48 Buddhist bioethics
Mrs. B is aged 35 and lives in a remote part of the Chiang Mai region of northern Thailand. She is an agricultural worker with only a basic education. She does not use contraception because there is no local family planning facilities. She is married with three children, and has just found out she is eight weeks’ pregnant. She and her husband barely earn enough to support their existing children, and a fourth child would place an unbearable economic strain on family resources.
The Venerable C, a Burmese monk resident in the USA, suffered a severe stroke at the age of 59. He had a history of diabetes, poorly controlled high blood pressure, atrial fibrillation, congestive heart failure, and chronic obstructive pulmonary disease. He had undergone a cardiac bypass operation several years earlier. The prognosis was guarded at best, even with surgery. The attending neurosurgeon asked whether Venerable C would want emergency surgery or if he would prefer to forgo aggressive measures. The monk had not discussed his wishes previously with his fellow monks or students, had made no advance directives, and remained unconscious throughout (Hood, 2005).
What is Buddhist bioethics?
Buddhism is a body of religious teachings attributed to an historical individual called Siddhartha Gautama, who lived in northeast India in the fifth century BCE. Following a profound spiritual transformation at the age of 35, he became known by the honorific title of “Buddha” (“enlightened one”). In common with other Asian traditions, Buddhism believes in reincarnation and teaches that individuals undergo a potentially infinite series of rebirths. However, Buddhism is distinctive in lacking a belief in a supreme being, as well as denying the existence of a personal soul. Buddhists follow the Buddha’s teachings (or Dharma) in the hope of putting an end to rebirth by attaining the transcendent state of nirvana. Buddhism has no head or central authority, and in resolving moral dilemmas Buddhists are encouraged to reflect on the teachings preserved in scripture, to seek the guidance of advanced practitioners such as monks, and to meditate on all aspects of a situation in order to ensure that any decision they reach is in harmony both with the spirit of the teachings and their conscience. There are no international organizations or colleges of Buddhist physicians that serve to formulate policy for the guidance of healthcare professionals. Despite this lack of central authority, there are fundamental moral values and principles that virtually all schools of Buddhism accept. Chief among these are compassion (karuna) and “non-harming” or respect for life (ahimsa), which between them underpin Buddhism’s approach to bioethics.
The most widespread set of precepts in Buddhism are the Five Precepts, and the first of these prohibits causing harm or injury to living creatures (human and otherwise). This is interpreted quite strictly and has an important bearing on bioethics, especially in relation to questions such as abortion and euthanasia. At a theoretical level, recent studies have suggested that Buddhism can best be understood as a form of virtue ethics (Whitehill, 2000; Keown, 2001a, 2005a; Cooper and James, 2005), and if so this offers an opportunity for dialogue with similar approaches to bioethics being developed in the West. The literature on Buddhist bioethics itself, however, remains limited at this time (e.g., Ratanakul, 1986; Harvey, 2000; Keown, 2001b; Tsomo, 2006).
Buddhism is a world religion with a large following both in Asia and the West. However, Buddhists are influenced not just by the formal teachings of their religion but also by the beliefs and practices of their indigenous cultures. In some cases, the influence of the latter may be so strong that it overrides the former, leading to the impression that there is little agreement or uniformity among Buddhists as a whole. For example, there is general agreement among Buddhists in Asia that abortion is contrary to the First Precept, but wide variation among countries where Buddhism is practiced as to what is legally permitted. There is also a diversity of views on this question among Buddhist converts in the West. In traditional Buddhist countries, the nucleus of social concern – as in many Asian cultures – is the extended family rather than the individual, and ethical questions, therefore, tend to be analyzed primarily in terms of duties rather than rights.
Since Buddhism is a transcultural phenomenon, it is impractical to discuss questions of law and policy here at any length. By way of example, some reference will be made to particular Buddhist countries, but readers should bear in mind that there is considerable legal and cultural diversity in the regions of Asia where Buddhism is practiced. More detailed information on local conditions may be found in the references.
Why is Buddhist ethics important?
Buddhism has had a major influence on Asian culture, spreading to every part of Asia and is now growing rapidly in the West. There are approximately five million Buddhists in the USA and around one million in Europe. The total number of Buddhists worldwide is put at 500 million. Given its global distribution, many individuals now look to Buddhist teachings for ethical guidance when facing problematic decisions on medical treatment. It is, therefore, important for physicians and other care providers to understand the underlying values that may influence Buddhist patients in taking treatment decisions. Furthermore, as an Asian culture, Buddhism can provide a complementary perspective on ethics and may have much to contribute to Western discussions.
