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.
Return to Contents
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.
Return to Contents
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: 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 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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