where ancient times. By extension, some modern no longer prevails. Buddhism’s methods may be considered permissible as long emphasis on the ultimate goal of liberation from as they do not function as . The samsara renders family issues secular, or “world- lack of clear guidance from textual sources has ly” by definition, bound by to the ongoing created disagreement over the normative cycle of existence. Since Buddhism has no anal- Buddhist stance on contraception. Buddhism ogy to the biblical injunction to be fruitful and views contraception with some ambivalence. On multiply, marriage and divorce are typically con- the one hand, since conception represents a life sidered cultural or civic rather than religious seeking rebirth, many Buddhists would be reti- affairs. Monogamous marriages and extended cent to block it; on the other hand, the lack of families are normative in Asian Buddhist cul- an imperative to procreate leads other Buddhists tures. The Buddha taught that children should to approve of contraception in certain circum- respect their parents, that parents should raise stances.19 their children properly, and that husband and wife have mutual duties and responsibilities.17 Sterilization For Buddhist monks and nuns, the third pre- The same ethical considerations apply here as cept regarding sexual misconduct is interpreted in the case of contraception, if sterilization vol- as prohibiting all sexual activity, whether hetero- untarily serves that purpose. Involuntary sterili- sexual, homosexual, or autosexual. Some zation would have to follow egalitarian protocols observers have remarked about Buddhism’s rel- and not target one group, such as the poor or atively benign attitude toward homosexuality. minorities, over others. Peter Harvey summarizes the views in Buddhism’s Asian homelands: “Homosexual New reproductive technologies activity among lay people has been sporadically Not surprisingly, given ancient Buddhism’s condemned as immoral in Southern [Theravada] valorization of renunciant , Buddhist and Northern [Mahayana and Vajrayana] texts offer little direct guidance in such modern Buddhism, but there is no evidence of persecu- issues as artificial insemination and in vitro fer- tion of people for homosexual activities. An atti- tilization (IVF). As Buddhist ethicist Damien tude of unenthusiastic has existed. In Keown observes, the feeling may have been China, there has been more tolerance, and in “that the proper purpose of medicine in the Japan positive advocacy.”18 Attitudes toward was not the satisfaction of lay desires, homosexuality among American-convert such as that of women to bear children.” Keown Buddhists appear generally liberal. concludes his discussion as follows: “We might

THE PARK RIDGE CENTER 5 sum up the Buddhist attitude to reproductive human consciousness enters the embryo or fetus technology by saying that the use of donor and the demands of Buddhist compassion in gametes would not be acceptable, and IVF using certain circumstances, such as unwanted or the couple’s gametes could only be counte- unsafe pregnancies. are performed in nanced in the simplest cases where the embryos Asian countries where Buddhism has been cul- were immediately implanted.” Such practical turally influential. The Japanese have developed restrictions would probably preclude IVF for a ritual for addressing the loss of fetal life as Buddhists, according to Keown.20 well as the associated mental anguish of the par- ents. Most Buddhists would place responsibility for the final decision about abortion with the Traditionally, abortion has been considered a pregnant woman.22 violation of the first precept against destroying life. Ancient monastic texts, for instance, Care of severely handicapped newborns expressly forbid monks from causing an abor- Handicapped human persons deserve the tion, specifying some of the common methods of same ethical considerations as others. Buddhists the day as “scorching, crushing, or the use of may consider handicap conditions to be the medicine.”21 However, debate has arisen in result of karmic predispositions, but compas- recent years regarding such issues as when sionate care would be provided nonetheless.

GENETICS

ncient Buddhist texts and commentaries proscriptions against harming life. Compassion Adefine human life as the interval between the for the suffering of one living being does not moment that consciousness arises in the embryo, justify inflicting suffering upon another sentient generally understood as conception, and the being, including animals (see below under moment of death, a period of up to 120 years.23 Medical Experimentation and Research).26 This constitutes the temporal span of human per- Barnhart suggests that Buddhism does not sonhood, though Buddhists see it as bracketed condemn genetic engineering, gene therapy, both before and after by other existences, not all cloning, and other new biotechnical procedures of which are human. Michael G. Barnhart points per se. Buddhist moral judgment would evaluate out that, in the Buddhist view, genes impinge on both motivations and consequences of particular only one of the constituent aspects of the human actions. Egocentric motives would be disap- being—the body. Thus Buddhism does not sup- proved and procedures that distract or deter a port a “hard” genetic : “The body person in their path toward enlightenment and its associated genetic endowments do not ... would be rejected.27 determine the rest of our nature in any interest- ingly lawlike manner.”24 CLINICAL ISSUES In discussing genetics and biotechnology gen- erally, the counsels compassion and Sex selection and selective abortion the non-harming of sentient beings. He also According to the Dalai Lama, gender and other rejects profit, personal preferences, and mere preferences for offspring arise from parental preju- utility as legitimate motivations for genetic dices that should not be exploited for profit.28 manipulation.25 Genetic experimentation involv- Ethical considerations about selective abortion ing the destruction of human embryos or other would follow the reasoning on abortion generally. living organisms would fall under basic Buddhist

