Continuing the Ancient Tradition of Holistic Care from Buddhist Temples
Rev./Dr. Masahiro Tanaka and Dr. Teiga Tanaka
edited by Jonathan S. Watts
Jodo Shu Research Institute, Tokyo, 2011
The Concern for Dis-ease and Medicine in Buddhism’s Foundations
Buddhism was started by a man, Siddhartha Gautama, who found the answer to the problem of suffering, which originates from the fact that there is no escape from death. The Buddha came from a noble family of the Shakya clan who shared in governing the small state of Kapilavastu, near the present border of India and Nepal. His whole life was quite different from that of Jesus Christ. He was not arrested nor crucified. He grew up as a wealthy aristocrat, got married, and had a child. His happiness ended, however, when he became conscious of the basic facts of existence. He saw old age, sickness, and death, and worried that he too would grow old, become sick, and die. These contemplations led him to leave his home when he was twenty-nine years old and chose a life of homelessness, seeking salvation from suffering through the practice of various forms of yoga. After six years of practice, he unraveled the problem of suffering, reconciling with the fact that there is no escape from death. The spiritual pain of aging, disease, and dying disappeared in the Buddha once he realized complete freedom from attachment to the self, which included the attachment to his own life. In this way, Buddhism has been related to palliative care—the relieving of pain and dis-ease—and especially spiritual care since its birth.
The Buddha’s first students were his five former ascetic companions. He encapsulated his realization in the teaching of the Four Noble Truths, which are suffering, the cause of suffering, the extinction of suffering (nirvana), and the path to nirvana. Here, the term “suffering” is a translation of the Sanskrit word dukkha, which means, literally, “to be denied of what we desire.” The Buddha said that there are eight forms of suffering. The first four are birth, aging, disease, and death. These are examples of experiences that simply exist regardless of our wishes. The last suffering the Buddha listed summarizes all of suffering. It is the attachment to one’s self, which has five components. These are the attachments to one’s body, perception, conception, volition, and cognition, known as the “five-armed-attachment” (panca upadana skandhas). Attachment to the self is, thus, the fundamental form of suffering.
The Buddha then taught that the cause of suffering is passion (trishna), such as the passion for sex (kama), the passion to live (bhava), and the passion to die (vibhava). These three passions correspond to the three elements of life in biology: reproduction, dynamic equilibrium, and death. From these causes, the Buddha taught that the extinction of suffering is the state of nirvana, where the three passions are extinguished and suffering, that is attachment to self, is also extinguished (analaya). Finally, the Buddha taught that the path to nirvana is the way of life where one continues to control these three passions completely (samyak). Attachment to the self is also controlled completely, and hence a compassion that does not discriminate others from oneself appears.
However, the Buddha’s teachings have no purpose in and of themselves. That is, they are not final ends, but the means that bring happiness to people. The Buddha showed, using the metaphor of a raft, that the essence of the teaching was to leave attachments behind. In this metaphor, one can imagine a person walking down a road. He comes to a large river. The shore on his side of the river is dangerous, but the shore on the distant side is peaceful. He makes a raft. He crosses the river using the raft and reaches the other shore. After arriving at the other shore, he should simply leave the raft on the shore and continue on his journey. In this way, the metaphor reveals the deeper message of leaving our attachments, like the raft, behind. In this case, the raft is a startling metaphor as it includes the Buddha’s teaching itself. A metaphor literally means “to carry (phora) over (meta)”, and Buddhism is also just a metaphor that carries people over to the other shore of happiness. The raft should be thrown away once it crosses to the other shore. As such, a Buddhist should not attach to Buddhism itself, and the non-attachment to Buddhism further does not attach to non-attachment itself.
Buddhism expanded throughout Asia thanks to this fundamental concern with transforming suffering and a subsequent association with medicine. Historically, Buddhist priests had to study five subjects: linguistics, logic, engineering, medicine, and Buddhism. In the third century B.C., Ashoka, the first great unifier of India, made a medicinal herb garden, which is one of the oldest known of its kind in the world. He sent Buddhist priests to many foreign regions to treat people with medicine from this garden. They could cure people of their physical pain through medicine and their spiritual pain through the Buddha’s teaching. In Japan, medicine and Buddhism have historically functioned side by side. In 593, Shitenno-ji temple in Osaka was built as the first officially administered Buddhist temple in Japan. It included a hospital, a poor house, and a pharmacy that grew and cultivated medicinal plants.
