Buddhism and Palliative Care in Japan
by Masahiro Tanaka
Buddhism was started by a man who found an answer to the problem of the suffering that stems from the fact that there is no escape from death. Hence, Buddhism has been related to palliative care, especially spiritually, since its birth. The Buddha was descended from the noble family of the Shakya clan, which shared in governing the small state of Kapilavastu, which is thought to have been located near the border between India and Nepal. His whole life was quite different from that of Jesus Christ. He was neither arrested nor crucified. He grew up as a wealthy aristocrat, married, and fathered a child.
His happiness ended when he became conscious of the basic facts of human existence. He witnessed for the first time old age, sickness, and death and worried that he too would grow old, sicken, and die. He decided to leave his home and chose a life of homelessness, seeking salvation from suffering--such as aging, disease, and dying--in the practice of yoga. He was twenty-nine years old. After six years of practice, he solved the problem of suffering, reconciling himself to the fact that there is no escape from death. That led him to a way of life in which one works to continually control one's egoism completely. The spiritual pain of aging, disease, and death disappeared in the Buddha once he realized complete freedom from attachment to the self, which included attachment to his own life. At the same time, the compassion not to discriminate others from oneself appeared in his heart.
The Buddha was enjoying a kind of yoga that blew away the spiritual pain related to death, but he hesitated to tell people about this path to salvation. Telling a person the truth often harms the person if the truth is that his or her life will end. But without telling others this truth, the opportunity for them to realize their own salvation would be missed. It is interesting to note the similarity between the Buddha's hesitation to convey the truth about his salvation and the still common hesitation in Japan about telling cancer sufferers the truth about their condition. To tell patients that their cancer cannot be cured could cause them spiritual pain. After an inner struggle with this paradox, the Buddha decided to teach others about his salvation out of his compassion for humanity.
The Buddha's first students were his five former ascetic companions. He told them about the Four Noble Truths, which are "the truth of suffering; the truth of cause of suffering; the truth of extinction of suffering, otherwise known as nirvana; the truth of the path to nirvana." Suffering was the Buddha's main concern. Here, suffering is a translation of the Sanskrit word duhkha, which literally means "to be denied what we desire."
The Buddha said that there are eight kinds of suffering. The first four are birth, aging, disease, and death. The last four are separation from what we love, contact with what we hate, unattained aims, and the suffering inherent in the aggregates of attachment to five components of oneself. The last suffering summarizes all sufferings. Attachment to the self is the fundamental suffering. The cause of suffering is passion, such as the passion for sex, the passion to live, and the passion to die (sometimes called the death instinct). These three passions correspond to the three elements of life in biology: reproduction, dynamic equilibrium, and death. The extinction of suffering is the state of nirvana, wherein passions are extinguished, and suffering, that is, attachment to self, is also extinguished. The path to nirvana is one on which one controls the passions completely. Attachment to the self being controlled, compassion for all others appears.
The Buddha's doctrine has no purpose in and of itself. It is but the means to bring happiness to people. And as the Buddha showed, using the metaphor of a raft, the essence of his doctrine was to leave all attachments behind. Imagine a person walking down a road. He comes to a large river. The shore on his side of the river is dangerous, but the shore on the distant side is peaceful. He makes a raft. He crosses the river on the raft and reaches the other shore. After arriving, he has to leave the raft on the shore to continue on his journey. In this case, the raft is a metaphor for the Buddha's doctrine itself. Metaphor literally means "to carry over." And Buddhism, too, is just a "raft" that carries people over to the other shore of happiness. The raft should be dispensed with once one has crossed over to the other shore. A Buddhist is not attached to Buddhism itself, and also the nonattachment of Buddhism does not become attached to the concept of nonattachment.
The Buddha said, "What I can control freely according to my desires is mine. But what I cannot control freely according to my desires is not mine." We do not have control over our bodies as far as birth, aging, disease, and dying are concerned. So in order to control ourselves, we must recognize that our bodies are not our own. There is nothing that can be said to be mine or myself because even this body does not belong to me. If we consider ourselves thus, we do not discriminate others from ourselves. This is the wisdom of equality in Buddhism. Having compassion for all people without attachment to self is the situation of a Buddhist who affirms all other religions equally. Therefore, many personalities gradually came to be included in Buddhism, and the concept of the mandala, which encompasses all types of human life, developed.
Buddhism as such expanded throughout Asia thanks to its association with medicine. In the third century BCE, Ashoka, ruler of an Indian kingdom, had a medicinal herb garden that was the oldest of its kind in the world. He sent Buddhist priests to many foreign countries to treat people with medicine from his garden. In this way they could save people from physical diseases through the medicine and from spiritual suffering through the Buddha's teaching. It is interesting to note that in Japan, the first national hospital was established in a Buddhist temple.
