The Buddhist Tradition - Advocate Health Care

The Buddhist Tradition

Religious Beliefs and
Healthcare Decisions

by Paul David Numrich

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

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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 being 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

Buddhism adheres to the basic Indian view, The Buddha’s most fundamental insights con-
one shared with Hinduism and Jainism, that cerned the predicament of human existence 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 experience. In his first sermon
of which are governed by one’s deeds or actions following enlightenment, called “Setting in
(karma). Death is an inevitable part of existence Motion the Wheel of the Dharma,” the Buddha
and subsequent rebirth reflects the outcome of laid out the Four Noble Truths: that life is
one’s karmic dispositions, which may occur at unsatisfactory, 5 that our own desires cause life’s
the human or another level, such as that of ani- unsatisfactoriness, that there can be cessation or
mals or disembodied beings. 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 nature 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
well as mental discomforts—isolates the cause,
Nirvana is impossible to explain in ordinary then prescribes the cure. In ways not available
terms “because human language is too poor to to medicine, but compatible with medicine’s
express the real nature of the Absolute Truth or concern for alleviating suffering, Buddhism
Ultimate Reality which is Nirvana.”3 Buddhists offers the ultimate remedy for human affliction.6
believe that upon death, an enlightened person
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 impermanence—change
by the unenlightened mind, 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 belief in nothing contains an unchanging essence 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 soul, and there is no God 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 souls in the divine
However, Mahayana philosophy pursued the image. The Buddha did recognize the existence
conclusion that, actually, “there is not the slight- of “gods” or spiritual beings above the human
est bit of difference 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 Four Noble Truths explain how
to overcome this dilemma. Buddhist tradition and iconography include
celestial Buddhas, which are not to be confused
Ancient Buddhist texts portray the Buddha with the historical Gautama Buddha, 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-guru (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 present lifetime. For any patient, regardless karma at death. The bodhisattva
of the level of spiritual attainment, the textual Avalokiteshvara’s very name invokes notions of
tradition encourages cultivation of a wholesome celestial care: the Lord Who Looks Down (with
mindset through contemplation of the dharma Compassion), known in China in female form as
and consideration of one’s own spiritual virtues. Kuan-yin, which translates to the One Who
These activities are portrayed as having healing Regards Cries or the One Who Hears Prayers.
efficacy. The texts also distinguish two types of
pain, physical and mental, explaining that when Many Buddhists seek the services of Buddhist
a person suffering from the former adds the lat- monks trained in ancient Indian medical prac-
ter, it is as if that person were shot with two tices known as Ayurveda. According to some
arrows instead of just one.7 Thus the Buddha scholars, Buddhist monastic practitioners played
taught his monastic followers to distinguish a key role in the historical development of
between the two: “You should train yourself: Ayurvedic medicine, although it is usually asso-
Even though I may be sick in body, my mind ciated with Hinduism.9 Buddhist monks also
will be free of sickness. . . . [A Buddhist disci- receive training in the ritual use of special vers-
es that carry protective and healing properties.10

OVERVIEW OF RELIGIOUS MORALITY AND ETHICS

The Fourth Noble Truth taught by the Buddha duct, not to tell falsehoods, and not to take
delineates 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 heart of Buddhist ethics.12 The behavior of
that is, nirvana. Three spokes comprise the ethi- Buddhist monks and nuns 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 five precepts, 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 individuals, groups, and cultures.

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

THE INDIVIDUAL AND THE PATIENT-CAREGIVER RELATIONSHIP

Although classical Buddhism did not develop CLINICAL ISSUES
the 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-
ual’s inherent worth and dignity. Buddhist ethical principles relevant to issues of patient
teachings about ethical duties imply individual choice and consent. A person lacking knowledge
rights for the beneficiaries of one’s dutiful of what is occurring, whether through mental
actions.13 disruption or extreme physical pain, is not con-
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
monk 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,
the Buddha expected nurses to attend to a Withholding the truth in certain cases may be
patient’s mental state by imparting spiritual guid- acceptable, for instance, when dealing with
ance through the truths of the dharma. On the Buddhists from cultures that subsume an indi-
patient’s part, the Buddha expected honest disclo- vidual’s right to the truth about their condition
sure of the nature of the illness, cooperation with to the impact of disclosure on the general well-
the treatment plan, and forbearance of pain.14 being of the family.