Unique Buddhist styles and rituals for dying were also developed in Japan. One of the ideas developed is contained in a nine-chapter text called The Most Important Mystery in This Life (一期大要秘密集 ichigo taiyo himitsu-shu) written by the great Shingon master Kakuban (1095–1143) for use in deathbed practices. In the first chapter, it says that while a disease can be controlled by medicine, one must never give up nor accept death. In the second chapter, however, it says that if a disease cannot be controlled, and there is no way to be healed, one must not cling to life. From the third chapter onward, it describes how one should prepare for death by concentrating one’s mind on an ideal personality of worship, e.g. Kannon Bodhisattva.
A Buddhist Approach to Dying with Dignity
The Most Important Mystery in This Life points us to a Buddhist approach to modern concerns of dying with dignity. Contemporary situations involving medical science and the ability to prolong life push us to ask ourselves whether or not there might be some basis on which life-prolonging treatment may be interrupted according to the patient’s self-determination? Of course, there are various ideas regarding one’s own death and none of them can be refuted by tests with experiments or observations. Therefore, science is not helpful in solving this problem. Hence, I would like to discuss these matters, not with reference to science and medical theory, but instead with reference to the classics; that is writings that have survived a long history of criticism.
I would first like to make reference to something written by Albert Camus. At the beginning of The Myth of Sisyphus, he writes, “There is but one truly serious philosophical problem and that is suicide … Galileo, who held a scientific truth of great importance, abjured it with the greatest ease as soon as it endangered his life. In a certain sense, he did right. That truth was not worth the stake.” (Camus, 1955, 11) On the other hand, Tommaso Campanella defended Galileo and wrote Apologia pro Galileo from prison at the risk of his life. Because he willingly risked death, there must have been something that was more important to him than his own life. If there is anything valuable beyond one’s own life, it could be said that that is the person’s religion. Such religion is necessary if one is to care for life.
Back in 1992, we had a controversial case at our hospital involving a comatose patient and the transplantation of her kidneys at death. At that time, a television station from Vienna came to our hospital to cover the story. In Vienna, they said, passive euthanasia, or so called “dying with dignity,” was forbidden under the teachings of Christianity. Since they had heard that such passive euthanasia (“dying with dignity”) was permitted in the hospital of a Buddhist temple in Japan, they came to cover the incident.
The case involved a 53 year-old woman who arrived at our hospital as a so-called “DOA” (dead-on-arrival). At around 1:00 p.m. on October 9th, 1992, a woman was stung by a hornet, and half an hour later she went into anaphylactic shock. Unconsciousness, convulsions, and cardiac arrest occurred while she was being carried to our hospital in a neighbor’s car. Cardiopulmonary resuscitation (CPR) was performed immediately on arrival. She was intubated by a trained anesthesiologist; intravenous fluids were administered through an I.V. drip; and drugs such as epinephrine and steroids were injected. Although her blood circulation recovered, around thirteen minutes had passed between her heart stopping and the starting of resuscitation. As a result, the patient’s brain did not recover despite our efforts. A deep coma continued during hospitalization. Artificial respiration by a respirator continued, and although spontaneous breathing was observed temporarily, it disappeared again. Although a weak, light reflex appeared temporarily, it too disappeared again.
After one week, we had to explain to her family that recovery was impossible. When this prognosis was presented to the family, the termination of life support and organ donation were proposed by the family, because the patient had both an organ donors card and a living will expressing her desire to die with dignity. However, both her desire to die with dignity and her desire to be an organ donor were met with difficulty. Unfortunately, she tested positive for the HBs (Hepatitis B surface) antigen, so the regional Kidney Transplant Network disqualified her as a donor and refused her donation. We did not agree with this judgment, and so we did a computer search for medical papers on the subject. Of the twenty papers that we found[1], references one through ten all concluded that the relationship between HBs antigen positivity and a transmission of hepatitis to the recipient was not definite, and, in most cases organ transplantation went successfully. While it was shown in two papers that the possibility of transmission was high when the recipient was HBe antigen positive, there were no papers that declared, positively, that a person who is HBs antigen positive was unsuitable as an organ donor. Therefore, medically, we concluded that a kidney from a HBs antigen positive donor who is also HBe antigen negative can be offered for transplant.
