Chua Duoc Su

In traditional Buddhist societies, medical ethics, as a systematic formulation of principles and their application to cases, has not been a major concern. That is not to say that Buddhists have ever ignored illness and health care. On the contrary, the metaphor of the Buddha as the supreme physician, who cures the ills of the world and of the individual sufferer, is ancient and major in the Dharma (1). Furthermore, caring for the sick both within and without the monastic order has been understood as an excellent way to manifest such primary virtues as compassion and friendship.

Nonetheless, it is only recently that there have been attempts to work out systems of health care ethics in Buddhist contexts (2). One of the latest and most ambitious is Buddhism and Bioethics by Damien Keown (3). His general theoretical approach is based mainly on Theravaada primary texts, and centres Buddhist ethics on three "basic goods": life, knowledge (prajna), and friendship (4). These three values inform the next lower level, the level of precepts or ethical rules. Precepts in turn guide decision-making in specific ethical situations.

Respect for life (ahimsa), the first of the "basic goods" according to Keown, is doubtless one of the pillars of Buddhist ethics and generally pervades the Lotus Suutra. It is a key to Buddhist health care ethics and will be discussed below. Knowledge (prajna) as the second "basic good" or core principle of Buddhist ethics in Keown's analysis is also very generally acknowledged as central in Buddhist thought. Prajna is both the supreme paramita in the bodhisattva path and the culmination of cultivation of mind in Theravaada traditions. It pervades the Lotus Suutra. Prajna is often coupled with karuna (compassion) as summing up the Mahaayaana or bodhisattva path. Together, artfully supporting one another, they lead the practitioner to realise his or her Buddha nature. Upaaya (skilful means), a fundamental theme which runs throughout the Lotus Suutra, can be understood as identical to karuna.

Keown, however, takes friendship rather than karuna/upaaya as the third "basic good" (5). Friendship as a Buddhist ideal, he argues, is a complex bundle of rules, virtues, behaviours, and the like which guide us in our relations with all other living creatures. Friendship includes compassion (karuna) when appropriate, but much more as well. Identifying friendship as a basic Buddhist good is one of the innovations (a fruitful one in my view) in Keown's book. In the Lotus Suutra the qualities of friendship that Keown describes are found in the relationships between the various characters. For example, the parable of Devadatta in chapter twelve shows the efficacy of friendship, which goes beyond one particular lifetime into future incarnations to enable a very wicked man to realise his true nature, his Buddhahood.

Other attempts to develop Buddhist health care ethical theories are generally both less complete and more conventional than that of Keown. One approach has been to try to fit Buddhist and other traditions' ideas about health care into four principles: autonomy, beneficence/non-maleficence, justice, and autonomy (6). These four principles have been very useful to many Western theorists, which is not surprising as they are drawn from Western philosophical, political, and medical sources. But do they apply well in the Buddhist context (7)?

Interestingly enough, in a later journal article, "Bioethics in Thailand," Ratanakul turns to his Thai Theravaadin tradition as the source for fundamental bioethical principles and comes up with four. They are veracity, non-injury to life, justice, and compassion (9). In the spirit of his comment, "There is much work to be done both in clarifying these and other principles and in applying them," (10) let us turn our attention to his 1986 and 1988 formulations with especial attention to how these principles cohere with the teachings of the Lotus Suutra.

Dr. Ratanakul describes autonomy as the ability of an individual "to order, plan, and choose among the diverse human potentialities, the pattern of their own lives, as long as it is consistent with meeting the rightful claims of others upon them and the fulfilment of their responsibilities as moral agents" (11). In traditional Buddhist ethics, autonomy is not featured as a major category. The Buddhist emphasis on the responsibility of each person for his or her own karma or moral character implies something like this notion; however, there is something in the modern Western insistence on autonomy that goes against the Buddhist grain. While Dr. Ratanakul is careful not to fall into extremes, individualistic autonomy is contrary to the central Buddhist insight of co-conditioned causality, which insists on the interdependency of all beings. It is particularly at odds with the bodhisattva ideal of sacrificing self for others that is at the heart of the Lotus Suutra At any rate, we note that in his later formulation, autonomy has dropped from Dr. Ratanakul's list of fundamental principles.