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
the body following death (see below under
bioethics field, advises Buddhists to prepare Death and Dying).16
advance directives and to appoint a healthcare

FAMILY, SEXUALITY, AND PROCREATION

The Buddha established a community of full CLINICAL ISSUES
time 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
renunciant ideals even in Asian cultures where tive methods like rhythm and withdrawal since
monasticism no longer prevails. Buddhism’s ancient times. By extension, some modern
emphasis on the ultimate goal of liberation from methods may be considered permissible as long
samsara renders family issues secular, or “world- as they do not function as abortifacients. The
ly” by definition, bound by desire to the ongoing lack of clear guidance from textual sources has
cycle of existence. Since Buddhism has no anal- created disagreement over the normative
ogy to the biblical injunction to be fruitful and Buddhist stance on contraception. Buddhism
multiply, marriage and divorce are typically con- views contraception with some ambivalence. On
sidered cultural or civic rather than religious the one hand, since conception represents a life
affairs. Monogamous marriages and extended seeking rebirth, many Buddhists would be reti-
families are normative in Asian Buddhist cul- cent to block it; on the other hand, the lack of
tures. The Buddha taught that children should an imperative to procreate leads other Buddhists
respect their parents, that parents should raise to approve of contraception in certain circum-
their children properly, and that husband and stances.19
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
as prohibiting all sexual activity, whether hetero- in the case of contraception, if sterilization vol-
sexual, homosexual, or autosexual. Some untarily serves that purpose. Involuntary sterili-
observers have remarked about Buddhism’s rel- zation would have to follow egalitarian protocols
atively benign attitude toward homosexuality. and not target one group, such as the poor or
Peter Harvey summarizes the views in minorities, over others.
Buddhism’s Asian homelands: “Homosexual
activity among lay people has been sporadically New reproductive technologies
condemned as immoral in Southern [Theravada] Not surprisingly, given ancient Buddhism’s
and Northern [Mahayana and Vajrayana]
Buddhism, but there is no evidence of persecu- valorization of renunciant celibacy, Buddhist
tion of people for homosexual activities. An atti- texts offer little direct guidance in such modern
tude of unenthusiastic toleration has existed. In issues as artificial insemination and in vitro fer-
China, there has been more tolerance, and in tilization (IVF). As Buddhist ethicist Damien
Japan positive advocacy.”18 Attitudes toward Keown observes, the feeling may have been
homosexuality among American-convert “that the proper purpose of medicine in the
Buddhists appear generally liberal. monastery was not the satisfaction of lay desires,
such as that of women to bear children.” Keown
concludes his discussion as follows: “We might 5

THE PARK RIDGE CENTER

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. Abortions 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
Abortion for the final decision about abortion with the
pregnant woman.22
Traditionally, abortion has been considered a
violation of the first precept against destroying Care of severely handicapped newborns
life. Ancient monastic texts, for instance,
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

Ancient Buddhist texts and commentaries proscriptions against harming life. Compassion
define 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-
sonhood, though Buddhists see it as bracketed Barnhart suggests that Buddhism does not
both before and after by other existences, not all condemn genetic engineering, gene therapy,
of which are human. Michael G. Barnhart points cloning, and other new biotechnical procedures
out that, in the Buddhist view, genes impinge on per se. Buddhist moral judgment would evaluate
only one of the constituent aspects of the human both motivations and consequences of particular
being—the body. Thus Buddhism does not sup- actions. Egocentric motives would be disap-
port a “hard” genetic determinism: “The body proved and procedures that distract or deter a
and its associated genetic endowments do not ... person in their path toward enlightenment
determine the rest of our nature in any interest- would be rejected.27
ingly lawlike manner.”24
CLINICAL ISSUES
In discussing genetics and biotechnology gen-
erally, the Dalai Lama 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
utility as legitimate motivations for genetic preferences for offspring arise from parental preju-
manipulation.25 Genetic experimentation involv- dices that should not be exploited for profit.28
ing the destruction of human embryos or other Ethical considerations about selective abortion
living organisms would fall under basic Buddhist would follow the reasoning on abortion generally.

