I think the topic for this paper has been chosen for me because I am a Buddhist monk who is a medical graduate attending a seminar on contemporary problems and Buddhist youth. However, before going on to consider specific areas of controversy, I think it is important to try and put the question of sickness and health into a Buddhist perspective.
First I would like to look at the relationship between mind and body and in this context to consider the definitions of life and death. Actually, in so doing, our first controversy will be introduced immediately, since conventional medical thinking sees the mind as some sort of product of the brain’s activity, while Buddhist science understands that it is an altogether different type of phenomenon.
The Nature of the Mind
The mind is a formless entity that has the ability to perceive objects. It is impermanent, that is changing from moment to moment. All impermanent phenomena are the product of causes, thus so is the mind- it does not arise- from nothing. Since effects must be similar in nature to their principal cause, the principal cause of the mind must also be formless and not some material substance such as the brain. If the mind were derived from the brain it would have to have the properties of physical matter, that is be composed of atoms and have shape and color. Clearly the mind is not of such nature; nor does physical matter have the property of consciousness, the ability to perceive objects.
The mind proceeds from the previous state of mind; each thought moment is preceded by a prior thought moment and there has never been a first. Moreover, each mind comes from its own previous continuity, and not from another mind such as some “cosmic consciousness” or the minds of one’s parents. Hence each individual’s mind is beginningless. And just as physical energy never goes out of existence, disappearing into nothingness, so too does mental energy continue forever; only its state changes. This mental continuity is what we refer to when we talk about rebirth or reincarnation and medical science has not yet accepted the fact of this phenomenon. Thus it is impossible for Western-trained doctors to understand the factor that is primarily responsible for causing sickness and health- karma.
Life and Death
A life begins when the mind, or consciousness, joins with the fertilized egg within the womb (see Vasubandhu’s Abhidharmakosha). The exact moment is not mentioned but it must be close to the time of joining of sperm and egg because sometimes the intermediate state being sees the future parents in the act of copulation and is then drawn into the womb. The principal cause of the body is physical- the sperm and egg of the parents; as mentioned above, the principal cause of the mind is the immediately preceding mind.
Death occurs when the mind leaves the body. This does not occur at the time of clinical death, but according to circumstances, some time after this.
Cause and Effect
As medical students we were always taught to strive for curative rather than symptomatic treatment of disease. In retrospect, it now seems that we never really knew what the principal causes to be treated were. For even physical disease has its main cause in the mind.
We can understand how karma, the principal cause, brings its effects by the analogy of the seed. A seed is certainly the principal cause of the plant it grows into, but the seed unplanted will never germinate. To do so it requires a supportive environment- soil, water, minerals, sun and so forth. These conditions are secondary causes; the co-operative interaction of primary and secondary causes is necessary to bring forth the result- a plant, or a karmic consequence.
Thus the karmic seed planted in one’s mind-stream is the principal cause of its corresponding effect- positive karmas bring happy experiences, such as health; negative karmas unhappy experiences, such as disease. Our bodies and the circumstances they encounter are merely secondary causes, but because they are so apparent to our senses we tend to believe they are principal. Thus all our efforts to be healthy are aimed at improving the body and the environment, and we neglect what is of supreme importance- our mind- and all our efforts are symptomatic, not curative.
It is also essential to be aware of the kinds of result that karma brings. Basically, there are two kinds of karma: throwing karma and completing karma. The former is so called because it is the force that throws us from one life, at death, into the next; it determines our realm of rebirth. Under the heading of completing karmas are three subdivisions of result: results similar to the cause in experience, results similar to the cause in reaction, and environmental results. An example will make this more clear. The action of killing will create the throwing karma of rebirth in the hells, the realm of greatest suffering, but will bring after-effects even when that being has later been born human, through the action of completing karma. One who has killed will have a short life and suffer from illness, and may even be killed, and will also have the tendency to kill other beings. These are the results similar to the cause. The environmental result will be that the person has to live in a dangerous place, such as one where there are constant wars. By the way, through the application of the four opponent powers, these four kinds of karmic results can be totally purified and thus their suffering consequences totally avoided.