Unique Buddhist manners and rituals for dying developed in Japan. One of these ideas was contained in a text titled "The Esoteric Exposition of the Most Important Matter in Life," which has nine chapters. The first chapter says that if a disease can be controlled by medicine, one must never give up nor give in to death. The second says that if a disease cannot be controlled, and there is no way to be healed, one must not cling to life. From the third chapter, one learns how to prepare for death by concentrating one's mind on one's own ideal personality of worship--which is the essence of yoga.
Next I would like to discuss how this relates to the current approach toward illness and death in Japanese medicine. The word "religion" in Japanese is written with two characters, shu and kyo, which literally mean "mystery" and "doctrine." The latter half, doctrine, corresponds to the rational part of religion, which can be transmitted easily by words. The first part, mystery, corresponds to that part of religion that is outside of rationality and cannot be transmitted by words and requires a master-disciple type of transmission. Almost all Japanese culture developed under the influence of esoteric Buddhism and followed the formality of mystery and doctrine, and included a master-disciple type of transmission. The Japanese cultural changes that grew from this esoteric influence include the Japanese arts of flower arranging, poetry, calligraphy, painting, and theater.
Also, a nonverbal communication style gradually became more important than one of open verbal communication. To understand something difficult that cannot be expressed in words easily, one needs to relive it or experience it vicariously. But vicarious experience requires that one has already, at some point, had the actual experience. If one has not, metaphors or symbols are frequently used to help people vicariously understand such experiences. The most difficult things to understand, such as the mystery of the Buddha's enlightenment, are called "secrets." The word "secret" in Japan did not originally mean hidden from view but described something that was difficult to understand by verbal communication.
To help in understanding the current state of palliative care in Japan, please consider some reports that have appeared in medical journals. The May 1988 issue of the weekly Medical Tribune described how an international conference on cancer was held using satellite communication. The chairman of the Soviet Union Cancer Society stated that he did not tell cancer patients their true diagnosis because it would cause the patients mental distress, and that in turn would have a negative influence on their condition. An American doctor said that he tells cancer patients their true diagnosis as a matter of course. I think it is because American hospitals have spiritual-care workers that doctors there can tell their patients the truth, whereas the former Soviet hospitals did not. How to prolong a life depends on refutable matters, so science and doctors can handle it properly. But how to live a limited life does not belong to science. So spiritual-care workers must take care of it.
In a paper ironically titled "Curable Cancers and Fatal Ulcers: Attitudes toward Cancer in Japan" published in 1982, it was pointed out that Japanese patients having terminal cancer were generally not told their true diagnosis. Japanese doctors do not approach patients through open verbal communication. It points out that vagueness is an important part of Japanese culture and that there is a principle of secrecy in Japanese culture. This culture of secrecy and vagueness originated in Buddhism.
Unfortunately, Buddhism was excluded from Japanese society in 1868 by the revolutionary government of the Meiji era. When Western culture was adopted to modernize Japan, the government tried to exclude Christianity, attempting instead to replace Christianity with Shinto, the native religion of the people. However, this attempt did not succeed, and the people in charge of spirituality disappeared from Japanese hospitals. After that revolution, the formal vagueness was left without any connection with its important Buddhist spirituality. The resulting absence of spirituality, and therefore, spiritual-care workers, in Japanese hospitals makes it difficult to give a true diagnosis to cancer patients.
Utilization of the principle of informed consent is still not universal in Japan, although it has become the most important principle in medical ethics through the Helsinki and Lisbon declarations. Buddhist priests are not doing their essential work, using the "raft" to transfer patients to the other shore of palliation, in present-day Japan. Currently, many palliative-care units exist in Japan, but the main task of those units is not the relief of spiritual pain but only the management of physical pain. The training of spiritual-care workers is urgently necessary, since they are currently absent from most medical institutions in Japan.
This essay is an edited version of a paper that was delivered by the author at an international conference sponsored by the Pontifical Council for Health Care Workers in November 2004 at the Vatican New Synod Hall, where Catholic spiritual care workers, priests, sisters, doctors, nurses, etc., were convened to study palliative care from all angles.
Reference
Long, S. O., and B. D. Long. "Curable Cancers and Fatal Ulcers: Attitudes toward Cancer in Japan." Social Science and Medicine 16 (1982): 2101-8.
|
|
Home
Copyright (C) 1997-2008 by Kosei Publishing
Co.
All rights reserved.
