One Buddhist View of Bioethics
by Carl Becker
Buddhism is not a single philosophy but a range of philosophies that have been accepted by some of the most densely populated sustainable cultures that the world has known. Sometimes these cultures have been criticized for failing to hold individual rights above the sustainability of their communities, or for failing to achieve the scientific developments that made possible the industrial and medical revolutions of the West. The densely populated civilizations of Japan, Korea, Indo-China, and pre-Islamic South Asia owed their sustainability to this Buddhistic reluctance to exalt the individual, to exploit the environment, and to promote forms of medicine and health care that produce more people than they can sustain. Conversely, traditional Buddhist societies have presupposed that quality of life--both physical and spiritual--was preferable to quantity--length of life or an expanding population. Modern medicine has cut infant mortality and enhanced life expectancy. This has not produced societies capable of supporting a high quality of physical as well as spiritual life for every baby brought to term, caring adequately for every mentally or physically challenged member of the societies, or raising the level of satisfaction of elders facing their own mortality, much less distributing the benefits of health care equitably.
Bioethics studies problems of the proper response to medical dilemmas. If we know what is right to do and nothing obstructs our doing so, then we have no ethical dilemma, merely the obligation to do what we know is right. Ethics, particularly bioethics, becomes essential only when plural demands force us to choose between conflicting desires or priorities. To oversimplify, bioethics studies our reasons for setting priorities. One of the major challenges of medical ethics in countries with medical-care programs is the prioritization of limited national medical funding. In Buddhist terms, it is unwise and uncompassionate to proffer certain levels of care to particular patients while denying the same care to others.
The Four Noble Truths, the center of the Buddha's enlightenment, common to every school of Buddhism, hold that
(1) Physical life, aging, sickness, and death are all duhkha---unsatisfactory and inextricably linked to suffering.
(2) The cause of these sufferings is self-centered desire.
(3) The elimination of self-centered desire eliminates these sufferings.
(4) The way to eliminate desire is the Eightfold Path, including meditation.
If there were no rebirth after death, then death would be the end of this cycle of suffering, and the Buddha would have had no need to seek the way to nirvana. In other words, Buddhism presupposes the wisdom that life continues as rebirth after death, as well as offers ways to confirm this presupposition through meditation. If the Buddha were unconcerned with the suffering of others, he would never have left his home for years of ascetic meditation. In other words, Buddhism presupposes the compassionate knowledge that our own welfare and suffering is inseparable from the welfare and suffering of others, as well as offering ways to confirm this presupposition through meditation. In response to human suffering in life and death, Buddhism presupposes the wisdom that this is not our only life and the compassionate understanding that we are not the only ones who suffer. The fundamental response of Buddhism is not to try to change reality to meet our unlimited desires but to try to change our desires to be able to accept reality as it is.
The Buddhist view is that painful material experience repeats itself indefinitely until desireless selflessness is attained. It points out that pain comes not only from being killed, hurt, or limited, but also from awareness that our human lives depend heavily upon killing, hurting, and limiting other sentient beings. The more "advanced" our civilization, the greater pollution, destruction, and exploitation each of us imposes on the ecosystem and the developing populations that support our consumptive lifestyles. The more aware we become of the burden that our desires impose upon other sentient beings and the unsustainability of life based upon limitless desire, the humbler we become about wanting to extend a particular life at the expense of others. Of course, we can imagine cases where a loving family desires to preserve the life of an ailing grandparent even at great expense. But Buddhism does not acknowledge that individuals have the "right" to demand the sacrifice of others' time or resources to improve their health or prolong their own particular life. The important thing is not the length of life but the equanimity and harmlessness with which it can be lived. An equanimity rooted in ignorance of the damage we wreak on others is not an acceptable and sustainable equanimity. The compassion and selflessness that is the ideal of Buddhism--and that has rendered Buddhist societies of dense populations sustainable for centuries--is incompatible with lifestyles and decision making that place self-interest above that of other sentient beings.