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

Buddhism’s emphasis on compassion and the transplants, which should not arbitrarily favor
alleviation 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
period after physical death complicates the mat- At the same time, Buddhists may evaluate
ter. Many Buddhists will not allow any tamper- recipients differently following transplantation
ing with the body for three days so as not to dis- depending on the use to which their lives are
turb the release of consciousness as it moves put. In some cases the recipient’s extended
toward its new mode of existence. Of course, this human lifespan may make the most of one’s
delay compromises organ and tissue harvesting. potential for enlightenment or nirvana, whereas
In China and Japan, where indigenous traditions in other cases the recipient may squander that
have influenced Buddhism historically, taboos opportunity by living a life of negative deeds.33
against desecrating the body hamper this Some recipients may express concern about the
process.32 Generally, however, the Buddhist karmic status of their transplanted organs/tissue,
understanding of human existence as an aggre- and may even attribute biological rejection as
gation of mental and physical strands allows indication that the donor’s karma was incompat-
individuals to disassociate personal identity from ible with their own.34
the physical parts of the body, thus opening the
possibility of transplantation. For donors
A contemporary Vajrayana teacher suggests
CLINICAL ISSUES
that some Buddhists may not be mentally pre-
For recipients pared to donate their organs. It is best to devel-
Buddhism’s ethical imperative of compassion op a mind that is strong, stable, and wise
enough to understand all the implications of
has universal rather than selective scope; trans- organ donation procedures and the relationship
plant recipients should therefore be chosen between mind and body.35 Two contemporary
according to compassionate criteria fairly teachers from the Chan/Zen tradition have
applied to all candidates. Two guidelines, right stressed the importance of the compassionate
action and right livelihood, imply just and equi- act of donation over any potential disturbance of
table treatment of others that they, too, might the release of the donor’s consciousness during
pursue happy and fulfilling lives. This has fur- the three-day waiting period. Buddhists may
ther implications for the allocation and cost of sign advance directives or appoint a healthcare
agent to address post-mortem donation.36
7
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MENTAL HEALTH

Decades ago psychoanalysts Carl Jung and cal terms. For instance, the six defilements—
Erich Fromm investigated the potential com- greed, anger, 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”
which predicted increasing therapeutic use of Buddhists attribute much mental health and
meditation.37 At the popular level this has indeed illness to a person’s spiritual progress along the
occurred; witness the recent profusion of self- path to enlightenment. The Dalai Lama, for
help meditation books and the increase in medi- instance, advises his readers that by “being bet-
tation centers.38 In Western mental health gener- ter grounded emotionally through the practice of
ally, the field of transpersonal psychology has patience, we find that not only do we become
gone furthest in integrating Buddhist insights much stronger mentally and spiritually, but we
into its approach. A few Buddhist psychothera- tend also to be healthier physically.” He goes on
pies have been imported from Asia.39 to explain, “I attribute the good health I enjoy to
a generally calm and peaceful mind.”43
In a sense Buddhism has followed an interac-
tive mind/body model of human personhood for A respected Theravada Buddhist scholar-
2,500 years. “In Buddhist psychology and in the monk writes, “He who has realized the Truth,
medical texts of Buddhist culture, mind and Nirvana, is the happiest being in the world. He is
body are not separate,” explains Mark Epstein, free from all ‘complexes’ and obsessions, the
Buddhist psychologist and author of the books worries and troubles that torment others. His
Thoughts without a Thinker and Going to Pieces mental health is perfect.”44
without Falling Apart. “Mind extends into body
and body extends into mind.”40 CLINICAL ISSUE