6 THE BUDDHIST TRADITION: RELIGIOUS BELIEFS AND HEALTHCARE DECISIONS Gene therapy and genetic screening Cloning Assuming proper motivation and concern for The Dalai Lama precludes the cloning of consequences, Buddhism could approve such semi-human creatures as human “spare parts” procedures. For instance, parents may wish to factories on the principles of compassion and protect their offspring from heritable diseases non-harming.30 Should a human clone ever out of compassion and the hope that their chil- emerge, Damien Keown suggests that Buddhism dren might pursue their own “life of enlighten- would not deny the status of human individuali- ment and compassion.”29 ty to such a case.31

ORGAN AND TISSUE TRANSPLANTATION

uddhism’s emphasis on compassion and the transplants, which should not arbitrarily favor Balleviation of suffering has led some some recipients over others. The notion that all Buddhist spokespersons to encourage organ and persons possess the potential for enlightenment tissue donation upon the donor’s death. also argues for egalitarian transplant allocation However, the belief in some Buddhist traditions procedures. that consciousness remains with the body for a At the same time, Buddhists may evaluate period after physical death complicates the mat- recipients differently following transplantation ter. Many Buddhists will not allow any tamper- depending on the use to which their lives are ing with the body for three days so as not to dis- put. In some cases the recipient’s extended turb the release of consciousness as it moves human lifespan may make the most of one’s toward its new mode of existence. Of course, this potential for enlightenment or nirvana, whereas delay compromises organ and tissue harvesting. in other cases the recipient may squander that In China and Japan, where indigenous traditions opportunity by living a life of negative deeds.33 have influenced Buddhism historically, taboos Some recipients may express concern about the against desecrating the body hamper this karmic status of their transplanted organs/tissue, process.32 Generally, however, the Buddhist and may even attribute biological rejection as understanding of human existence as an aggre- indication that the donor’s karma was incompat- gation of mental and physical strands allows ible with their own.34 individuals to disassociate from the physical parts of the body, thus opening the For donors possibility of transplantation. A contemporary Vajrayana teacher suggests that some Buddhists may not be mentally pre- CLINICAL ISSUES pared to donate their organs. It is best to devel- op a mind that is strong, stable, and wise For recipients enough to understand all the implications of Buddhism’s ethical imperative of compassion organ donation procedures and the relationship has universal rather than selective scope; trans- between mind and body.35 Two contemporary plant recipients should therefore be chosen teachers from the Chan/Zen tradition have according to compassionate criteria fairly stressed the importance of the compassionate applied to all candidates. Two guidelines, right act of donation over any potential disturbance of action and right livelihood, imply just and equi- the release of the donor’s consciousness during table treatment of others that they, too, might the three-day waiting period. Buddhists may pursue happy and fulfilling lives. This has fur- sign advance directives or appoint a healthcare ther implications for the allocation and cost of agent to address post-mortem donation.36