We felt that the regional Kidney Transplant Network should not have been opposed to this view unless they had a paper that could refute this view by showing new evidence—something such as an accepted paper appearing in Index Medicus, a comprehensive index of medical scientific journal articles. Such a paper did not exist, at least at that time. Therefore, we made contact with a university hospital outside of the area governed by the regional Kidney Transplant Network, and the organ donation became possible.
After the loss of spontaneous respiration was confirmed by an apnea test with her family present, the dopamine infusion was stopped. The patient’s blood pressure then fell, and her pulse stopped after ten minutes. The cardiac arrest was checked by the electrocardiogram monitor with her family present. At that point, her death was diagnosed. Then, an operation for the extraction of the kidneys was performed. The kidneys were immediately carried to the university hospital and transplanted into recipients.
In the wake of this incident, however, the newspaper reports that followed were not so well done. They were written in a way that made it seem that we proceeded with the transplantation when the patient was brain dead but still able to sustain her vital functions, which as shown above was not the case. In Japan at this time there was still no law declaring that for the purposes of organ transplantation brain death is sufficient to proceed. In this way, the public assumed that we withdrew treatment for the purpose of organ transplantation on the basis of brain death. As a result, some doctors and citizens who read these newspaper articles accused and prosecuted us for murder. Of course, medical staff should not make judgments regarding brain death one-sidedly and for the sole purpose of organ transplantation. On this point we are in complete agreement with our prosecutors. This case shows the problems of passive euthanasia in Japan, particularly the difficulty for medical professionals to discontinue a medical intervention when it is clear that it no longer benefits a patient and merely serves to maintain their physical sentience. The core of this problem is the culture of the denial of death in Japanese society, which is also described by other authors in this volume.
The interest in this case by the Viennese television station raises an interesting question about the relationship between religions and dying with dignity, whose relationship I would like to discuss further. I would like to quote the first part of Arthur Schopenhauer’s On Suicide, which refers to this matter:
As far as I can see, it is only the monotheistic, and hence Jewish, religions whose followers regard suicide as a crime. This is the more surprising since neither in the Old Testament nor in the New is there to be found any prohibition or even merely a definite condemnation of suicide. (Schopenhauer, 1974, 306)
Does Buddhism accept the idea of dying with dignity? Does Buddhism accept suicide? In the Buddhist scriptures, the Buddha accepted an incident when a monk committed suicide.[2] In this way, one could conclude that Buddhism encourages suicide. However, to quote Emil Durkheim’s work, Suicide:
Though Buddhism has often been accused of having carried this principle to its most extreme consequences and elevated suicide into a religious practice, it actually condemned it. It is true that it taught that the highest bliss was self-destruction in Nirvana; but this suspension of existence may and should be achieved even during this life without need of violent measures for its realization. (Durkheim, 2002, 182)
I feel that Durkheim’s interpretation of nirvana is quite correct. The Buddha said that what one can control freely according to one’s desires is one’s own. However, what one cannot control freely according to one’s desire is not one’s own. We do not have control over our bodies as far as birth, aging, disease, and dying are concerned. Thus, in order to control ourselves, we must recognize that our bodies are not our own. There is nothing that can be said to be mine or myself, because even this body does not belong to me. Buddhist monks are those who take the oath to walk on the path to nirvana. As they control both the passion to live and the passion to die, they neither commit suicide nor attach to living unreasonably. That is one point that they have in common with those who decide to die with dignity. In this way, it is proper to give advice and to help patients make their own decisions when we, as Buddhist monks, are called on. The position of Buddhism regarding organ transplants is the same as well. We, Buddhist monks, should participate in donor registration on the one hand, and, on the other hand, support the position of those who receive organ transplantation.
However, this is the case especially for monks, and Buddhism does not command that all people must choose to die with dignity. There is no discrimination at the arrival point of the way to non-attachment that Buddhist monks walk. In disowning the body and the self, a person does not discriminate others from oneself. This is the wisdom of equality in Buddhism. Having compassion for all people without attachment to one’s self is the situation of the Buddhist who affirms all other religions equally. As shown by the metaphor of the raft, Buddhist monks should not attach to Buddhism itself or non-attachment as well. This allows us to support a person’s decision to die with dignity or the decision to prolong life through medical intervention. However, it is important that each individual be offered such a choice, which is often not the case in Japan.