Thus the prescription for perfect health given by the supreme physician, the Buddha, was: “Avoid evil, do good; purify your mind “ By avoiding negative actions we prevent ourselves from creating the cause of suffering- this is the best preventive medicine. By purifying our mind we eradicate the latent potential of negative actions already done, the future causes of disease- this is the real curative treatment.
And so in very brief summary have some fundamental differences between Western and Buddhist approaches to sickness and health been outlined.
1. In-vitro fertilization. The ovum is fertilized in a test-tube and implanted in the womb. When does the consciousness enter? We cannot say, but perhaps those with clairvoyance can. If the consciousness enters at fertilization, that is in the test-tube, and the embryo is frozen, that living being must undergo incredible suffering, and certainly Buddhists could not condone this, just as they could not condone experimentation on such embryos. And what about disposing of unwanted embryos? This would be murder. On the other hand, if the consciousness joins only at implantation, these problems do not arise. But ethically, with so many unwanted children and so much abortion in the world, do we really need to invest so much energy in such techniques?
2. Surrogacy. One has to wonder if some of these new advances are not introduced by the newspapers- you can imagine them funding all kinds of medical research, as long as it’s sensational! I suppose there’s nothing heinous about someone having the baby of an infertile woman’s husband and then handing it over, but it is certainly unnatural and doesn’t feel right. And again, the questions of over-population, abortion and so forth arise, throwing the whole procedure into doubt. The thing that seems to have bothered most people is the payment surrogate mothers are given- this doesn’t bother me so much; people are paid to do all sorts of strange things that don’t generate so much public outcry.
3. Contraception. If we accept the practice of contraception we have to distinguish between acceptable and unacceptable methods from the Buddhist point of view. Amongst the former are the pill, condoms, caps and the mastery of techniques of timing, such as the rhythm method and coitus interruptus. The more permanent methods of tubal ligation and vasectomy would also be OK. However, each of these has its own problems. Intrauterine devices- coils etc.- are abortifacients and therefore totally unacceptable.
But should we condone contraception? What is it for? (A rhetorical question.) The hard-line morality school frowns on contraception as the door to promiscuity, sexual misconduct, hedonism and so forth. Even now, such issues are at the center of a battle raging in the UK as to whether or not parents’ consent should be obtained before contraceptives are prescribed for girls under a certain age. Well, there are lots of immoralities and we have to weigh them up. All desires are to be abandoned, but we can’t abandon all of them- or any of them- all at once. On the path to desirelessness let’s have as few problems as possible- if we are not going to be celibate we should have a pure relationship with one partner, and if we don’t want children, let’s avoid them sensibly.
4. Infertility. In many cases under investigation, no obvious cause can be found for a married couple’s inability to conceive: the reproductive organs of both partners are found to be functioning normally. The answer may lie in karma- that at that time the karma does not exist for those people to have a child, or for any sentient being to be born to them. Thus, although the sperm and egg meet in a perfectly healthy tube and womb, no consciousness enters and no baby is conceived.
5. Abortion. As soon as the consciousness has entered the fertilized egg, there is a human being there. Aborting it by any means is murder, a violation of the fundamental Buddhist precept to abstain from taking life, and the heavy karma of killing a human being is incurred, with the four limbs of a karmic action complete. The medico-legal idea of viability, where the baby can survive outside the womb (machine-aided, of course) is quite misguided. Buddhist texts describe in detail the feelings experienced by the developing embryo-fetus, and although these are in the nature of suffering of suffering, abortion will help no more than will taking the life of a child or adult with some painful disease. Even when it is known that the fetus is deformed it should not be killed. This perhaps more difficult point requires a clear understanding of the nature of cyclic existence, something that can be gained only by the study of the Buddha’s teachings. Of course, all karmas are not equal and are modified according to motivation and several other factors, and comprehension of this also requires study.