The human being is an aggregation of one Psychotherapy and behavior modification
physical and four mental strands, factors, or
aspects. In Buddhist understanding, “mind” is Most Buddhist psychotherapists consider
included as one of the sense organs or faculties Western psychotherapy and Buddhism to be
of the body—as other organs sense objects complementary rather than incompatible,
around us through sight, hearing, smell, taste, although they would argue that Buddhism deep-
and touch, the mind senses mental objects such ens the insights of conventional psychology. Ryo
as thoughts, ideas, and imagination, and also Imamura, a Japanese-American Buddhist priest-
interprets and assimilates input from the physical therapist, sees Buddhist psychotherapy as “an
sense organs. Such input affects our thoughts. expansion of Western psychotherapy. It appends
Buddhism places great emphasis on the mind’s dimensions of compassion and nonduality to the
ability to control various states of health, both rational clarity and precision of Western psy-
physical and mental. Clarity of mind is essential; chotherapy.” Imamura gives the example of
meditation helps achieve it. This is underlined by human suffering and happiness: both Western
the prohibition against intoxication in the fifth and Buddhist psychotherapies seek to relieve
precept. suffering and enhance happiness, but only the
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

The key ethical consideration here concerns good of life and a breach of the first precept. If
whether 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

According to Buddhism, death for the vast grief so as to encourage an auspicious mindset
majority 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 clergy
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
goal of enlightenment, the final liberation for Buddhism recognizes that the person is not
those who attain it. Dying Buddhist patients may the body—the body being only one of five aggre-
ponder their progress—or lack of it—along the gates comprising a human being—thus the body
path toward final liberation, and may experience is not sacred in some sense at death. Neither is
anxiety about being reborn into less desirable the person essentially a soul, since Buddhism
human circumstances or even as a lower life does not recognize such an entity. At death a
form. Discussion of impending death is not typi- person's aggregated organism disassembles, to
cally avoided, though positive thoughts and be reassembled in the next rebirth—or not, in
encouragement are preferred over sadness or the case of the enlightened few.

THE PARK RIDGE CENTER 9

CLINICAL ISSUE Foregoing life-sustaining treatment
In discussing the case of patients in a
Determining death
Little scholarly or ethical attention has been Persistent Vegetative State (PVS), Damien
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
circumstances.57 Based on this Phillip Lecso
Improvements in pain management that mini- argues that Buddhism advocates hospice care
mize mental impairment have been welcomed.51 over euthanasia.58 As to the latter, Peter Harvey
Buddhist patients may also attempt alleviation of observes that “Euthanasia scenarios present a
physical and mental pain through concentrated test for the implications of Buddhist compas-
mental efforts in meditation or through ceremo- sion, but the central Buddhist response is one of
nial acts. aiding a person to continue to make the best of
his or her ‘precious human rebirth’, even in very
Some Buddhist-influenced hospice and other difficult circumstances.”59
programs for the dying have emerged in recent
years, including the Zen Hospice Project in San Autopsy and post-mortem care
Francisco (http://www.zenhospice.org) and the Post-mortem care of the body should be kept
work of Buddhist teacher Joan Halifax in Santa
Fe, New Mexico (http://www.peacemakercommuni- to the barest minimum, and, if possible, an
ty.org). A small study of women in Thailand indi- autopsy should be delayed for three days due to
cated that “meditation can be a useful interven- the Buddhist belief in the slow release of con-
tion to support women with HIV/AIDS and to sciousness from the body (see above under
provide a measure of control, to enhance their Organ and Tissue Transplantation). Buddhist
immunological response to stress, to reduce the texts are often recited or chanted at death,
side effects of treatment, and to diminish anxiety though not necessarily in the presence of the
and fear.”52 The Dalai Lama counsels that wis- body. Buddhist clergy usually officiate at these
dom might dictate submitting to the karmic rituals. In fact, officiating at the occasion of
manifestations of physical suffering at the end of death became the special province of monks in
this life rather than face their prolongation into many parts of Asia.
the next life.53

