The Lotus Sutra and Health Care Ethics
By
Robert E. Florida
Professor of Religion
Brandon University
Brandon,
Manitoba Canada
florida@brandonu.ca
Contents
Buddhist
Medical Ethical Principles
Autonomy
Non-maleficence or Ahimsa
Justice
Compassion and Beneficence
Veracity
References to Medicine in the Lotus Sutra
Conclusion
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In the last several years there has been an increase in interest in the field
of Buddhist ethics, particularly health care ethics. In this paper I will
review the medical implications found in the Lotus Suutra. I will first discuss
some general ethical principles that apply in health care with reference to the
Lotus Suutra, and then go on to specific references in the sutra to medicine.
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Buddhist medical ethical principles
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)?
Dr. Pinit Ratanakul of Mahidol University in Thailand is one of the leading
Buddhist writers in the field of health care ethics. As would be expected, he
is Theravaadin, and his work is deeply rooted in his Thai Buddhist tradition.
He also has his doctorate in Philosophy from Yale and this too has influenced
his thinking.
In Dr. Ratanakul's 1986 book Bioethics: an Introduction to the Ethics of
Medicine and Life Sciences, he takes fidelity to the medical profession,
autonomy, beneficence, non-maleficence and justice as the "prima facie
duties" that underlie bioethics (8). He does not develop them from
Buddhist texts, traditions, or arguments. Rather they come from the Western
philosophical and medical traditions.
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.
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Autonomy
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.
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Non-maleficence or ahimsa
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.
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Justice
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.
Such a synthesis may well be different from the current egalitarianism in
Western theories, if not practices, of justice. I have not found much evidence
for egalitarian justice as a major theme in Buddhist tradition. Consider, for
example, the way that Buddhaghosa interpreted the precept against taking life:
"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).
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Compassion and beneficence
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.
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Veracity
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).
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References to medicine in the Lotus Suutra
(1) Parable of the skilful physician
This parable, which occurs in chapter sixteen, is perhaps the most relevant
and important passage in the Lotus Suutra in regard to the practice of
medicine.It has been discussed above.
(2) Parable of the medicinal herbs
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.
(3) Bodhisattva-mahasattva Medicine King
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.
In summary, it appears that the passages about the bodhisattva Medicine
King, rather surprisingly, tell us little about the practice of medicine or of
medical ethics.
(4) Medical benefits to those who revere the Lotus Sutra
and medical penalties to those who do not respect it
Both chapter fourteen on bodhisattva practices and chapter eighteen on the
benefits of joyous response to the Lotus Suutra detail the health benefits
which accrue to those who have joy and faith in the Suutra itself. As noted
earlier, chapter twenty-three mentions similar wonderful effects.
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.
(6) Inquiries about the health of the Lord Buddha
The appearance of the jewelled stupa in the sky in chapter eleven and the
emergence from the earth of an astounding number of bodhisattvas in chapter
fifteen are examples of the very exalted nature of buddhas in the Mahaayaana.
It is a little jolting to find similar simple inquiries about the health and
vigour of the World-Honoured One:
Is the World-Honoured One at ease,
With few ailments and few troubles?
In instructing the all the living beings,
Is he free from weariness? (42)
It is very strange to me that one so inconceivably splendid could possibly
be ill or weary, and thus these well-meaning inquiries seem out of place.
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Conclusion
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.
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Editions of the Lotus Suutra consulted
Bunno, H., W. E. Soothill, et al., trans. The Threefold Lotus Sutra. Tokyo,
New York: Kosei, Weatherhill, 1975.
Hurvitz, Leon, trans. Scripture of the Lotus Blossom of the Fine Dharma. New
York: Colombia University Press, 1976.
Kern, H., trans. SadDharma–Pundarika, or the Lotus of the True Law. Oxford:
Clarendon Press, 1884.Watson, Burton, trans. The Lotus Sutra. New York:
Columbia University Press, 1993.
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Notes:
1. Raoul Birnbaum, The Healing Buddha (Boulder: Shambhala,
1979). Return to text
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. Return to text
3. Damien Keown, Buddhism and Bioethics (New York: St. Martin's Press,
1995). Return to text
4. Ibid., pp. 43ff. Return to text
5. Ibid., pp. 51ff. Return to text
6. Raanan Gillon, ed., Principles of Health Care Ethics (Chichester: Wiley,
1994). This very large book attempts to apply the four principles across the
board around the world with varying success. For a good discussion of the four
principles see the editor's introductory essay, "Medical Ethics and the
Four Principles." Return to text
7. What follows in the remainder of this section is based upon my paper
"Buddhism and the Four Principles" in Gillon, Principles, pp.
105–116. Return to text8. P. Ratanakul, Bioethics: an Introduction to the
Ethics of Medicine and Life Sciences (Bangkok : Mahidol University, 1986), p.
86. Return to text
9. P. Ratanakul, "Bioethics in Thailand: the Struggle for Buddhist
Solutions," The Journal of Medicine and Philosophy (1988), pp.