Non-injury to living beings must, I think, be central to any Buddhist medical ethical system. As Dr. Ratanakul put it, "In a Buddhist society it is well known and accepted that a primary obligation is non-injury to others" (12). Non-injury to life (ahimsa) applies to all sentient life, but otherwise is the same as non-maleficence, which in the Western world has usually referred only to human life, although this may be slowly changing now. As mentioned earlier, Keown also identifies ahimsa as a basic concept at the foundation of Buddhist bioethics. Obviously, it is very powerful as a general principle in health care ethics and, as noted above, pervades the Lotus Suutra.

In his 1988 article Dr. Ratanakul identifies justice as a basic Buddhist teaching and singles it out as one of the fundamental principles on which to base a Buddhist bioethical system for Thailand. He explains his concept of justice to be understood in terms of impartiality and equal treatment, giving to each one what is his due. People may be different from us either by their economic condition or by their social status, but as moral potentialities they are equal to us and therefore deserve equal treatment. (13)

This concept of justice is a modern Western one; compare it to Gillon's formulation in Principles of Health Ethics where justice is "often regarded as synonymous with fairness, and reasonably summarised as the moral obligation to act on the basis of fair adjudication between competing claims" (14). In practice, he continues, justice is based on the principle of equality for all persons and is discussed under three headings: "distributive justice" or fairness in the allocation of resources, "rights-based justice" or respect for individuals' rights, and "legal justice" or reliance on fair legal codes and procedures.

Traditional Buddhist sources have very little to say about justice. Buddhaghosa, for example, a Theravaadin scholar of the fourth or fifth century CE, who may be the greatest exegete that Buddhism has produced, does not seem to mention justice at all in his masterpiece, the Visuddhimagga (15). Tachibana, in his still valuable 1926 path-breaking book The Ethics of Buddhism, attempts to formulate a comprehensive ethical system from the texts of Theravaada Buddhism. In the early parts of his book, he stays very close to the traditional terminology and formulations, and does not mention justice at all. Then he changes his tack and decides to reformulate Buddhist ethics according to modern categories. "This is firstly to make the moral ideas of the Buddha clearer, and secondly to see how far a moral system designed twenty-four centuries ago can appeal to the modern mind" (16).

Justice appears as a major category in his modern reformulation, but he notes that it is not at all easy to find precise equivalents from the Buddha's time to our own twentieth century for such basic terms as justice, righteousness and impartiality (17). In effect, he seems to admit that he was unable to show that justice is a fundamental ancient Buddhist principle of social ethics. Nonetheless, recognising that justice is a keystone for any ethical system which is to appeal to people shaped by modern Western thought, he goes ahead in a very appealing but not quite convincing way to use justice in his scheme of Buddhist ethics.

A review of current work in the field of Buddhist ethics generally confirms the impression that justice is not a fundamental category of understanding in Buddhist thought. First, in the 1991 book Buddhist Ethics and Modern Society, a compendium of papers from a major international conference of Buddhist scholars, justice is only mentioned in one passage, in the contribution of Sulak Sivaraksa, the noted Buddhist reformer from Thailand (18). In his paper Sulak argues that there is indirect support in Buddhist thought for a "minimum distributive justice" (p. 163) from general Buddhist principles of the middle way. Sulak notes that there is nothing in the scriptures or in Theravaada tradition that directly advocates radical social transformation.

Both Gunapala Dharmasiri's Fundamentals of Buddhist Ethics (19), which appeared in 1989, and Damien Keown's The Nature of Buddhist Ethics (20), a 1992 title, fail to discuss the issue of justice as such although there are indirect discussions of related issues. Two major books in the field appeared in 1995. The first, Buddhism and Bioethics by Damien Keown, is interesting for its complete lack of any discussion of justice (21). The term itself, I believe, does not occur. Keown restricts his field of sources to the Pali texts and thus does not draw upon historical or ethnographical material. David Kalupahana, on the other hand, in his Ethics in Early Buddhism, which mines the same sources as does Keown, devotes chapter fifteen to "Law, Justice, and Morals" (22). There he argues that dhamma (Sanskrit: dharma), which is one of the most fruitfully pregnant terms in Buddhism, is the equivalent of "justice." At one level this is true, but I think the equation is ultimately misleading, since "justice" in the context of ancient India (the Pali and Sanskrit context) is quite a different kettle of fish from justice in the contemporary English-speaking world. Kalupahana also recognises this implicitly, noting throughout the book that the Buddha's specific teachings on social order focus on two quite different models.

