Buddhism and Medical Ethics: A Bibliographic Introduction
James J. Hughes
MacLean Center for Clinical Medical Ethics
Damien Keown
Goldsmiths, University of London

Published in the Journal of Buddhist Ethics, Volume Two, 1995
ISSN 1076-9005

It has not gone unnoticed that the Buddhist aim of eliminating suffering coincides with the objectives of medicine (Duncan et al, 1981; Soni, 1976). The Buddhist emphasis on compassion finds natural expression in the care of the sick, and according to the Vinaya the Buddha himself stated "Whoever, O monks, would nurse me, he should nurse the sick" (Zysk, 1991:41). Buddhist clergy and laity have been involved with the care of the sick for over two thousand years. The Indian Buddhist emperor Asoka states in his second Rock Edict that provision has been made everywhere in his kingdom for medical treatment for both men and animals, and that medicinal herbs suitable for both have been imported and planted.
Birnbaum (1979) and Demieville (1985) provide good general introductions to Buddhism and medicine. Buddhism appears to have played an important role in the evolution of traditional Indian medicine (Zysk, 1991), and there are many parallels between Buddhist medicine, as recorded in the Pali canon, and Aayurveda (Mitra, 1985). There are short monographs by Haldar on the scientific (1977) and public heath aspects (1992) of medicine in the Pali sources. It is likely that as Buddhism spread through Asia it would have interacted with indigenous medical traditions promoting the cross-fertilization of ideas. Redmond (1992) discusses the relationship of Buddhism to medicine from Theravaada and Mahaayaana perspectives and compares Buddhist and Daoist concepts of disease. Discussions of Tibetan medicine may be found in Clifford (1984), Dhonden (1986), and Rechung (1976), while Ohnuki-Tierney (1984) discusses illness and culture in contemporary Japan.
Buddhism's holistic understanding of human nature encourages a psychosomatic approach to the pathology of disease (Soni, 1976), something to which Western medicine is now increasingly attuned. It may also be suggested that the Buddhist philosophy of origination in dependence is both a fruitful diagnostic model and a philosophy which encourages a preventive approach to healthcare. However, disquiet has been voiced recently about how "natural" certain forms of traditional Buddhist medicine are - notably the Tibetan "black pill" - some recipes for which specify rhinoceros horn and bear-bile among the ingredients (Leland, 1995).
Despite Buddhism's long association with the healing arts, little attention has been paid to the ethical issues which arise from the practice of medicine. A small number of monographs provide introductions to the issues and dilemmas which arise in medical practice. These are Ratanakul (1986), Nakasone (1990) and Keown (1995), and these volumes should be consulted in conjunction with the sources listed under the specific subject-headings below. Also relevant is the unpublished Masters thesis by Shoyu Taniguchi (1987a). For general discussions in the periodical literature see Taniguchi (1987b), Mettanando (1991), and Ratanakul (1988; 1990). A useful discussion of Buddhism in terms of the "four principles" approach to medical ethics developed by Beauchamp and Childress (1989) is provided by Robert Florida (1994).
The Encyclopedia of Bioethics contains articles on medical ethics in India (Jaqqi, 1987), Asia (Unschuld, 1987), and Japan in the nineteenth century (Kitagawa, 1987). Also on Japan see Umezawa (1988). On medical ethics in imperial China see Unschuld (1979) and on Thailand Violette Lindbeck (1984) and Ratanakul (1988; 1990).
The principal issues to be addressed in contemporary medical ethics may be summarised as moral personhood (the question of who is and who is not entitled to moral respect), abortion, embryo experimentation, genetic engineering, consent to treatment, resource allocation, defining death, organ transplantation, living wills, the persistent vegetative state, and euthanasia. Little systematic attention has yet been directed to these subjects by Buddhist practitioners or scholars, and some subjects have not been discussed at all from a Buddhist perspective. The arrangement of the topics below is neither comprehensive nor final. It is inevitable there will be overlap between the sections, and items which appear under one category may contain discussion of issues or principles which have broader relevance.
At this time, however, it seems useful to identify three groups of issues and related literature. These concern: moral personhood, issues surrounding life at its beginning, and issues surrounding life at its end. There is insufficient literature on resource-allocation, socio-economic issues, or other questions about general medical practice to justify a category on those topics in this review. There are signs, however, that a Buddhist perspective on certain aspects of medical treatment is beginning to appear, for example Epstein (1993) and Kabat-Zinn's (1990, 1994) integration of Buddhist meditation into medical practice, and the growing literature on Buddhism and social justice, such as Jones (1989) and Sizemore and Swearer (1993).
