- The Lotus Suutra and Health Care Ethics
- By Robert E. Florida
- Professor of Religion Brandon University Brandon,
- Manitoba Canada
- Contents
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 text
8. 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 text
10. Ibid., p. 312. Return
to text
11. Ratanakul, "Bioethics: an Introduction,"
pp. 83–84. Return to text
12. 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: 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. Return to text
16. 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 text
18. 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 text
19. 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 text
25. 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 text
32. 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 text
34. 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 text
40. 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 text
42. 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.
Source: http://jbe.la.psu.edu/global.html