THE PARK RIDGE CENTER 7 MENTAL HEALTH

ecades ago psychoanalysts Carl Jung and cal terms. For instance, the six defilements— DErich Fromm investigated the potential com- greed, , ignorance, pride, doubt, and false patibility of Buddhist thought and Western psy- views—can be seen as universal human neuroses chology, the latter collaborating with noted Zen beyond individual neurotic tendencies.41 The six author D.T. Suzuki. The first comprehensive realms of existence—human, animal, hell, heav- book on Buddhism in America, written by a psy- en, hungry ghosts, and jealous gods—can stand chologist in the 1970s, included a chapter enti- for various states of mind.42 tled “Buddhism, Psychology, and Psychotherapy” Buddhists attribute much mental health and which predicted increasing therapeutic use of illness to a person’s spiritual progress along the meditation.37 At the popular level this has indeed path to enlightenment. The Dalai Lama, for occurred; witness the recent profusion of self- instance, advises his readers that by “being bet- help meditation books and the increase in medi- ter grounded emotionally through the practice of tation centers.38 In Western mental health gener- patience, we find that not only do we become ally, the field of transpersonal psychology has much stronger mentally and spiritually, but we gone furthest in integrating Buddhist insights tend also to be healthier physically.” He goes on into its approach. A few Buddhist psychothera- to explain, “I attribute the good health I enjoy to pies have been imported from Asia.39 a generally calm and peaceful mind.”43 In a sense Buddhism has followed an interac- A respected Theravada Buddhist scholar- tive mind/body model of human for monk writes, “He who has realized the Truth, 2,500 years. “In Buddhist psychology and in the Nirvana, is the happiest being in the world. He is medical texts of Buddhist culture, mind and free from all ‘complexes’ and obsessions, the body are not separate,” explains Mark Epstein, worries and troubles that torment others. His Buddhist psychologist and author of the books mental health is perfect.”44 Thoughts without a Thinker and Going to Pieces without Falling Apart. “Mind extends into body CLINICAL ISSUE and body extends into mind.”40 The human being is an aggregation of one Psychotherapy and behavior modification physical and four mental strands, factors, or Most Buddhist psychotherapists consider aspects. In Buddhist understanding, “mind” is Western psychotherapy and Buddhism to be included as one of the sense organs or faculties complementary rather than incompatible, of the body—as other organs sense objects although they would argue that Buddhism deep- around us through sight, hearing, smell, taste, ens the insights of conventional psychology. Ryo and touch, the mind senses mental objects such Imamura, a Japanese-American Buddhist priest- as thoughts, ideas, and imagination, and also therapist, sees Buddhist psychotherapy as “an interprets and assimilates input from the physical expansion of Western psychotherapy. It appends sense organs. Such input affects our thoughts. dimensions of compassion and nonduality to the Buddhism places great emphasis on the mind’s rational clarity and precision of Western psy- ability to control various states of health, both chotherapy.” Imamura gives the example of physical and mental. Clarity of mind is essential; human suffering and : both Western meditation helps achieve it. This is underlined by and Buddhist psychotherapies seek to relieve the prohibition against intoxication in the fifth suffering and enhance happiness, but only the precept. Buddhist approach reveals the true meaning of Ancient Buddhist beliefs and mythological suffering and offers the “complete transforma- views can be interpreted in modern psychologi- tion” necessary to attain true happiness.45

8 THE BUDDHIST TRADITION: RELIGIOUS BELIEFS AND HEALTHCARE DECISIONS Electroshock and stimulation Psychopharmacology Considerations of compassion and non-harm Buddhists would want clouding of the mind would enter into decisions about use of any pro- kept to a minimum in pharmacological therapy. cedure that would cause pain to a patient.

MEDICAL EXPERIMENTATION AND RESEARCH

he key ethical consideration here concerns good of life and a breach of the first precept. If Twhether a particular experiment or research the goal is theoretical knowledge, it would procedure violates Buddhism’s first precept amount to the subordination of life to knowl- against destroying life and the principle of non- edge, and as with any instrumentalisation [sic] harm to living beings. If so, even the purported of a basic good would be impermissible.” Keown benefits of alleviation of suffering would be out- notes that the Buddhist position makes no ethi- weighed by these fundamental Buddhist ethical cal distinction here between animated and imperatives. unanimated embryos.46 Likewise, Buddhist ethi- cal prescriptions about human research apply CLINICAL ISSUES equally to animal research since animals are sentient beings that suffer pain. “What about Damien Keown’s summary of the Buddhist issues like vivisection,” asks the Dalai Lama, position on human embryo experimentation can “where animals are routinely caused terrible suf- be generalized to similar kinds of research: “In fering before being killed as a means to further- Buddhist terms, destructive experimentation on ing scientific knowledge?” To a Buddhist, he embryos represents a direct assault on the basic answers, such practices are “shocking.”47

DEATH AND DYING

ccording to Buddhism, death for the vast grief so as to encourage an auspicious mindset Amajority of people falls within the cycle of for the transition. Some Buddhist patients may samsara as a passage to rebirth into a new life attest to visions or intimations of the circum- form, another change amidst the impermanence stances of their next rebirth. Buddhist of existence that is governed by one's own often chant bedside blessings or protective ritu- karmic dispositions. Although penultimate in als, and dying patients may wish to meditate or this sense, human life is nevertheless highly val- to contemplate sermons on the dharma.48 ued as the only possible venue for the ultimate Buddhism recognizes that the person is not goal of enlightenment, the final liberation for the body—the body being only one of five aggre- those who attain it. Dying Buddhist patients may gates comprising a human being—thus the body ponder their progress—or lack of it—along the is not sacred in some sense at death. Neither is path toward final liberation, and may experience the person essentially a soul, since Buddhism anxiety about being reborn into less desirable does not recognize such an entity. At death a human circumstances or even as a lower life person's aggregated organism disassembles, to form. Discussion of impending death is not typi- be reassembled in the next rebirth—or not, in cally avoided, though positive thoughts and the case of the enlightened few. encouragement are preferred over sadness or