Illness and Treatment
1. Preventive medicine. “Prevention is better than cure”, we were always taught, but these words are empty when we look at much of the practice of modern medicine. This subject is dealt with more in another paper- “A Buddhist Approach to Healthy Living”- but there is no doubt that an enormous amount of disease, physical and mental, results from lives led by ignorance instead of wisdom and the resulting mess that we find the world in today. Environmental pollution, bad food, worse habits…these kinds of thing destroy our bodies and arise from fundamentally disturbed minds, the “normal” mind of today.
2. Death from cure. The disease is cured but the patient dies- symptomatic of the samsaric approach to problems. Much treatment, medical and surgical, has side effects. There are drug reactions- allergic, overdoses or wrong drugs given- deaths from anesthetics or from operative or post-operative complications. We accept these as hazards of life in the world, which of course is fraught with risk, but don’t look deeper to see the possibilities beyond. It is said that this is not the job of doctors but I think that this is a cop-out. Those who confront these problems the most should look at them the closest.
3. Alternative medicine. This is the term given to anything that is not of the Western, modern approach, implying somehow that the latter is the method of choice and that if it fails, try something (anything!) else. This is a somewhat narrow, arrogant attitude, given that people have been getting sick and being treated successfully since time immemorial. Western-trained doctors would do well to study some of the ancient healing arts such as acupuncture, aryuvedic and Tibetan medicine, homeopathy and so forth, and, in fact, many are doing so.
4. Unnecessary treatment. The instantaneity (if there is such a word) of 20th century life has led to carelessness and expedience in the treatment of disease. It is too easy to prescribe some tablets with inadequate thought or just to repeat a prescription to get rid of a regular patient from a busy surgery or outpatient clinic. Thus diseases are mistreated, overlooked or continue to be treated even when they’ve gone. All this is great news for the pharmaceutical industry, which itself is highly suspect. There are huge budgets for advertising, small ones for research. Drugs known to be toxic continue to be marketed, especially in third-world countries. And are most of them necessary? Not long ago the head of the World Health Organization said that we could manage with only two percent of the available drugs and do without the other ninety-eight. In the meantime, the battle between trade name and generic prescribing continues.
5. Which brings us to why doctors treat patients. For most it is to earn a living- a very good one- doing something that is quite a pleasant job and brings social status as a welcome by-product. Few doctors are altruistically motivated, and why should they be? Nobody else is. This would indeed appear to be the sorry state of the world today, but it is a great pity, because treatment of disease would be much more effective if the welfare of the patient was the doctor’s prime consideration, instead of the reverse being, in most cases, true. Thus greed allows the proliferation of questionable practices such as those mentioned above, of unnecessary surgery (especially cosmetic), of cheating national health schemes and so forth. All of which brings the medical profession, once so highly esteemed, into further disrepute, which decrease its efficacy, with doctors tending to live up to only lower expectations, and so yet another inexorably degenerative cycle continues.
6. The role of the mind. In case all this is getting too negative and depressing, and I’m not at all trying to say that the medical profession is the worst part of samsara, let’s look at the mind as a means of treating or preventing disease. Some studies have shown that people are more likely to have heart attacks or get cancer when they are depressed. There may be other studies that have shown or could show similar correlations between mental states and physical illness. Amongst the most interesting reports are those of patients who have cured themselves of cancer through meditation- books have been written about this and I don’t think they have received serious enough consideration. The power of the mind is always underestimated- even the simple ability of some people to relax their minds so that they don’t need local anesthetic when undergoing dental or minor surgical procedures should be given more attention. And I think that the whole of that vast (and lucrative) field of psychiatry is based on totally false premises regarding the nature of the mind and is extremely limited in its objectives.