Buddhism teaches that life inevitably involves psychological suffering, concomitant with the realization of the suffering that we cause to other sentient beings. The Jatakas are replete with stories of enlightened animals and humans who gladly give their own lives to reduce the suffering of others who still cling to the desire for life or health. In short, the enlightened Buddha no longer desires physical life, except to teach others the way to selfless equanimity. Buddhist monks live off the surplus of the society; when there is no surplus, they go without eating or depend upon the compassion of others who will share their fast. Buddhist laity, while not psychologically ready to commit to a life of ascetic mendicancy, admire and support their monks because they recognize the value of a spiritual path and hope to follow it in a future rebirth. In short, a realization of the cycle of birth, death, and rebirth decimates our desires to cling to any particular bodily life; and these are precisely the desires upon which markets for high-tech medicine, genetic engineering, and organ harvesting are based.
Traditional Buddhist cultures take sickness as an invaluable opportunity to reevaluate one's thoughts and actions. Whether resulting from stress, anxiety, overwork, cold, imbalanced diet, overindulgence, lack of exercise, or other karma, ailments enforce a period of inactivity and recuperation. This becomes a time of self-reflection in which patients can determine to balance their lifestyle and interpersonal relationships as well. What a waste it would be if illness were simply considered an inconvenience, "lost time" to be overcome with a pill or an injection, if no personal or existential insights were gained about lifestyle in the process!
If the goal of life is to achieve desirelessness, we might well wonder why we should feed or wash our bodies. Asked why Buddhist monks care for their bodies, Nagasena responded with the analogy of a fetid oozing wound. People bandage or care for a wound not because they love the wound but because they do not want it to fester or trouble them more (Vinaya Pitaka 1.302; Mahavagga 8.26). In fact, monks have served as compassionate caretakers for the sick and the dying throughout Buddhist history. They developed a herbal apothecary; their temples served as dispensaries; and monks cared for the sick, aged, widows, and dying. Buddhists never presumed that they could "overcome" sickness, aging, or death. Rather, each of these existential crises presented an opportunity to awaken to the transitoriness and troubles of life.
After all of this, it does not follow that Buddhists do not practice compassionate medicine. On the contrary, it was Buddhist monks who carried natural herbal medicine to the corners of civilized Asia, from the time of Emperor Ashoka until recent centuries.
The Buddhist ministry toward the sick, compassionately designed to heal illness or alleviate pain wherever possible, is first and foremost a ministry of enlightenment, to heal the mind of selfish delusions and attachments. The Buddhist rules for living (Vinaya, Mahavagga, 1.30) state that Buddhists are to use no medicines but natural ones. Buddhists are only to care for their own and others' bodily well-being so that they may better demonstrate and teach the way of selfless compassion (Maha-parinibbana-sutta, 9). Buddhists are enjoined to relieve suffering, by legal and physical remedies when possible, but above all by using every such occasion to preach the Noble Truths (Srimaladevi-simhanada-sutra, 21). Buddhist herbal medicine is designed to alleviate suffering, to prevent or minimize disease, and to create conditions conducive to the maintenance of health in ways compatible with sustainable ecosystems and equal availability. It does not depend upon animal experimentation nor strive for enhancement of physical prowess or attractiveness.
For centuries, Buddhist priests have served as doctors of the bodies and souls of their constituencies; Buddhist temples have served as hospitals and hospices; and the relief of suffering has been a cornerstone of Buddhist practice as well as teaching. The truth of Buddhist enlightenment does not mean total resignation to whatever ill health may befall, but, rather, an understanding that (a) aging, illness, and death are inescapable aspects of biophysical life; (b) the reduction of suffering is good, but many medical activities simply postpone the inevitable, giving rise to the counterproductive delusion that aging, illness, and death might be defeated or avoided; and (c) if the means for reducing suffering or prolonging life create greater inequalities, damage other sentient beings, or are otherwise unsustainable, then it were better from the outset not to promote them.
The wandering mendicant "brothers" and "sisters" of the original Buddhist community (sangha) did not intend specifically to become a ministry of medicine, welfare, or elder care. The Buddha had laid down numerous rules of hygiene and health care, and to maintain their own health, his disciples added to their own store of herbal lore. The contemporary Indian society dictated that many of their members were elderly males who had already finished the social duties of the "householder" life stage. While traditional Indian society decreed that children should care for their aging parents, the Buddhist sangha members had all renounced family and society for the life of meditation, so it fell to them to care for their own elders and conduct funerals for their own dead.