THE PARK RIDGE CENTER 9 CLINICAL ISSUE Foregoing life-sustaining treatment In discussing the case of patients in a Determining death Persistent Vegetative State (PVS), Damien Little scholarly or ethical attention has been Keown notes that the Buddhist prohibition paid to constructing a Buddhist definition of against destroying life does not imply an impera- death in the light of modern biomedical issues.49 tive to prolong life in all circumstances. “There Basing his view on the ancient Buddhist notion is no obligation, for example,” Keown writes, “to of death as the disaggregation of the human connect patients to life-support machines simply organism, Damien Keown suggests that to keep them alive.” 54 PVS patients should con- Buddhism conceives of death as “the irre- tinue to receive nutrition and hydration, Keown versible loss of integrated organic functioning.” explains, since such patients have not suffered Thus Buddhism’s criterion for individual death brain stem death and are therefore still alive.55 is irreversible brain stem death, since the brain “There would, however, be no requirement to stem controls integrated organic functioning.50 treat subsequent [medical] complications.”56

Pain control and palliative care Suicide, assisted suicide, and euthanasia Buddhism’s emphasis on clarity of mind— Despite examples of suicide and other types recall the fifth precept eschewing intoxicants— of voluntary death by religious notables in may lead some Buddhists to forego pharmaco- ancient texts, Buddhism generally condemns logical palliation in order to maintain mindful- deliberate attempts to end one’s own life. This ness in the midst of pain and the dying process. prohibition extends to any agent, such as a On the other hand, Buddhists may approve of physician, who assists another’s suicide—the pharmacological palliation as an expression of texts label such an agent a “knife-bringer”—or compassion for physical suffering. even encourages it out of compassion for tragic Improvements in pain management that mini- circumstances.57 Based on this Phillip Lecso mize mental impairment have been welcomed.51 argues that Buddhism advocates hospice care Buddhist patients may also attempt alleviation of over euthanasia.58 As to the latter, Peter Harvey physical and mental pain through concentrated observes that “Euthanasia scenarios present a mental efforts in meditation or through ceremo- test for the implications of Buddhist compas- nial acts. sion, but the central Buddhist response is one of Some Buddhist-influenced hospice and other aiding a person to continue to make the best of programs for the dying have emerged in recent his or her ‘precious human rebirth’, even in very years, including the Zen Hospice Project in San difficult circumstances.”59 Francisco (http://www.zenhospice.org) and the work of Buddhist teacher in Santa Autopsy and post-mortem care Fe, New Mexico (http://www.peacemakercommuni- Post-mortem care of the body should be kept ty.org). A small study of women in Thailand indi- to the barest minimum, and, if possible, an cated that “meditation can be a useful interven- autopsy should be delayed for three days due to tion to support women with HIV/AIDS and to the Buddhist belief in the slow release of con- provide a measure of control, to enhance their sciousness from the body (see above under immunological response to stress, to reduce the Organ and Tissue Transplantation). Buddhist side effects of treatment, and to diminish anxiety texts are often recited or chanted at death, and fear.”52 The Dalai Lama counsels that wis- though not necessarily in the presence of the dom might dictate submitting to the karmic body. Buddhist clergy usually officiate at these manifestations of physical suffering at the end of . In fact, officiating at the occasion of this life rather than face their prolongation into death became the special province of monks in the next life.53 many parts of Asia.

10 THE BUDDHIST TRADITION: RELIGIOUS BELIEFS AND HEALTHCARE DECISIONS Burial and mourning traditions may raise concerns over the destination of cer- Decorum in the face of death is typical and tain individuals. is the traditional does not necessarily indicate lack of either con- method of final disposition, following the three- cern or grief. The Buddhist beliefs about imper- day waiting period. Departed ancestors are peri- manence and multiple lifetimes tend to create a odically remembered and revered by family, stoic regard for the passing of a person from the especially in those Asian cultures influenced by present existence, though the belief in karma Chinese traditions.