Personhood is both a central problem for Buddhist ethics and Western medical ethics, and consequently a very promising area for a dialogue between the two. The problem for Buddhist ethics has always been why should people act ethically if there is no act, no actor and no consequences of action (Collins, 1982). If there is no self or other, how can there be karmic consequences, responsibility, loyalty, or even compassion? Theravaadin scholars continue to be divided over whether Buddhism suggests different ethics for those who persist in the illusion of self (kammic ethics) and for those who would transcend the illusion of self (nibbanic ethics). The paradoxical unity of compassionate ethics and nihilistic insight into selflessness has been the central koan of Mahaayaana Buddhism. Tantra and Zen suggest that the person who sees that there is no "I" is beyond good and evil.
For bioethics, struggles over abortion, animal rights and brain death have brought personhood to the forefront (Nelkin, 1983). Opponents of abortion and euthanasia, and advocates for the disabled and animals, on the other hand, assert that mere humanness or merely being alive should bestow a "right to life." But most bioethicists believe that human beings and animals take on ethical significance to the extent that they are "persons." Some, such as Tooley (1984), would set a standard which would exclude almost all animals, newborns, and the severely retarded or demented. When they specify which elements of sentience and neurological integrity create the illusion of personhood, Western bioethicists begin to sound remarkably Buddhistic: "the awareness of the difference between self and other; the ability to be conscious of oneself over time; the ability to engage in purposive actions" (see, for instance, Fletcher, 1979).
At the same time, Western bioethicists have become increasingly troubled by questions about the autonomy, continuity and authenticity of the self. Do anti-depressants create an inauthentic self, or is the self more authentic when its cheerful? Is one respecting a patient's autonomy by respecting the treatment preferences they expressed when healthy, or those they express in the throes of illness? Is it ever possible for a patient to give truly free and informed consent to treatment?
The most radical challenge to Western ethics of self- determination came in 1984 with the publication of British philosopher Derek Parfit's Reasons and Persons. In this meticulously argued tome, Parfit rejects the existence of continuous selves and concludes that an individual is as discontinuous from itself at some later time as it is from other individuals. Consequently, working for the future welfare of all beings is the same as working for one's own future welfare, since there will be no "I" to benefit in the future.
Bioethicists are only now incorporating Parfit's argument. For instance, researchers find that is impossible to accurately anticipate one's state of mind when one is sick or dying, much less when one is unconscious, undercutting the assumption of continuous personhood undergirding "living wills."
From a Buddhist/Parfitian perspective, the search for "real" preferences, central to the identity of the person, is a pointless one. With this acknowledgement, it is less troubling to place our trust in our family and friends to make decisions for our future selves (Kuczewski, 1994). More to the point, a Buddhist/Parfitian would encourage citizens to look beyond their personal preferences in dying, which may be to "die with dignity" but may also be to use as many resources as possible to stave off death, and instead participate in creating a health care system that served the needs of everyone in society.
Another area of potential dialogue is in the efforts to go beyond Cartesian (and Hindu etc.) mind-body dualism in defining life and death. Over the last twenty years the West has slowly accepted that a "person" is dead if their brain is destroyed, even if the body continues to function. Yet it still troubles many Westerners and Buddhists to declare the permanently unconscious "dead," believing that this is an example of inappropriate mind-body dualism. Other Westerners and Buddhists believe that only a "neocortical" definition of death recognizes the centrality of consciousness and personhood in ethics (Gervais, 1986). More challenging, some Western ethicists have begun to discuss the status of personhood as future technologies make possible the continuity of personality from one body to another (More, 1994). When medical technology offers reincarnation, Buddhist bioethics will certainly flourish.
Buddhism, like all religious and secular philosophies, focuses on two central questions concerning abortion: (a) when does the embryo or fetus acquire the property which makes termination of pregnancy "killing"?; and (b) is termination of a pregnancy, before or after this point, ever justifiable?
While there was a minority tradition in classical Hindu embryology that held that incarnation does not occur till as late as the seventh month (Lipner, 1989), most Buddhist commentators have adopted classical Hindu teachings that the transmigration of consciousness occurs at conception, and therefore that all abortion incurs the karmic burden of killing. Before modern embryology, however, in both Buddhist countries and the West, ideas about conception were scientifically inaccurate, and often associated the beginning of life with events in the third or fourth month of pregnancy (for a discussion of traditional Tibetan embryology, see Dhonden, 1980 and Lecso,1987).