7. Terminal illness. The heroic efforts we make to preserve and prolong life indicate that we have some underlying appreciation of the preciousness of the human existence, but unfortunately we don’t really know what to do with many of the patients whose lives we have preserved. For example, those whose brains are dead but whose bodies are kept going by life-support systems- respirators, monitors, intravenous drips and so forth. There is something that could be done to make those extra months or years beneficial, but usually it isn’t. And controversy abounds as to what should be transplanted and when into whom (quite apart from the discussion on when it should be taken out of the donor). Vast amounts of money are spent on keeping the odd individual alive, while thousands die of starvation in less fortunate parts of the world. From a Buddhist point of view one could say that saving the life of a Dharma practitioner who is striving for enlightenment for the benefit of all sentient beings would ultimately be better than letting him or her die to save hundreds of non-practitioners, but sadly such considerations are merely academic, as usually none of those concerned are truly religious people.
This is a subject about which there would be much controversy if the medical world gave serious consideration to the other possibility that everything does not stop at death. Yet still there is confusion- materialists fear death although it will bring their troubles to an end; eternalists fear death although it will bring them to God and heaven. Suicide is (rightly) frowned upon, or even illegal, but nobody quite knows why.
1. Suicide. A human life is the most precious thing we can have, since it gives us the chance to practice Dharma. Yet it is attained with great difficulty and is extremely rare, and, generally, those who kill themselves exhibit one of the worst kinds of ignorance. Still, there are organizations that advocate the right of people to take their own lives, and they do society a great disservice. What about the Buddhist monks who burnt themselves to death in protest in Vietnam? We cannot say if these were acts of ignorance or wisdom- it depends on their motivation for and the actual results of their actions. Were they liberated or reborn in hell? Did they help stop the war and thus save thousands of lives? Did they set an example for many other ignorant people similarly to kill themselves? Those who can answer these questions can answer the first.
2. Euthanasia. “Mercy killing”- one needs the wisdom and compassion of a buddha or a bodhisattva to take another’s life with happy consequence. Shakyamuni Buddha did it in a previous life when he acted radically to prevent someone from killing 500 other people. We can’t do this. No matter how well intentioned, we should not shorten living beings’ lives, even though they are experiencing great pain and suffering. We can benefit dying beings’ minds by reciting audibly prayers and mantras or by doing pujas on their behalf. Of course, what happens to them when they die is up to their own karma, but through Dharma practices such as these we can help to ripen the positive seeds in their mental continuums. As long as their minds remain in their bodies- that is as long as they are alive- the possibility of assisting in this way exists.
3. The time of death. The medical profession takes clinical, or more recently, electrical criteria as signs that a person has died: the heart and breathing have stopped, the pupils are dilated and there is no electrical activity in heart or brain. According to the Buddha, that person may still be alive; the mind may not yet have left the body. This more subtle and accurate description of the death process has been made through the employment of a more delicate instrument to observe it- the mind. As death is defined as the mind’s having left the body, one has to be able to see where the mind is, or is not, to really know if someone is dead- and only the mind, one’s own or someone else’s, can do this. When death is sudden and traumatic, the mind leaves immediately, but a natural death allows an evolution of two or three days, during which the sense powers gradually dissolve, the elements weaken and the consciousness perceives various visions. Advanced meditators familiarize themselves with this clearly defined process such that they can observe and control it when they die, the purpose being to direct their minds into rebirths highly favorable for continued Dharma practice. To allow this, their bodies should not be disturbed until certain signs indicate that their meditation has finished and their mind has left the body. Similarly, it is best not to touch the bodies of even ordinary people for a few days after clinical death to give them the best chance possible of experiencing a peaceful death. The usual practices of violent (failed) resuscitation, tying off etc., refrigeration and autopsy or, in some countries, almost immediate cremation, ensure a disturbed death. And this means almost inevitably a bad rebirth, for the state of the mind at the moment of death- the moment it leaves the body- determines the state in which it will be reborn. Thus death is the most important time in our lives.
Some of the issues mentioned above are actual medical controversies. Others would be if given sufficient credence by a significant proportion of the (Western) medical profession. I can’t imagine this happening in the foreseeable future, but let us hope that it does happen, for from doubt, questioning and controversy can the truth emerge.