Buddhism diffused from the wandering mendicancy of India into the settled agricultural temple communities of China and Korea. Like European monasteries of the Middle Ages, some Asian temples also served as hostels to travelers, and some became known for their good care of the sick and aged. When Buddhism was transmitted from Korea to Japan, it was arguably the superiority of Buddhist hygiene and medicine that enabled its followers to gain a foothold against the militantly reactionary native Shinto opposition. Some of the oldest temples in Japan today, like Nara's Horyuji and Osaka's Shitennoji, distinguished themselves by setting up infirmaries as early as the seventh century. By the tenth century, Buddhist monks in Japan had assumed the role of guiding elders through that last great rite of passage. Monks followed detailed instructions on the palliative and spiritual care of the dying, recording their deathbed visions, guiding their transition from the dying body to the next, disembodied, state. Some monks meditated on the foulness of the body and painted scrolls of dead bodies in states of decomposition; others recorded the images of heavens and hells that they saw in their meditations.
By the thirteenth century, new schools of Buddhism were growing up in Japan, centering upon preserving a calm state of mind throughout life and especially at the moment of death. From this time until the beginning of the modern era in the 1860s, most doctors were Buddhist monks, and many Buddhist monks were doctors, caring holistically for the minds as well as bodies of their patients. Even more than healing and terminal care, however, Buddhism became so inextricably intertwined with the last passage that people derided it with the epithet "funeral Buddhism." Yet in recent years, Japanese Buddhists again have been establishing hospices, pain-control clinics, counseling centers, and ministries of care--a development long overdue and greatly welcomed.
Buddhism emphasizes not aggravating suffering, not increasing the disparities between the privileged and the unprivileged. Kant's Categorical Imperative catches one aspect of this Buddhist view. In other words, if the operation or action that we contemplate cannot be generalized to a principle that all people would follow--or if the results of imagining all people following the same course of action would prove undesirable/unsustainable--then that particular course of action should not be undertaken. When it becomes clear that a medical procedure will likely prove futile, the Buddha recommends preparing one's mind for life (including the spiritual life following the death of this physical body) rather than clinging to the life of one particular body. This stance becomes doubly important when the probably futile operation would deprive resources from others with greater chances of peaceful life. This sees organ harvesting as morally problematic when there are inevitably more people potentially in need of organs than there are brain-dead people (or corpses) able to donate viable organs. The result is that doctors or "God committees" must decide who will live and who will die. It tends to promote the desire for long life in a particular body and to perpetuate the illusion that longevity is somehow more important than the quality of spiritual equanimity therein.
The Buddhist critique of the Western-style multinational medical and pharmaceutical industry is that it is less the product of compassion than of the money-making attachment of its purveyors. It is demonstrably more effective to elevate national health and life span by addressing public funds to the basic common denominators of sanitation, health education, family planning, safe sex, and the preventive health care of lifestyle improvement. But it is more in the interests of the multinational pharmaceutical and medical industries to spend billions in the pursuit of elusive cancer drugs, artificial organs, and genetic engineering. The patenting and commercialization of genetic information and materials in the not-so-distant future threatens to create ever-greater gaps between the genetic as well as financial "haves" and "have-nots."
While Buddhism criticizes the tendency to judge people on their salaries or appearances, the capitalist medical-educational system tends to implant in its doctors those very concerns with salary and status seeking while reducing their patients to the status of statistics in their reports. Already, medical professionals in Tokyo and Bangkok approach the epitome of a worldview that sees people strictly in terms of numbers--test scores, salaries, golf scores, frequent flyer miles, horsepower, carats, patents, controlling votes, etc.--rather than for deeper intrinsic or spiritual values such as wisdom, compassion, or kindness. If present trends continue, genetic engineering will inevitably entail even deeper-rooted discrimination on the basis of genetic makeup--and perhaps on the basis of the financial ability or inability to modify it. In the words of Buddhadasa, "Make things humble so they don't trip the mind."
Buddhists cannot condone a medical system that empowers and reimburses rich drug companies to harvest drugs and genetic materials from barefoot peasants in the rainforests or that enriches elite groups of Western-educated golf-playing jet-setting surgeons at the cost of ignoring the problems of poverty and sanitation under our noses. The greater Buddhist agenda, like that of the Third World at the Rio Summit, is how to get the elite minority to take seriously the suffering of the poor--the majority of the world! For the rich to ignore the suffering of the poor while debating the morality of unavailable transplantation and genetic engineering is perilously analogous to towered scholastics debating the number of angels dancing on the head of a pin while plagues and Crusades rage--in Buddhist terms: not conducive to enlightenment.
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