The Buddhist Roots of Secrecy and Truth Telling in Modern Japan
After awakening to the highest Bodhi ( “enlightenment”), the Buddha at first basked in the glow of his experience that blew away the spiritual pain related to death. Yet he hesitated at this time to tell people about this salvation. Indeed, telling the truth often harms a person if the truth is that their life will end. However, by not telling this truth, the Buddha realized the chance that others would realize their own salvation would be missed. It is interesting to note the similarity between the Buddha’s hesitation to talk about his salvation based on the truth of suffering and telling a cancer patient the truth about their condition. To tell patients that their cancer cannot be cured could cause them spiritual pain. After an inner struggle with this paradox, the Buddha decided to teach others about the truth behind his salvation out of compassion for humanity.
I would like to talk about how such “truth telling” relates to the current approach toward illness and death in Japanese medicine. The word “religion” has been translated into Japanese using two Chinese characters, shu and kyo, which literally mean “mystery” and “teaching” respectively. The latter character, “teaching” (kyo), corresponds to the rational part of religion that can be transmitted easily by words. The first character, “mystery” (shu), corresponds to the part of religion that is outside rationality and cannot be transmitted by words. It requires a master-disciple type transmission. Almost all Japanese culture developed under the influence of esoteric Buddhism that followed the formality of “mystery and teaching” and included a master-disciple type transmission. The Japanese cultural forms that grew from this esoteric influence include the Japanese art of flower arrangement, poetry, calligraphy, painting, and theatrical performances.
From this influence, a non-verbal communication style gradually became more important than that of open verbal communication. To understand something difficult that cannot be expressed in words easily, one needs to relive it or experience it vicariously. However, vicarious experience requires that one has already, at some point, had the actual experience. If they have not, metaphors or symbols have frequently been used to help people vicariously understand these experiences. The most difficult things to understand, such as the mystery of the Buddha’s realization, are thus called “secrets.” In this way, the word “secret” in Japan has not mean to hide the truth but rather has described something that was difficult to understand by verbal communication.
To understand the current state of palliative care in Japan, one needs to consider some things that have appeared in medical journals. In the May, 1988 issue of a weekly journal called the Medical Tribune, there was a report on a summit conference on cancer held using satellite communication. The chairman of the then Soviet Union Cancer Society mentioned that he did not even tell cancer patients their true diagnosis (the name of the disease), because it gave the patients mental pressure that had a negative influence on their condition. An American doctor said that he tells cancer patients their true diagnosis as a matter of course. I think this difference existed, because American hospitals have the influence of spiritual care workers that creates a culture in which doctors can tell their patients the truth, whereas former Soviet hospitals did not have spiritual care workers. How to prolong life depends on refutable matters, so science and doctors can handle this situation properly. However, how to live a limited life is not an issue which science can handle, so spiritual care workers must take care of it.
In a paper ironically titled, “Curable Cancers and Fatal Ulcers: Attitudes toward Cancer in Japan” (Long & Long, 1982), it was pointed out that Japanese patients having terminal cancer were generally not told their true diagnosis.[3] In general, Japanese doctors do not approach patients using open verbal communication. This shows that the vagueness and “secrecy” originating in Japanese Buddhism is still an important part of Japanese culture. Unfortunately, Buddhism was pushed to the margins of Japanese society in 1868 by the revolutionary government of the Meiji period Emperor. At this time, western culture was adopted to modernize Japan, yet the government tried to exclude Christianity from this adopted western culture. The government tried to replace Christianity with State Shintoism, the religion of the Emperor. However, this attempt did not succeed, and the people who dealt with spirituality disappeared from Japanese hospitals as modern secularism took over. After that revolution, the formal vagueness was left without any attachment to its important roots in Buddhist spirituality. The resulting absence of spirituality as well as spiritual care workers in Japanese hospitals makes it difficult to give a true diagnosis much less a prognosis to cancer patients. The principle of informed consent in which a patient is given a detailed diagnosis still is not well maintained in Japan, although it has become the most important principle in medical ethics through the Helsinki (1964) and Lisbon (1981) declarations.