Another problem in early Buddhists' embryology is their assumption that the transmigration of consciousness is sudden rather than gradual. Based on the findings of modern neuro-embryology Buddhists today might maintain that the fetus does not fully embody all five skandhas and the illusion of personhood until after birth; this is the argument developed by most Western ethicists to defend abortion (Tooley, 1984; Flower, 1985; Bennett, 1989). If the fetus is not yet a fully embodied person, then the karmic consequences of abortion would be even less than the killing of animals, which Buddhism teaches do have moral status. This neurological interpretation of the skandhas may be more consistent with Western Buddhism, which often sees the doctrine of rebirth as peripheral or interprets rebirth metaphorically rather than literally (Batchelor, 1992; King, 1994).
The second question is whether abortion always generates bad karma, or in Western terms, is it ever "justified." This relates to the debate about whether Buddhist ethics are absolutist, utilitarian or "virtuist," i.e. seeing the good in the development of personal qualities. The absolutist would hold that bad karma is incurred from any act of murder, whatever the justifications. The utilitarian would argue that murder can be a compassionate act with positive karmic consequences, taking into account factors such as the health of the fetus or mother, the population crisis, and the readiness of the parents to raise a child.
A virtue-oriented Buddhist would argue that the attitude and motivations of the pregnant woman and her collaborators would determine the ethics of an abortion. Along this line, Tworkov (1992) argues that the karmic skilfulness of an abortion is related to whether the person became pregnant and made her decision to abort without serious mindfulness. From this perspective, aborting a fetus conceived without an effort at contraception would be more karmically significant than an abortion necessitated in spite of contraception.
The much discussed Japanese tolerance for, and ritualization of, abortion appears to combine both utilitarian and virtue approaches. The Japanese believe that abortion is a "sorrowful necessity," and Buddhist temples sell rituals and statues intended to represent parents' apologies to the aborted, and wishes for a more propitious rebirth. The Japanese have reached these accommodations consensually, with little debate, and without discussion of the rights of women or the unborn (LaFleur, 1990, 1992).
The Theravaadin commentator Buddhaghosa appears to have combined all three views. He held that killing produces karma jointly through the mental effort and intensity of the desire to kill, and the virtue of the victim (Florida, 1991). Since killing big animals required more effort, and was therefore worse than killing small animals, the karma of feticide would be less than murder of adults, and less in earlier stages of pregnancy. On the other hand, for Buddhaghosa, the karma of feticide would be greater than that of killing villains in self-defence.
Buddhists have thus far given little thought to the third important question, the connection between morality and law, specifically how, and on what grounds, the state should regulate abortion. Some Buddhists have adopted the stance of many moderates in the West: abortion is murder of a person, but women should have that choice (for instance, Imamura, 1984 and Lecso, 1987). Since most Buddhists have no problem with laws to discourage and punish murder in general, implicit in this position is that murder is either justifiable when it conflicts with bodily autonomy or, since few Buddhists would imprison butchers, that fetuses are closer in status to animals. Clearly there is much room for clarification of the relationship between religious ethics and law in pluralistic societies.
Some scholars (such as Ling, 1969, and LaFleur, 1992) have looked beyond the strictly ethical concerns with abortion to examine the cultural aspects of the question. From this perspective it is sometimes pointed out that Buddhism is not "pro-natalist," i.e. does not hold that reproduction is a religious duty - quite the reverse in fact - and does not advocate "family values," at least in the sense that Confucianism did. Buddhist skepticism about family and reproduction was a central cause of Confucian and Shinto persecution. The Sinhalese embrace of contraception and abortion was so enthusiastic in the 1960s, compared to Sri Lanka's Muslims, Catholics and Hindus, that racialist monks began to argue that Buddhists had an obligation to "race-religion-nation" to reproduce.
The themes of impermanence, decay and death are omnipresent in Buddhist literature. In many Asian cultures Buddhism is identified as the authority par excellence on matters pertaining to death, and is closely linked to the rites and ceremonies associated with the transition from this life to the next. Buddhist literature emphasises the importance of meeting death mindfully since the last moment of one life can be particularly influential in determining the quality of the next rebirth.
General reflections on death will be found in Philip Kapleau's 1972 anthology The Wheel of Death and his 1989 The Wheel of Life and Death. Stephen Levine is the author of several books dealing with the subject of death from a Zen perspective while a contemporary Tibetan perspective is provided by Sogyal Rinpoche's popular Tibetan Book of Living and Dying, Glenn H. Mullin (1986) and John Powers (1995, Ch.10). James Whitehill (1974) discussed what can be learned from the death of the Buddhist masters, and the development of a corpus of "Great Death" stories of various Buddhist masters is examined by LaFleur (1974). Other writings on death in Buddhism include Smart (1968), Amore (1974), and Bowker (1991).