First is the more or less democratic order of monks, and second is lay society for which a universal king, following the ancient Indian model, whose job it is to turn the wheel of Dharma for the world, is offered as the ideal ruler. Neither of these forms, in my opinion, has much to do with justice as understood in contemporary Western countries such as Canada. These forms, however, have worked well in the past in South and Southeast Asia as the foundations for a good society, and are still live options. In East Asia, the wheel-turning king as portrayed in the Lotus Suutra and other texts has also been the model for the ideal ruler.

Kalupahana argues that both the polity of the monks and the underlying basis for the universal wheel-turning monarch are consistent with John Rawls' view of the foundations for achieving a just society (23). I would agree with both Sulak and Kalupahana that there is indirect support for ideas of social and individual justice in Pali text Buddhist traditions. Or perhaps it would be better to say that there is no contradiction between Buddhist traditional teachings and the modern Western concepts of justice. Since Buddhism has been very successful in adapting itself to all sorts of social realities, and since we seem to be in an era where Western social forms are increasingly dominant, perhaps it will be the work of Buddhists in the twenty-first century to synthesise Buddhadharma and justice.

"Taking life" is then the will to kill anything that one perceives as having life…insofar as the will finds expression in bodily action or in speech….In the case of humans the killing is the more blameworthy the more virtuous they are. Apart from that the extent of the offence is proportionate to the intensity of the wish to kill. (24)The severity of the offence is a function of the amount of virtue of the victim, hardly an egalitarian concept.

Dharmasiri notes that although the Buddha rejected the caste system and taught that all persons are equal in that they are subject to the same moral law and in that every person is a potentially enlightened being (25), he also taught that class society is inevitable. Classes do not have equal rights and duties; rather they "should have reciprocal moral relationships with each other" (26). Indeed, this seems to be the major principle behind social relationships in traditional Buddhist countries and is quite consistent with the teaching of the Lotus Suutra. The basic model is paternalistic, as is very explicit in the case of the king, who, the Buddha taught, should rule according to Dharma, "treating his subjects as parents treat their own children" (27). Some of the parables of the Lotus Suutra, such as the parable of the rich man and his sons in the burning house (chapter three), the jewel in the gown (chapter eight), and the skilled physician (chapter sixteen) spring to mind as powerful teachings in favour of patriarchy.

These ancient, traditional social teachings do, however, strongly support the provision of adequate health care for all people, even all living creatures, in society. The higher individuals in the reciprocal relationships have a duty to be concerned for the welfare of those in their care, and this most definitely includes health matters. For example, masters are taught to give their servants help in times of sickness (28); and at the highest level, the king's first duty to his subjects is to give them "help when and where it is needed, i.e., a material or verbal or manual help" (29).

In Buddhist political thought, the Dharmaraja (the king who rules by righteousness or by Buddhist principles) or cakravartin (literally, the wheel-turner, or the king who turns the wheel of righteousness) is the ideal ruler (30). The royal precepts and virtues enumerated above are drawn from that tradition. Asoka, an emperor in India who reigned in the third century BCE, is the king revered today as the one who most nearly embodied the Dharmaraja ideal, and he was very vigorous in promoting non-harming as a principle of governance and as a way of life for his subjects. As well, he took great interest in the physical welfare of his subjects and provided medical herbs to be distributed free of charge to the people of his kingdom and also to the animals (31).