SPECIAL CONCERNS

he multiple expressions of Buddhism in these dietary restrictions. Drugs that include TAmerica call for sensitivity to variations in intoxicants as ingredients are generally avoided beliefs, practices, and cultural nuances among unless overriding medical benefits are indicated. Buddhist patients and others involved in health care. The major distinction between the so- Religious rituals and observances called “two Buddhisms” of America deserves Buddhism is primarily an individual and fam- special attention. Due to immigration and con- ily oriented , although regular congrega- version patterns in American history, we find, on tional gatherings have become more common in the one hand, Buddhists whose faith is an the United States as immigrants adopt the typi- expression of their cultural heritage as Asians cal American style of religion. The concept of and, on the other hand, non-Asian Buddhists “” does not capture the religious experi- who converted to Buddhism as adults. ence of most Buddhists, who instead practice Buddhism fulfills a different sociological func- meditation or a ritual of the histori- tion for each group—affirming ethnic identity in cal Gautama Buddha and various celestial Asian-American Buddhists and transforming Buddhas and . Candles, incense, perspective and self-identity in non-Asian con- flowers, gongs or bells, sacred and paint- verts.60 Within each of these “two Buddhisms,” ings, beads, meditation cushions, and other ritu- of course, variations of expressions and under- al accoutrements may be used. Chanting, dhar- standings also exist. ma sermons, and reading/reciting of scriptural and liturgical texts are common practices. Each Diet and drugs Asian culture celebrates its own set of religious Although the first precept against destroying festivals, most tied to the lunar calendar. Special life and the ethical imperative of non-harming importance is attached to the observation of the imply an ideal of , most Buddhists historical Buddha’s birth (Wesak, observed in do not practice this ideal. Some Buddhist clergy the Mahayana tradition, usually in March/April) and may prefer vegetarian meals as a mat- or combined birth/enlightenment/death ter of piety, and a few Buddhist groups may (Visakha, observed in the Theravada tradition, expect their members to follow the ideal. Most usually in May). An important cultural festival is Buddhist monks and nuns are restricted by New Year’s, held at various times depending on monastic disciplinary rules to two meals per day, the Asian culture. These occasions draw large to be completed before noon. After noon they numbers of Buddhists and others to may consume liquids and soft foods that do not activities across the United States. require chewing. Pious laity taking at certain times of the year may also adopt

THE PARK RIDGE CENTER 11 NOTES

1. See, e.g., William Theodore de Bary, ed., The Buddhist 14. de Silva, “Ministering to the Sick and the Terminally Tradition in India, China, and Japan (New York: Ill.” Vintage Books, 1972); Thanissaro , The Buddhist Monastic Code (Valley Center, California: 15. Peter Harvey, “ Principles for Assigning Degrees , 1994). For the sake of con- of Culpability,” Journal of Buddhist Ethics, 6 (1999), venience I have deleted diacritical marks in foreign 271-291. terms and have not distinguished the languages from which these terms come (usually and ). 16. Casey Frank, “Living Organs and Dying Bodies,” Tricycle: The Buddhist Review, 7.1 (Fall 1997), 76-77. 2. Paul David Numrich, et al., “Buddhists in America: Following a Different Religious Path,” Buddhists, 17. Paul D. Numrich, Health, Marriage, and Family in , and Sikhs in America, Religion in American Selected World : Different Perspectives in a Life series (New York: , forth- Pluralist America, Marriage, Health, and the coming). Professions: The Implications of New Research into the Health Benefits of Marriage for Law, Medicine, 3. Walpola Rahula, What the Buddha Taught, 2d and Ministry, Therapy, and Business, Don Browning, enlarged ed. (New York: Grove Press, 1974), 35. William Doherty, Steven Post, and John Wall, eds. (Grand Rapids, Michicagan: Eerdmans, 2001). Also, 4. The quote is from the eminent second century see on Sexuality (: The Park Mahayana , cited in Peter Ridge Center for the Study of Health, Faith, and Harvey, An Introduction to Buddhism: Teachings, Ethics, forthcoming). History and Practices (New York: Cambridge University Press, 1990), 103. 18. Peter Harvey, An Introduction to Buddhist Ethics: Foundations, Values and Issues (Cambridge, : 5. The common translation for the term dukkha in the Cambridge University Press, 2000), 434. First Noble Truth is “suffering,” but that does not carry the full weight of meaning. Dukkha refers to 19. Keown, Buddhism and Bioethics, 128-132. life's fundamental unsatisfactoriness, which we readily acknowledge in times of suffering but also experience 20. Keown, Buddhism and Bioethics, 126, 136. in the best times of life, which do not last forever and leave us wanting more. 21. Keown, Buddhism and Bioethics, 93-94.