In a 1993 monograph on the subject of death in Buddhism, Becker asserts that the Buddhist tradition, especially in Japan, is very tolerant of suicide and euthanasia. Evidence of this is the Buddha's tolerance of suicide by monks (Wiltshire, 1983) and Japanese stories praising suicide by monks, samurai and laypeople. Becker suggests that Buddhism values self-determination and praises those who decide when and how they will die when they do so in order to have a dignified conscious death. Becker also concludes that the key point is not whether there is still warmth or reflexes (as suggested by some readings of the Visuddhimagga) but whether the patient's skandhas have permanently left, i.e. the patient is permanently unconscious. In other words, Buddhism would endorse a brain death definition of death. On the understanding of death in Japanese religion see also Picken (1977).
A number of issues in medical ethics turn upon the problem of defining death, but few writers have addressed the question of a Buddhist definition of death directly. Only van Loon (1978), Keown (1995), and Mettanando (1991) have argued for a specific definition: van Loon equates death with neocortical death whereas Keown and Mettanando support the "whole brain" criterion.
There has been considerable resistance to the adoption of the brain death standard in Japan, both from the public and within the medical profession, due in no small measure to its association with organ transplantation. The brain death criterion allows organs to be harvested with the minimum delay, thereby enhancing the prospects for a successful transplant. Japanese tradition, however, requires the performance of rituals over a lengthy period before an individual is regarded as having passed on, and is also reluctant to countenance plundering the bodily organs of future ancestors. Some commentators suggest that public acceptance of brain death is growing as professional groups and universities develop criteria, and as pressure from potential beneficiaries grows. Also, countries such as the Philippines have raised objections to Japanese patients going abroad for transplants rather than building an organ retrieval system of their own. The best analysis available (in English) of the Japanese situation is Hardacre (1994), but relevant material may also be found in Lock and Honde (1990), Feldman (1988), Becker (1990), and Nudeshima (1991). For discussions of the issue outside of Japan see Ratanakul (1988, 1990), Sugunasiri (1990), and Nakasone (1994).
A more positive attitude towards transplantation is revealed in Tsomo (1993). The author surveyed teachers from many different traditions about their attitudes to donation. All were very positive, and emphasized that the corpse is merely an empty vessel, and that to give of oneself is a great thing, and an act of compassion.
There are no monographs devoted specifically to euthanasia in Buddhism. There are a few periodical articles and the subject is dealt within one or two books. Relevant issues are the distinction between various forms of euthanasia (e.g. "active" and "passive") and the use of narcotics in palliative care which may cloud the mind and interfere with the process of dying (Keown, 1995; Kapleau, 1989; Lecso, 1986; Ratanakul, 1988, 1990).
Kapleau's volume The Wheel of Life and Death (1989) contains a short discussion of euthanasia in conjunction with suicide and it is suggested that Buddhism would reject the practice of either. Ratanakul concurs, reporting "a growing consensus among the Thai public that euthanasia (passive or active) is morally unjustifiable" (1990:27). Keown and Keown (1995) explore Buddhist and Christian attitudes to euthanasia and suggest both oppose it for similar reasons. Nakasone, however, is of the opinion that "Evidence indicates that Buddhists would favor the 'right-to-die' position" (1990:76). Jennifer Green's short article "Death with Dignity: Buddhism" (1989:40-41) discusses only the practicalities of funeral arrangements and does not mention euthanasia. Neuberger (1987) is likewise concerned with practical as opposed to moral issues.
Euthanasia has been a special feature in two Buddhist magazines, Raft, and Tricycle. London-based Raft, the Journal of the Buddhist Hospice Trust, devoted its No. 2 Winter 1989/90 issue to Euthanasia. Sixteen pages in length it contains short pieces by authors such as Elisabeth Kubler-Ross, Ajahn Sumedho, Dame Cicely Saunders and David Stott, exploring the cases for, against, and in terms of a middle way. A similar range of opinions will be found in the Winter 1992 edition of Tricycle, which contains short articles by Patricia Anderson, Jeffrey Hopkins, Philip Kapleau, Chogyam Trungpa, and an interview with author Stephen Levine.
Note: not all the items in the bibliography which follows are mentioned in the discussion above.
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