It seems that justice in the egalitarian sense does not have a firm base in Buddhist traditional thought. Perhaps a sounder Buddhist case for an equitable distribution of health services could be built on the foundations of karuna (compassion), a fundamental virtue for all Buddhists, friendship as a "basic good" (borrowing from Keown), and on the noblesse oblige expected of the ideal Buddhist monarch, all of which seem to be consistent with the teachings of the Lotus Suutra. All three of these entail helping the poor: karuna and friendship as primary virtues should motivate individuals, whether commoners or royal, and the state should manifest the ideals of the Dharmaraja, the king who rules according to the teachings of the Buddha (32).

Compassion is one of the most fundamental Buddhist categories, so fundamental that the entirety of the tradition can be described as compassion (karuna) and wisdom (prajna) working together. It is important to keep in mind that the two are linked and one without the other is dangerous. For example, a person who is not wise may cause enormous problems by witlessly attempting to be compassionate, and a person who has penetrating insight without compassion is very dangerous indeed.

In order to help one attain this balance, to make sure that the practitioner develops skilful means (upaaya), certain sublime states of mind are cultivated in Buddhism. There are four of these taught by all schools of Buddhists and recognised as necessary for living a moral life, generating kusala karma, or skilful deeds, rather than the opposite. The four are loving kindness for all sentient beings, compassion for the unhappiness of others, sympathetic joy for the happiness and good fortune of others, and equanimity (33). On the level of practice, the Lotus Suutra could be interpreted as no less than an extended sermon on how to live the transcendental bodhisattva path by using skilful means compassionately, thus embodying the four sublime states just detailed. Were a nation to be governed according to these impulses, its health care system would be a most excellent manifestation of Buddhist beneficence.

The fourth principle which Dr. Ratanakul sees as essential in Buddhist biomedical ethics is veracity, which he firmly bases on another of the five basic moral precepts: "I undertake to observe the rule to abstain from false speech." In applying this precept to medical ethics, he concludes that one must always tell the complete truth to the patient. Failure to disclose the truth is generally, he argues, due to denial and fear on part of medical personnel. If the patient does not know all the facts of his or her condition, then his or her "strength, will-power, and endurance" (34) will be compromised. Buddhists know that life is hard and full of suffering and have always taught that these truths must be dealt with frankly and openly. Hiding from the unpleasant side of things is not part of the Buddhist way.

This insistence on veracity fits in very well with the current doctrine in Western medicine that the patient as an autonomous moral agent has a responsibility for his or her own health and care. However, in the Mahaayaana tradition, there is rather different approach to the issue of veracity. In chapter sixteen of the Lotus Suutra, there is a parable where the Buddha compares himself to a skilful physician. All his sons have foolishly taken some powerful, poisonous medicine. Those who are most deranged by the poison refuse to take the antidote which he has quickly prepared. Therefore, he deceives them by feigning his own death, thereby shocking them back into their right minds so that they will take the remedy. Lord Buddha rhetorically asks the assembly, "Is there any man who can say that this good physician is guilty of the sin of wilfully false speech, or is there not?" And they reply: "There is not, O World-Honored One" (35). In his discussion of the Lotus Suutra in his recent book of readings, Buddhism in Practice, Donald Lopez demurs from the judgement of the assembly. He argues that "the claim to legitimacy of the earlier tradition is usurped by the Mahaayaana through the explanation that what the Buddha had taught before was in fact a lie" (36), albeit a compassionately motivated lie. Too strong by far (37), but it does point to an interesting question: is it not possible for the doctrine of skilful means, in less than skilful hands, to lead in a direction away from the Dharma? The parables of the Lotus Suutra are taught as examples of upaaya or skilful means. It would seem that deception on the level of relative truth is quite justified as long as it advances the cause of absolute truth and, as in the story of the skilful physician, is beneficent. Of course, if a deception led to harm of sentient beings, it would be unskilful rather than skilful. Thus, in Mahaayaana thought at least, a case could be made for the health care team withholding the truth or even deceiving a patient if such withholding or deception was thought for good reason to be therapeutic.