6. Damien Keown, Buddhism and Bioethics (New York: 22. Phillip A. Lecso, “A Buddhist View of Abortion,” St. Martin’s Press, 1995), 1-2. Journal of Religion and Health, 26.3 (Fall 1987), 214- 218; Michael G. Barnhart, "Buddhism and the 7. Lily de Silva, “Ministering to the Sick and the Morality of Abortion," Journal of Buddhist Ethics, 5 Terminally Ill,” Bodhi Leaves series, BL 132 (Kandy, (1998), 276-297; Damien Keown, ed., Buddhism and Sri Lanka: Buddhist Publication Society, 1994). Abortion (Honolulu: University of Hawaii Press, 1999); William R. LaFleur, Liquid Life: Abortion and 8. Quoted in Tricycle: The Buddhist Review, 7.1 (Fall Buddhism in Japan (Princeton, N.J.: Princeton 1997), 37. University Press, 1992); Harvey, Introduction to Buddhist Ethics, 328-341. 9. Keown, Buddhism and Bioethics, 3. 23. Keown, Buddhism and Bioethics, 93-94. 10. Harvey, Introduction to Buddhism, 180-182. 24. Michael G. Barnhart, “Nature, Nurture, and No-Self: 11. Paul D. Numrich, “Posting Five Precepts: A Buddhist Bioengineering and Buddhist Values,” Journal of Perspective on Ethics in Health Care,” The Park Ridge Buddhist Ethics, 7 (2000), 131. Center Bulletin (November/December 1999), 9-11. 25. His Holiness The Dalai Lama, Ethics for the New 12. Damien Keown, Buddhism: A Very Short Introduction Millennium (New York: Riverhead, 1999), 155-157. (New York: Oxford University Press, 1996), 10. 26. Dalai Lama, Ethics for the New Millennium, 157; 13. Keown, Buddhism: A Very Short Introduction, 109-112. Keown, Buddhism and Bioethics, 120.

12 THE BUDDHIST TRADITION: RELIGIOUS BELIEFS AND HEALTHCARE DECISIONS NOTES

27. Barnhart,“Nature, Nurture, and No-Self,” 138. 45. Imamura, “Buddhist and Western Psychotherapies,” 231. 28. Dalai Lama, Ethics for the New Millennium, 156. 46. In the Buddhist view, an embryo is “animated” when 29. Barnhart, “Nature, Nurture, and No-Self," 141. human consciousness arises in it, usually understood to occur at conception. An “unanimated” embryo has 30. Dalai Lama, Ethics for the New Millennium, 156-157. not been infused with human consciousness or has lost it in some way. Keown, Buddhism and Bioethics, 31. Keown, Buddhism and Bioethics, 90. 120-122.

32. Keown, Buddhism and Bioethics, 158; Karma Lekshe 47. Dalai Lama, Ethics for the New Millennium, 157. Tsomo, “Opportunity or Obstacle? Buddhist Views on Organ Donation,” Tricycle: The Buddhist Review, 2.4 48. de Silva, “Ministering to the Sick and the Terminally (Summer 1993), 34-35. Ill.”

33. Tsomo, “Opportunity or Obstacle?” 49. James J. Hughes and Damien Keown, “Buddhism and Medical Ethics: A Bibliographic Introduction,.” 34. See S. H. J. Sugunasiri, “The Buddhist View Journal of Buddhist Ethics, 2 (1995), 105-124. Concerning the Dead Body,” Transplantation Proceedings, 22.3 (June 1990), 948. 50. Keown, Buddhism and Bioethics, 158.

35. Tsomo, “Opportunity or Obstacle?” 34. 51. Patricia Anderson, “Good Death: Mercy, Deliverance, and the Nature of Suffering,” Tricycle: The Buddhist 36. Frank, “Living Organs and Dying Bodies.” Review, 2.2 (Winter 1992), 36-41.

37. Emma McCloy Layman, Buddhism in America 52. Barbara Dane, “Thai Women: Meditation as a Way to (Chicago: Nelson-Hall, 1976), chapter 10. Cope with AIDS,” Journal of Religion and Health, 39.1 (Spring 2000), 19. 38. Don Morreale, ed., The Complete Guide to Buddhist America (Boston: Publications, Inc., 53. Dalai Lama, Ethics for the New Millennium, 155. 1998). 54. Keown, Buddhism and Bioethics, 167; emphasis in 39. Ryo Imamura, “Buddhist and Western original. Psychotherapies: An Asian American Perspective,” The Faces of Buddhism in America, Charles S. Prebish and 55. Keown, personal communication. Kenneth K. Tanaka, eds. (Berkeley: University of California Press, 1998), 230-231. 56. Keown, Buddhism and Bioethics, 167.