10 THE BUDDHIST TRADITION: RELIGIOUS BELIEFS AND HEALTHCARE DECISIONS

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

SPECIAL CONCERNS

The multiple expressions of Buddhism in these dietary restrictions. Drugs that include
America 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
special attention. Due to immigration and con- Buddhism is primarily an individual and fam-
version patterns in American history, we find, on ily oriented religion, although regular congrega-
the one hand, Buddhists whose faith is an tional gatherings have become more common in
expression of their cultural heritage as Asians the United States as immigrants adopt the typi-
and, on the other hand, non-Asian Buddhists cal American style of religion. The concept of
who converted to Buddhism as adults. “worship” does not capture the religious experi-
Buddhism fulfills a different sociological func- ence of most Buddhists, who instead practice
tion for each group—affirming ethnic identity in meditation or a ritual veneration of the histori-
Asian-American Buddhists and transforming cal Gautama Buddha and various celestial
perspective and self-identity in non-Asian con- Buddhas and bodhisattvas. Candles, incense,
verts.60 Within each of these “two Buddhisms,” flowers, gongs or bells, sacred statues and paint-
of course, variations of expressions and under- ings, beads, meditation cushions, and other ritu-
standings also exist. al accoutrements may be used. Chanting, dhar-
ma sermons, and reading/reciting of scriptural
Diet and drugs and liturgical texts are common practices. Each
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 vegetarianism, 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 laity 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 temple
may consume liquids and soft foods that do not activities across the United States.
require chewing. Pious laity taking religious
vows 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 Bhikkhu, The
Buddhist Monastic Code (Valley Center, California: 15. Peter Harvey, “Vinaya Principles for Assigning Degrees
Metta Forest Monastery, 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 Pali and Sanskrit). 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
Hindus, and Sikhs in America, Religion in American Selected World Religions: Different Perspectives in a
Life series (New York: Oxford University Press, 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 World Religions on Sexuality (Chicago: The Park
Mahayana philosopher Nagarjuna, 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: Shambhala 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;
Perception: 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 the Doors of Perception,” 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. Buddhism and Abortion. 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,
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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

R eligious beliefs provide meaning for people gious views on clinical issues. Rather, they
confronting 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,
many healthcare workers are unfamiliar with the We hope that these handbooks will help prac-
religious beliefs and moral positions of traditions titioners see that religious backgrounds and
other than their own. This handbook is one of a beliefs play a part in the way patients deal with
series that provides accessible and practical pain, illness, and the decisions that arise in the
information about the values and beliefs of dif- course of treatment. Greater understanding of
ferent religious traditions. It should assist nurses, religious traditions on the part of care providers,
physicians, chaplains, social workers, and admin- we believe, will increase the quality of care
istrators in their decision making and care giving. received by the patient.
It can also serve as a reference for believers who
desire to learn more about their own traditions. THE PARK RIDGE CENTER

Each handbook gives an introduction to the FOR THE STUDY OF HEALTH, FAITH, AND ETHICS
history of the tradition, including its perspectives
on health and illness. Each also covers the tradi- 211 E. Ontario ● Suite 800 ● Chicago, Illinois 60611
tion’s positions on a variety of clinical issues, http://www.parkridgecenter.org
with attention to the points at which moral
dilemmas often arise in the clinical setting. Final- The Park Ridge Center explores and
ly, each handbook offers information on special enhances the interaction of health, faith,
concerns relevant to the particular tradition. and ethics through research, education, and

The editors have tried to be succinct, objec- consultation to improve the lives of
tive, and informative. Wherever possible, we have individuals and communities.
included the tradition’s positions as reflected in
official statements by a governing or other formal ©2001 The Park Ridge Center. All rights reserved.
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 sect that holds
views in opposition to mainstream positions, or
groups that maintain different emphases.

The editors also recognize that the beliefs and
values of individuals within a tradition may vary
from the so-called official positions of their tradi-
tion. In fact, some traditions leave moral deci-
sions about clinical issues to individual
conscience. We would therefore caution the read-
er against generalizing too readily.

The guidelines in these handbooks should not
substitute for discussion of patients’ own reli-

THE BUDDHIST TRADITION: RELIGIOUS BELIEFS AND HEALTHCARE DECISIONS