How should I approach Buddhist ethics in practice?
Buddhism imposes few special requirements on either patients or physicians in connection with medical treatment, and there is no reason why the care of Buddhist patients should pose any special problems. The only exception would be that it would not be appropriate for a monk or nun to be on a mixed ward, and it would be preferable for them to be treated by a physician of the same sex. Unlike Western clergy, Buddhist monks do not function as chaplains, nor do they visit hospitals in a pastoral role or to perform religious services for the sick.
Buddhism is a flexible and moderate religion in which concepts of taboo and religious purity have little, if any, part to play. Religious law imposes no special requirements or limitations on medical treatment, nor are there any special hygiene, purificatory, or dietary requirements (while many Buddhists are vegetarians, others are not). Cremation is the most common means of disposing of the dead.
In practice, local custom tends to have a greater bearing on the physician–patient relationship than Buddhist doctrine. It is difficult to generalize about local customs, but provided the conventions of normal medical etiquette are respected there is no reason why difficulties should arise. This is particularly so in the case of the many Westerners who have converted to Buddhism and who are unlikely to have any problems with the conventions of Western medical practice. As with all societies there is diversity among Buddhist populations arising from socioeconomic factors and level of education, which makes it difficult to generalize how any individual Buddhist is likely to react. At the village level in Asia, for instance, Buddhism coexists with animism, and belief in the power of local gods and spirits to cure illness is widespread. Allowance, therefore, needs to be made for such variation, and the temptation to generalize should be avoided.
Notable differences are found across Asia, particularly between the countries of East Asia, such as China, Japan, and Korea, and those of South Asia, such as Burma, Thailand, and Sri Lanka. The former group follow the Mahayana form of Buddhism, while in the latter the more conservative Theravada form predominates. To highlight just one example, in Japan, the criterion of brain death is deeply unpopular because of its association with cadaver transplants. Being a party to what is seen as the desecration of the corpse of a close relative, particularly a parent, causes deep unease (LaFleur, 2001). There is also skepticism about the validity of the brain death criterion itself as a reliable test for human death, a skepticism increasingly voiced by dissidents in the West (Youngner et al., 1999; Potts et al., 2000).
Another distinctive feature of the Buddhist perspective is the emphasis it places on mindfulness and mental clarity, as seen in the practice of meditation. Buddhism emphasizes the importance of an unclouded mind, particularly when a patient is close to death, as it is believed this can lead to a better rebirth. Some Buddhists may, therefore, be unwilling to take pain-relieving drugs or strong sedatives, and even those who are not in a terminal condition may prefer to remain as alert as possible rather than take analgesics that will impair their mental or sensory capacities.
Abortion
Most Buddhists regard fertilization as the point at which individual human life commences and believe that the embryo is entitled to moral respect from that time onwards. Abortion is, therefore, seen as morally in the same category as the intentional killing of an adult. The only exception is likely to be when the procedure is necessary to save the life of the mother.
The contemporary legal position varies from country to country. The more conservative Buddhist countries of southeast Asia, such as Thailand and Sri Lanka, have laws prohibiting abortion, except when necessary to save the life of the mother. Nevertheless, illegal abortions are common. Somewhat surprising for a country in which Buddhism is the state religion, abortions in Thailand are running at some 50% higher than the number in the USA for the equivalent number of citizens. Married women, who appear to use it as a means of birth control, account for 85% or more of abortions. Recent studies refer to an estimated 300 000 abortions per year, the vast majority of which are illegal. The Thai Penal Code of 1956 allows abortion in only two circumstances: first, “if it is necessary for the sake of the woman’s health” and, second, in cases of rape. Official figures from the 1960s record as few as five legal abortions in some years. Opinion polls in Thailand also reveal an intriguing paradox: while most Thais regard abortion as immoral, a majority also believes the legal grounds for obtaining it should be relaxed (Florida, 1991, p. 22).
In east Asian countries, attitudes are more liberal. The rate of abortion in Japan has been very high in recent years, perhaps peaking at over a million (some would put the figure much higher) before decreasing in the last few years as the contraceptive pill has become more easily available. Central to the contemporary Japanese experience is the phenomenon of mizuko kuyo, a memorial service held for aborted children. This service involves erecting a small statue to commemorate the lost child and includes an apology to the spirit of the aborted fetus. William LaFleur (1992) has explored the complex symbolism and cultural history of the practice, and a feminist perspective has been provided by Hardacre (1997).