This sort of paternalism is no longer stylish in the West and many current health care ethicists reject it, including Dr. Ratanakul, who writes, "The practice of paternalism in regard to truth-telling is therefore unacceptable to Buddhism" (38). Although his argument for veracity on medical, general ethical, and Buddhist grounds is strong, it nonetheless seems to me that his conclusion is overstated, especially in regard to the Mahaayaana. Medical paternalism may be justifiable in traditional Buddhist societies, which accept that society is to be governed by ancient hierarchical principles enshrined in the texts and traditions of Buddhism. It certainly is the current practice in Japan in regard to cancer diagnosis, where physicians practically never reveal the truth to their patients. While Mahaayaana teachings on skilful means provide a theoretical justification for this, Japanese cultural attitudes towards bodily disintegration are also important (39).

Chapter five consists of a lovely parable about how beneficent waters nourish all plants without discrimination, whether they are tiny medicinal herbs or awe-inspiring giant trees. In the Chinese version of the text, the one which is influential in the Far Eastern Buddhist communities, there does not seem to be anything in this chapter that applies to medicine or medical ethics. The Sanskrit version (translated by Hurwitz and Kern) ends with a lengthy parable that is interesting in this regard. In this parable a man who has been blind from birth relies on his own experience to deny that there are any shapes at all in the world to be seen. A compassionate and supremely skilful physician takes pity on this man and collects and prepares four wondrous herbs which restore the man's sight. Seeing heavenly bodies for the first time, he now claims to be all-seeing and to have attained perfect extinction. Wise seers quickly correct him and point out how ignorant he actually remains.

This parable makes use of the classical metaphor of the Buddha as the supremely skilled physician. It could be taken as a practical example for all Buddhists, who should emulate his compassion by applying their efforts and skills to treating the ill. It is also making one of the primary points of the Lotus Suutra, that those who follow the lesser of the three vehicles need to be reminded that they are a long way indeed from the ultimate goal.

The bodhisattva Medicine King (Bhaisajya-raja) occurs in several places in the Lotus Suutra. These passages seem to foreshadow the celestial Medicine Buddha (Bhaisajya-guru), who became very important in the Buddhist traditions of the Far East (40). The Medicine Buddha is very explicitly charged with taking care of the physical and mental health of devotees and has taken vows to that effect. In the Lotus Suutra the medical aspects of the bodhisattva Medicine King are not obvious.

Chapter ten on the Teacher of the Law begins with the Lord Buddha addressing the assembly through the bodhisattva Medicine King, but I find no medical references at all in the chapter. Similarly chapter thirteen on Holding Firm begins by mentioning bodhisattva Medicine King as part of the audience, but has nothing in it about medicine. Some of the Buddha's previous existences are covered in chapter twenty-three, a very interesting chapter in which the bodhisattva offers his entire body, his arms, and his fingers out of reverence as fire offerings, a practice which was frequently emulated up until recent times (41). Near the end of chapter twenty-three there is a reference to the medical efficacy of the Lotus Suutra: anyone who hears it will be cured of sickness, old age, and death.

In the Dharani chapter, chapter twenty-six, the bodhisattva Medicine King offers a dharani for the protection of those who preach the Lotus Suutra. The spell has no medical references. However, in the same chapter, a horde of female demons offer a dharani that protects men, women, boys, and girls against all manners of demonic beings and against all manners of fevers. The final mention in passing of the bodhisattva Medicine King, along with his brother Medicine Superior, is in chapter twenty-seven dedicated to these two bodhisattvas' father. There are no medical references.

On the other hand, those who slander or disparage the Lotus Suutra have much to lose. In chapter three there is a passage that says that anyone who speaks badly of the teachings shall be afflicted with all sorts of congenital deformities and illnesses. Furthermore, he or she will be unable to heal anyone else, and any medical attention he or she receives will exacerbate the condition treated. At the very end of the Lotus Suutra—perhaps the placement of this passage is a sign of its importance—terrible medical results are promised for those who disparage believers of the Suutra. Blindness, deformity, or leprosy will be their fate for generation after generation.(5) Bodhisattva practices

Chapter fourteen details appropriate activities for one who is cultivating the bodhisattva path, and chapter twenty-five is a marvellous account of how a bodhisattva of great attainment, namely Avalokitesvara, is able to help anyone who calls on him in a time of need. I find it interesting and somewhat surprising that medical matters are completely absent from both sets of practices. However, in the introductory chapter, bodhisattvas are commended for offering hundreds of different kinds of medicines to the Buddha and his monks.