13:301–312. Return to text10. Ibid., p. 312. Return to text
11. Ratanakul, "Bioethics: an Introduction," pp. 83–84.
Return to text12. Ibid., p. 54. Return to text
13. Ratanakul, "Bioethics in Thailand," p. 311. Return to
text
14. Gillon, "Medical Ethics," Principles, p. xxv. Return to
text
15. Buddhaghosa, The Path of Purification (Visuddhimagga), 2 vols. (Berkeley
and London, 1976), Lamotte, Histoire du Buddhisme Indien, vol. 1, (Louvain:
Universit 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.
Return to text16. S. Tachibana, The Ethics of Buddhism (1926; reprint, London:
Curzon, 1975), p. 95. Return to text
17. Ibid., pp. 264–265; see A. L. Basham, The Wonder that was India (New
York : Grove Press, 1959), pp. 114–117 and passim, for an indication of how
very different the ancient Indian concept of justice is from the current
Western notion. Return to text18. Sulak Sivaraksa, "Buddhist Ethics
and Modern Politics: A Theravada Viewpoint," Buddhist Ethics and Modern
Society: An International Symposium, ed. Charles Wei-hsun Fu and Sandra A.
Wawrytko (New York: Greenwood Press, 1991), pp. 163–64. Return to text19.
Gunapala Dharmasiri, Fundamentals of Buddhist Ethics (Antioch, California:
Golden Leave, 1989). Return to text
20. Damien Keown, The Nature of Buddhist Ethics (New York: St. Martin's
Press, 1992). Return to text
21. Damien Keown, Buddhism and Bioethics. Return to text
22. David J. Kalupahana, Ethics in Early Buddhism (Honolulu: University of
Hawai'i Press, 1995). Return to text
23. Kalupahana, Ethics, p. 125. Return to text
24. E. Conze, trans. Buddhist Scriptures (Harmondsworth: Penguin, 1959), pp.
70–71. Return to text25. Dharmasiri, Fundamentals, p. 62. Return to text
26. Ibid., p. 61. Return to text
27. S. B. Indr, "The King in Buddhist Tradition," Buddhism in Thai
Life, p. 61. Return to text
28. Phra Dhammadhajamuni, Outline of Buddhism, 2nd. ed. (Bangkok: Mahamakut
Buddhist University, B.E. 2530). p. 43. Return to text
29. Ibid., p. 53. Return to text
30. S. J. Tambiah, World Conqueror and World Renouncer: a Study of Buddhism
and Polity in Thailand against a Historical Background (Cambridge: Cambridge
University Press, 1976). Return to text
31. Basham, Wonder, pp. 53–57, 500. Return to text32. It seems to me
from my time in Thailand that the royal family there lives up to these Buddhist
ideals very well indeed by sponsoring and financing many public health and
other health-related projects. See, for example, T. Kraivixien, His Majesty King
Bhumibol Adulyadej: Compassionate Monarch of Thailand (Bangkok: Kathavethin
Foundation, 1982). Return to text
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. Return to text34. Ratanakul, "Bioethics in
Thailand," p. 308. Return to text
35. L. Hurvitz, trans., Scripture of the Lotus Blossom of the Fine Dharma
(New York: Columbia University Press, 1976), p. 240. Return to text
36. Donald S. Lopez, Buddhism in Practice (Princeton, New Jersey: Princeton
University Press, 1995), p. 29. Return to text
37. Nikayo Niwano, A Guide to the Threefold Lotus Sutra (Tokyo: Kosei,
1981), pp. 110ff., provides a good corrective to Lopez's position. Return
to text
38. P. Ratanakul, "Bioethics in Thailand," p. 308.
Return to text
39. E. Ohnuki-Tierney, Illness and Culture in Contemporary Japan: An
Anthropological View (Cambridge: Cambridge University Press, 1984), pp. 62–65,
207–208. Return to text40. Birnbaum, Healing Buddha, and Nakamura Hajime,
"Buddhism, Schools of: Mahayana Buddhism," The Encyclopedia of
Religion, vol. 2, Mircea Eliade, ed. (New York: Macmillan, 1967), p. 459.
Return to text
41. Lopez, Practice, chapter 36; Paul Williams, Mahayana Buddhism: The
Doctrinal Foundations. (London and New York: Routledge, 1989), pp. 154–155. In
the introductory chapter to the Lotus Suutra it is noted with approval that
bodhisattvas give their own flesh, hands, and feet as offerings. Return
to text42. Bunno Kato, W.E. Soothill, et al., trans., The Threefold Lotus Sutra
(Tokyo, New York: Kosei, Weatherhill, 1975), p. 239. Return to text
43. F. Eppsteiner and D. Maloney, eds. The Path of Compassion: Contemporary
Writings on Engaged Buddhism (Berkeley, California and Buffalo, New York:
Buddhist Peace Fellowship and White Pine Press, 1985). This book is a good
introduction to this phenomenon. Return to text.
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