Currently, many palliative care units exist in Japan, but the main job at those palliative care units is not the relief of spiritual pain but simply the relief of physical pain. The training of spiritual care workers is thus necessary since they are currently absent from most medical institutions in Japan. However, Buddhist priests are not showing any interest in such work and have turned their back on their essential work of teaching salvation from the truths of suffering. As such, I think the words of Schopenhauer offer a lesson to Buddhist monks, “A genuine (Buddhist) monk is exceedingly venerable, but in the great majority of cases the cowl is a mere mask behind which there is just as little of the real monk as there is behind one at a masquerade.” (Schopenhauer, 1974, 319)
Temple as Holistic Care Complex
From this situation of the marginalization of the priests, temples, and teachings of Buddhism from medical and comprehensive care for those experiencing aging, illness and death, I would like to discuss the activities of our temple. Saimyo-ji is located just north of Tokyo. The temple was first built in 737 A.D. and is associated with one of the four main Buddhist pilgrimage routes in Japan. In this way, it differs from the typical temple supported by a parishioner system that is very busy in performing funerals and memorial rites for its members. Having been born at that the temple as the son of the chief priest, I grew up expecting that I would become the chief priest of Saimyo-ji in the future. However, since I was a child, I was also interested in science. One day I asked my father what I should study to become the chief priest of the temple. His answer was, “Learn anything special other than Buddhism first, and then study Buddhism after that.” Hearing that, I thought that I should become a scholar of science first.
Just before the deadline for my university applications, my father brought me an application form for Jikei University and asked me to enter the medical school there. I had no idea why my father wanted me to become physician. Despite the fact that I was not interested in becoming a physician, I enrolled and graduated from medical school. I obtained a physician’s license. Still, I could not work up any enthusiasm for clinical practice, so I thought that I should do medical research. Since early gastric cancer endoscopic diagnosis was a popular subject among intern doctors at that time, I became an intern at the National Cancer Center in order to learn about the techniques of endoscopy. The National Cancer Center had a hospital and a research institute. After a few years, I became both a government employee as a researcher in the research institute and also a physician at the hospital at the same time.
I treated inpatients and outpatients as a physician of the National Cancer Center. Most of the patients that I saw had advanced cancer. Usually, patients with advanced cancer never make a complete recovery. Patients could become better temporarily, but in the end almost all of the patients passed away. Curable patients were usually treated by surgeons, so most of the patients that I saw as a physician of internal medicine were incurable.
After I practiced medicine for twelve years at the National Cancer Center, my father had a heart attack and passed away suddenly at the age of sixty. The next year, I resigned from the National Cancer Center and entered Taisho University to study Buddhism in order to become the chief priest of Saimyo-ji temple. I graduated after two years and spent another five years studying Buddhism as a postgraduate. Then, I and my wife, who is also a doctor, established a small hospital at Saimyo-ji, which we call Fumon-in. It has nineteen beds in total with seven nurses and four doctors. We perform a lot of rehabilitation therapy for handicapped children, esepcially those who have undergone surgery, and the elderly. Thus, we have a total of ten physical therapists and occupational therapists also on staff. As both my wife and daughter are trained anesthesiologists, they are skilled in palliative care and pain control. Thus, we are able to perform hospice care for those who need, which is about two persons at any one time. About half of the patients come from the nearby rural community and the other half from relatively distant regions.
From this basis, we have created several other institutions for health care, such as a nursing home for the aged, and two group homes for the aged with dementia. All facilities are presently full with patients and in ongoing demand. The nursing home for the aged, called Kanseibo, is the largest of these facilities with sixty residents and twenty others who come for daily rehabilitation services. There are 19 caregivers, 6 nurses, 2 physical therapists, and 1 doctor at Kanseibo. We also have another ten people who come for non-medical “day service” in a separate facility called Chuzenbo. In the past, half the residents at Kanseibo had been from Tokyo, but due to an increase in aging in rural areas, we now have mostly local people, who receive priority of admission.
The two group homes for the aged with Alzheimer’s disease and other types of dementia called Norabo are also another important part of our work. The two homes house nine persons each and support them to live somewhat independently with proper care and assistance. There are six caregivers per house and one nurse who is also the care manager for both units. As with the nursing home, there has been an increase in local needs and thus residents. Finally, we have a unit to assists local residents to handle home care called Konrenbo. This consists of two care managers who support families to care for ill or elderly patients in the home by organizing various specialized care givers to visit their homes and helping with other logistics.