40. Cited in Kate Prendergast, “Opening the Doors of 57. Keown, Buddhism and Bioethics, 58-60, 168-187; : Buddhism and the Mind: An Interview Damien Keown, “Attitudes to Euthanasia in the Vinaya with Mark Epstein,” Science and Spirit Magazine, 11.1 and Commentary,” Journal of Buddhist Ethics, 6 (March/April 2000), 33. (1999), 260-270.

41. Imamura, “Buddhist and Western Psychotherapies,” 58. Phillip A. Lecso, “Euthanasia: A Buddhist 234. Perspective,” Journal of Religion and Health, 25.1 (Spring 1986), 51-57. 42. Prendergast, “Opening ,” 32. 59. Harvey, Introduction to Buddhist Ethics, 309. 43. Dalai Lama, Ethics for the New Millennium, 106. 60. Paul David Numrich, “How the Swans Came to Lake 44. Rahula, What the Buddha Taught, 43. Venerable Michigan: The Social Organization of Buddhist Rahula's gender-exclusive writing style should not be Chicago,” Journal for the Scientific Study of Religion, taken literally. The Buddha recognized women's ability 39.2 (June 2000), 189-203. to reach enlightenment.

THE PARK RIDGE CENTER 13 REFERENCES

Patricia Anderson. “Good Death: Mercy, Deliverance, and Ryo Imamura. “Buddhist and Western Psychotherapies: An the Nature of Suffering.” Tricycle: The Buddhist Asian American Perspective.” The Faces of Buddhism Review, 2.2 (Winter 1992), 39-42. in America. Charles S. Prebish and Kenneth K. Tanaka. eds. (Berkeley: University of California Press, Michael G. Barnhart. “Buddhism and the Morality of 1998), 228-237. Abortion.” Journal of Buddhist Ethics, 5 (1998), 276- 297. Damien Keown. “Attitudes to Euthanasia in the Vinaya and Commentary.” Journal of Buddhist Ethics, 6 (1999), ——— “Nature, Nurture, and No-Self: Bioengineering and 260-270. Buddhist Values.” Journal of Buddhist Ethics, 7 (2000), 126-144. ——— ed. . Honolulu: University of Hawaii Press, 1999. William Theodore de Bary, ed. The Buddhist Tradition in India, China, and Japan. New York: Vintage Books, ——— Buddhism and Bioethics. New York: St. Martin’s Press, 1972. 1995.

Thanissaro Bhikkhu. The Buddhist Monastic Code. Valley ——— Buddhism: A Very Short Introduction. New York: Center, Calif.: Metta Forest Monastery, 1994. Oxford University Press, 1996.

Barbara Dane. “Thai Women: Meditation as a Way to Cope William R. LaFleur. Liquid Life: Abortion and Buddhism in with AIDS.” Journal of Religion and Health, 39.1 Japan. Princeton, N.J.: Princeton University Press, (Spring 2000), 5-21. 1992.

Casey Frank, “Living Organs and Dying Bodies,” Tricycle: Emma McCloy Layman. Buddhism in America. Chicago: The Buddhist Review, 7.1 (Fall 1997), 76-77. Nelson-Hall, 1976.

His Holiness The Dalai Lama. Ethics for the New Phillip A. Lecso. “A Buddhist View of Abortion.” Journal of Millennium. New York: Riverhead Books, 1999. Religion and Health, 26.3 (Fall 1987), 214-218.

Peter Harvey. An Introduction to Buddhism: Teachings, ——— “Euthanasia: A Buddhist Perspective.” Journal of History and Practices. New York: Cambridge University Religion and Health, 25.1 (Spring 1986), 51-57. Press, 1990. Don Morreale, ed. The Complete Guide to Buddhist ——— An Introduction to Buddhist Ethics: Foundations, America. Boston: Shambhala Publications, Inc., 1998. Values and Issues. Cambridge, UK: Cambridge University Press, 2000. Paul David Numrich. “Buddhists in America: Following a Different Religious Path.” Buddhists, Hindus, and ——— “Vinaya Principles for Assigning Degrees of Sikhs in America. Religion in American Life series. Culpability.” Journal of Buddhist Ethics, 6 (1999), 271- New York: Oxford University Press, forthcoming. 291. ——— “Health, Marriage, and Family in Selected World James J. Hughes and Damien Keown. “Buddhism and Religions: Different Perspectives in a Pluralist Medical Ethics: A Bibliographic Introduction.” Journal America.” Marriage, Health, and the Professions: The of Buddhist Ethics, 2 (1995), 105-124. Implications of New Research into the Health Benefits of Marriage for Law, Medicine, Ministry, Therapy, and