Korea provides an interesting comparison with Japan. Both countries have a very high rate of abortion, but in Japan it is legal (since 1948) whereas in Korea, it is not. Annual figures of between one and two million are quoted for Korea, a country with a population of around 46 million. Over a quarter of the population are Buddhists, which makes them the main religious group. Statistics quoted by Tedesco (1999) reveal that Buddhists are slightly more likely to have abortions than other segments of the population. In 1985, an anti-abortion movement began to gain ground following the publication of a book by the Venerable Sok Myogak (1985), a Buddhist monk of the Chogye order. His book, entitled My Dear Baby, Please Forgive Me! became popular, and readers began to demand rites and services for aborted children similar to the Japanese mizuko kuyo service, although distinctively Korean in form.
Some Western Buddhists take a more liberal stance on the abortion question. James Hughes (1999) suggested that “clear and defensible distinctions can be made between fetuses and other human life,” and found the moral logic of utilitarianism persuasive in the context of abortion, although tempered by the requirements of a virtue ethic, which takes into account the mindset of the actors. Abortion may, therefore, be allowable where the intention is compassionate and the act achieves the best outcome for all concerned. One American Zen Buddhist group, the Diamond Sangha, has produced a liturgy that can be performed following an abortion or miscarriage.
Euthanasia
By euthanasia is meant intentionally causing the death of a patient by act or omission in the context of medical care. We are concerned here only with voluntary euthanasia, that is, when a mentally competent patient freely requests medical help in ending his life.
As a case of intentionally taking life, euthanasia is generally regarded as prohibited by the First Precept. As noted above, however, compassion is also an important Buddhist moral value, particularly when linked to the concept of the Bodhisattva, a Buddhist saint distinguished by self-sacrificing compassion for others. Some sources reveal an increasing awareness of how a commitment to the alleviation of suffering can create a conflict with the principle of the inviolability of life. Opinion on these questions divides between conservative and liberal positions, although the great majority of traditional Buddhists would see euthanasia as prohibited by the First Precept.
Despite opposition to euthanasia, however, it does not follow that Buddhism teaches that there is a moral obligation to preserve life at all costs. Recognizing the inevitability of death is a central element in Buddhist teachings. Death cannot be postponed forever, and Buddhists are encouraged to be mindful and prepared for the evil hour when it comes. To seek to prolong life beyond its natural span by recourse to ever more elaborate technology when no cure or recovery is in sight is a denial of the reality of human mortality and would be seen by Buddhism as arising from delusion (moha) and excessive attachment (tanha).
In terminal care, and in cases where a permanent vegetative state has been conclusively diagnosed, there is no need to go to extreme lengths to provide treatment where there is little or no prospect of recovery. There would, therefore, be no requirement to treat subsequent complications, for example pneumonia or other infections, by administering antibiotics. While it might be foreseen that an untreated infection would lead to the patient’s death, it would also be recognized that any course of treatment that is contemplated must be assessed against the background of the prognosis for overall recovery. Rather than embarking on a series of piecemeal treatments, none of which would produce a net improvement in the patient’s overall condition, it would often be appropriate to reach the conclusion that the patient was beyond medical help and allow events to take their course. In such cases it is justifiable to refuse or withdraw treatment that is either futile or too burdensome in the light of the overall prognosis for recovery. For further discussion of end of life issues see Keown (2001b, 2005b). Table 48.1 details the essential considerations discussed in this chapter.
The cases
Mrs. T attended one of the many illegal abortion clinics in Thailand and had a termination at 14 weeks. In Thailand, abortion is used as a method of birth control by married women because of the lack of family planning clinics and contraceptive advice, particularly in rural areas. As is usual, Mrs. T did not discuss her plans with any member of the Buddhist clergy, since intimate family matters are not seen as appropriate matters of concern for celibate monks who have renounced worldly concerns. In having the abortion, Mrs. T felt she had done wrong and would incur bad karma as a result. However, she believed she had no alternative, and hoped to mitigate any negative karmic effects by performing good works and making offerings at the local temple.
Since he did not fit the mould of the standard American patient, there was confusion as to who had authority to make treatment decisions on behalf of Venerable C. Staff had little understanding of Buddhism, and so the hospital ethics committee sought a court-appointed guardian to manage the case. In the end, the surgery went ahead. This was not because Buddhist teachings required it, and a decision not to operate would equally have been in accordance with Buddhist ethics. Deciding against intervention, even with the expectation that this would shorten the patient’s life, would not have been regarded as an instance of passive euthanasia since at no time was the death of the patient the outcome sought.