In terms of specific spiritual care workers, we are still somewhat limited in what we offer. Of course, since the facilities are located on the grounds of Saimyo-ji temple, residents can participate in the religious activities of the temple, like our monthly “fire offering” (goma) service. Of course, as most of our residents are elderly and somewhat incapcipated not many can come up the mountain to our main hall. Therefore, I give a dharma talk at the Kanseibo nursing home every two weeks. Until recently, we had another priest who resided here for ten years. He helped take care of the temple and also was active in working individually with patients as well as giving weekly dharma talks. Since his return to his native home in Hokkaido in the north, it has been hard to find a priest who is willing to live here and be involved in our medical work and spiritual care work. Indeed, with permission of the residents, I have issued open invitations to priests of the home temples of our residents to come visit their parishioners here. I even followed these up with individual telephone calls. However, many did not come or continues with regular visits.
In this way, the nurses and my wife are very involved in psychological and spiritual care for the residents. We also openly show our religious and spiritual intentions with the six-foot, 750 year old Kannon Bodhisattva image—a designated important cultural property by the Tochigi prefectural government—and Shingon tantric mandalas installed in the main area of the Kanseibo nursing home. Patients regularly and openly pray in front of this image. We have another small image in our Fumon-in hospital as well.
In conclusion, modern medicine is a science, and science is limited to matters that are refutable by experiments or observations, and all that a doctor can do with respect to life is to prolong a patient’s life. How to live and how to die is not a matter of science. The pain related to the loss of existence, the loss of oneself through death, is a spiritual pain. This pain is unique to human beings. No animals, other than humans, complain of spiritual pain. Neither medical drugs, nor treatments, are effective in relieving the pain of a patient who says, “I dread dying.” Buddhism, however, has been dealing with spiritual pain since its inception. However, these days, the pain of aging, disease, and death, are isolated to medical facilities. Further, Buddhist priests in Japan shut themselves away in temples and are not beside the patients who are suffering from spiritual pain in hospitals. Knowing what I know now, I feel that I have realized what my father meant when he said, “Enter medical school first,” to me all those years ago. By chance, I’ve had the career that my father intended for me.
Postscript: Rev./Dr. Masahiro Tanaka passed away from pancreatic cancer in 2016. For the complicated and intense issues of his last days, NHK Japan made a documentary in English which can be seen here.
References
Camus, Albert. The Myth of Sisyphus. Translated by Justin O’Brien. London:
Hamish Hamilton, 1955.
Durkheim, Émile. Suicide : A Study in Sociology. Trans. John A. Spaulding and George
Simpson. London: Routledge Classics, 2002.
Long, Susan O., Long, B.D. “Curable Cancers and Fatal Ulcers: Attitudes toward
Cancer in Japan” Social Science and Medicine, Vol. 16 (24):2101-2108, 1982.
Schopenhauer, Arthur. Parerga and Paralipomena: Short Philosophical Essays. Vol. 2
Trans. E.F.J. Payne. London: Oxford University Press, 1974.
Tanaka, Masahiro. “The Identity of Buddhist Health Care Institutions.” Paper presented
at the 17th International Conference “The Identity of Catholic Health Care
Institutions” on November 7-9, 2002 at New Synod Hall, Vatican City, Rome.
http://fumon.jp/vatican.htm
[1] For a listing of these papers see, (Tanaka, 2002).
[2] There are actually three such incidents in which the Buddha does not condemn a monk who has committed suicide in the cases of Godhika, Vakkali, and Channa. See Attwood, Michael. Suicide as A Response to Suffering. The Western Buddhist Review. Vol. 4 (May 2004).
http://www.westernbuddhistreview.com/vol4/suicide_as_a_response_to_suffering.html#_edn4;
Becker, Carl B. Buddhist Views of Suicide and Euthanasia. Philosophy East and West. V. 40 No. 4 (October 1990) 543-555.
[3] As shown in Rev. Yoshiharu Tomatsu’s chapter, the percentage of patients who were told their diagnosis (29.5%) and poor prognosis (18.1%) were still very low well into the 1990s.