14 THE BUDDHIST TRADITION: RELIGIOUS BELIEFS AND HEALTHCARE DECISIONS REFERENCES

Business. Don Browning, William Doherty, Steven Post, John Renard, Responses to 101 Questions on Buddhism and John Wall, eds. Grand Rapids, Mich: Eerdmans, (New York: Paulist Press, 1999). 2001. Lily de Silva, “Ministering to the Sick and the Terminally ——— “How the Swans Came to Lake Michigan: The Social Ill.” Bodhi Leaves series, BL 132. Kandy, Sri Lanka: Organization of Buddhist Chicago.” Journal for the Buddhist Publication Society, 1994. Scientific Study of Religion, 39.2 (June 2000), 189- 203. S. H. J. Sugunasiri. “The Buddhist View Concerning the Dead Body.” Transplantation Proceedings, 22.3 (June ——— “Posting Five Precepts: A Buddhist Perspective on 1990), 947-949. Ethics in Health Care.” The Park Ridge Center Bulletin (November/December 1999), 9-11. Karma Lekshe Tsomo. “Opportunity or Obstacle? Buddhist Views on Organ Donation.” Tricycle: The Buddhist Kate Prendergast. “Opening the Doors of Perception: Review, 2.4 (Summer 1993), 30-35. Buddhism and the Mind: An Interview with Mark Epstein.” Science and Spirit Magazine, 11.1 World Religions on Sexuality. Chicago: The Park Ridge (March/April 2000), 32-33. Center for the Study of Health, Faith, and Ethics, forthcoming. Walpola Rahula. What the Buddha Taught. 2d and enlarged ed. New York: Grove Press, 1974.

The author wishes to thank Damien Keown and Edwin DuBose for their helpful comments on earlier drafts of this work.

THE PARK RIDGE CENTER 15 Introduction to the series

eligious beliefs provide meaning for people gious views on clinical issues. Rather, they Rconfronting illness and seeking health, par- should be used to supplement information com- ticularly during times of crisis. Increasingly ing directly from patients and families, and used health care workers face the challenge of provid- as a primary source only when such firsthand ing appropriate care and services to people of dif- information is not available. ferent religious backgrounds. Unfortunately, We hope that these handbooks will help prac- many healthcare workers are unfamiliar with the titioners see that religious backgrounds and religious beliefs and moral positions of traditions beliefs play a part in the way patients deal with other than their own. This handbook is one of a pain, illness, and the decisions that arise in the series that provides accessible and practical course of treatment. Greater understanding of information about the values and beliefs of dif- religious traditions on the part of care providers, ferent religious traditions. It should assist nurses, we believe, will increase the quality of care physicians, chaplains, social workers, and admin- received by the patient. istrators in their decision making and care giving. It can also serve as a reference for believers who desire to learn more about their own traditions. Each handbook gives an introduction to the history of the tradition, including its perspectives on health and illness. Each also covers the tradi- tion’s positions on a variety of clinical issues, with attention to the points at which moral dilemmas often arise in the clinical setting. Final- ly, each handbook offers information on special concerns relevant to the particular tradition. The editors have tried to be succinct, objec- tive, and informative. Wherever possible, we have included the tradition’s positions as reflected in official statements by a governing or other formal body, or by reference to positions formulated by authorities within the tradition. Bear in mind that within any religious tradition, there may be more than one denomination or that holds THE PARK RIDGE CENTER views in opposition to mainstream positions, or FOR THE STUDY OF HEALTH, FAITH, AND ETHICS groups that maintain different emphases. 211 E. Ontario ● Suite 800 ● Chicago, Illinois 60611 The editors also recognize that the beliefs and http://www.parkridgecenter.org values of individuals within a tradition may vary from the so-called official positions of their tradi- The Park Ridge Center explores and tion. In fact, some traditions leave moral deci- enhances the interaction of health, faith, sions about clinical issues to individual and ethics through research, education, and . We would therefore caution the read- consultation to improve the lives of individuals and communities. er against generalizing too readily. The guidelines in these handbooks should not ©2001 The Park Ridge Center. All rights reserved. substitute for discussion of patients’ own reli-

THE BUDDHIST TRADITION: RELIGIOUS BELIEFS AND HEALTHCARE DECISIONS