In the study of ethics in the West there is widespread agreement, perhaps an emerging consensus, that certain principles—autonomy, beneficence, non-malfeasance, and justice—apply prima facie to health care issues. Not all of these four principles fit into a Buddhist framework. Two of them, however, do fit well. Non-malfeasance and the Buddhist principle of ahimsa (non-harming) appear to be practically identical. Furthermore, karuna (compassion), which perhaps is the central ethical principle of the Buddhist tradition, is very similar indeed to beneficence. Autonomy is also important in Buddhist practice, but, as argued above, is not central, and there are important differences both in theory and in application to health care from the way it is understood in the West.Justice seems to be the sticking point. Egalitarian justice is not part of traditional Buddhism, although justice in health care can be approached using other Buddhist ideas and practices. As noted in the introduction, Buddhism has a wonderful flexibility, enabling it to adapt to and to learn from new situations. It is noteworthy, I think, that converts to Buddhism in the Western world, eastern Buddhists who have settled in the West, and those like Dr. Ratanakul who have been influenced by Western thought, are tending to make justice a central Buddhist value (43).

"Cease to do evil, learn to do good, cleanse your own heart," the catch phrase which is popularly used to sum up the essence of Buddhism, suggests how important non-malfeasance, beneficence, and self-reliance or moral autonomy are in Buddhist thought. All three are aspects of karuna (compassion) and upaaya (skilful means), the qualities necessary to function well in the world as a Buddhist. These relative qualities must, of course, work in conjunction with prajna (wisdom), insight into absolute truth. To be true to the Buddhist tradition, any theoretical system of health care ethics must be based on wisdom and compassion, and all applications should manifest skilful means. The underlying principles of the Lotus Suutra are consistent with these, and the parables and references to medical matters offer some specific guidance. At the present, with the tremendous changes and challenges taking place in the heath care field, Buddhist thought, by applying wisdom, compassion, and skilful means to both theory and practice, can make a tremendous contribution to bioethics.

2- The Journal of Buddhist Ethics, vol. 3 (1996), has six papers from the 1995 American Academy of Religion panel "Revisioning Buddhist Ethics." These papers reflect some of the current excitement and flux in the general field of Buddhist ethics. Their general comments are very apt as well for Buddhist health care ethics. One of their recurring themes is to suggest that there is very little commonality in theoretical approaches to ethical reasoning in Buddhist texts and traditions. It seems to me that there are many authentic ways or tools that Buddhists have used throughout the centuries to think about ethical issues, just as there are many paths in Christian and Western ethics. Today, modern Buddhists, both Eastern and Western, are coming to grips with new problems and issues and are struggling to come up with practical solutions that are true to their religious heritage and their national traditions. No unified answers or approaches can be expected, and such really are not to be hoped for in the Buddhist tradition which respects diversity.

15- Buddhaghosa, The Path of Purification (Visuddhimagga), 2 vols. (Berkeley and London, 1976), Lamotte, Histoire du Buddhisme Indien, vol. 1, (Louvain: Université du Louvain, 1976), pp. 25ff., and several other basic source books yielded nothing on justice as an early Buddhist concern. Similarly, S. Punyanubhab, "An Outline of Buddhist Tenets," in National Identity Board's Buddhism in Thai Life (Bangkok: Funny Publishing Limited Partnership, 1981), pp. 19–28, and other contemporary popular treatments of Buddhism fail to include justice as a fundamental tenet.

33- S. Taniguchi, A Study of Biomedical Ethics from a Buddhist Perspective (Berkeley: Graduate Theological Union and Institute of Buddhist Studies), pp. 65–69 and E. Conze, Buddhist Meditation (London: Unwin, 1972), pp. 118–132. Dr. Steven K.H. Aung in his "Loving Kindness: The Essential Buddhist Contribution to Primary Care," Humane Health Care International [formerly Humana], vol. 12.2 (April, 1996), pp. 81–84, does an excellent job of explaining how metta can function in the day to day practice of medicine.