Buddhist Ethics

Brief pieces on the Twin Hindu Epics

2011-06-07T22:20:00.000-07:00

Sean Hillman, 2011
M.A. (c) Religion (Buddhist Studies)/Bioethics
B.A. East Asian Studies
Department and Centre for the Study of Religion
Joint Centre for Bioethics
University of Toronto, CANADA

(1)

Most intriguing, when considering epic as genre, are the ideas concerning the relationship between authorial/performer intent and reader/audience experience and the debate over the existence or non-existence of an original text.

Richard P. Martin’s Epic as Genre states that the “…genre [is] inhered in its performers” and the “notion of “epic” will not be too large if it expands to fit the performance repertoire…and the cognitive/aesthetic capabilities of their audiences” (Martin 2008, p.15) To me, having spent a great deal of time in the Buddhist texts, this is reminiscent of the question of the authenticity of the teachings of the Buddha, and I suppose by extension, to that of other teachers/founders as well. Did the Buddha teach differently but simultaneously to all of the disciples present for a discourse in order to most appropriately address each individual’s specific needs, or, rather, did they each receive a single message differently according to their own capacity to understand what was being taught? This question also reminds me of Monty Python’s rendition of the Sermon on the Mount in “Life of Brian,” the satirical story that follows a fellow born in the manger next door to Jesus of Nazareth. He and his mother are so far back from Jesus during the discourse, they have trouble hearing and the listeners start coming up with their own ideas of what is being taught:

Jesus: How blest are the sorrowful, for they shall find consolation. How blest are those of gentle spirit. They shall have the earth for their possession. How blest are those who hunger and thirst to see right prevail. They shall be satisfied. . .

Mandy: Speak up!

Brian: Mum! Shh!

M: Well, I can't hear a thing! Let's go to the stoning…

Man: I think it was "Blessed are the Cheesemakers."

Mrs. Gregory: What's so special about the cheesemakers?

G: It's not meant to be taken literally. Obviously it refers to any manufacturers of dairy products.

Martin makes it clear that the performer/author does not operate from their own side, but in interdependent mutuality. This takes the form of a shared context as “…the performance depends on an audience and performer’s unspoken awareness of the totality of a story and its conceivable permutations.” (Martin 2008, p.18) Also, the preferences of the audience drive performance, not the performer or their intent, as “…audience interest [is] the determining factor in how unspecified, as to time and place, a story can be, and what belief it engenders.” (Martin 2008, p.17) and “[a]s dozens of field studies show, the total “epic” is in fact never performed unless elicited by an outsider…” (Martin 2008, p.18)

To take this even further, Lowell Edmunds’s in his Epic and Myth, attempts to show that he original author and story, if they even existed at all, actually disappear altogether. He states that "on the occasion of any retelling, the present, individualist version is authoritative one" (Edmunds p.32) and "authorship disappears in proportion as story succeeds." (Edmunds p. 33)

Martin’s emphasis on ‘performance’ is also helpful to remind of the pre-written origins of story-telling, so easily forgotten in our age of digital media where we are even losing our reliance on hardcopy books.

The linguistic bent of Katz’s article The Indo-European Context thrilled me. If I had chosen another field of study after religion, Asian Studies and anthropology it would have definitely been linguistics. The relationship between thought, behaviour and language has always been fascinating to me. Now, after studying many languages over the years but finally becoming very proficient in one other than English to the point where I can comfortably say that I am bilingual, I can never look at language the same again. The struggle of acquiring the ability to speak and read a language other than my mother tongue has fundamentally changed the way that I think and communicate. However, Katz in his says in regard to the differences in refinement and in being robust that there is “no way to measure…since all languages manifestation of a single very real underlying Human Language.” (Katz: p.20) I have trouble with this view and it seems that later, Katz himself defeats this idea by stating that if “cognates, [have] arisen, via a series of regularly chartable successful speech errors from a distinct form…” which I would take to mean that some languages are closer to their original form than others and therefore we can measure the refinement of a language in relation to its prototype.

Interesting to see the source of Chinese referred to as Proto-Sino-Tibetan (Jones p.21), as discrete from Proto-Indo-European (from which Sanskrit is said to have come), since Tibetan is very much related to Sanskrit. The Proto-Tibetan must refer to Tibetan before the influence of the Sanskrit alphabet. The fact that Tibetans have great difficulty pronouncing certain Sanskrit syllables/phonemes (Vajra is pronounced Bendza) would attest to this.

An ongoing and unanswered question for me in religious textual analysis can be put to Jones with regard to similarities found between texts of cultures separated by space and time: Do textual similarities necessarily mean there is contact between them? A contemporary science fiction show, The Event, has the appearance on Earth of humanoid extraterrestrial biological entities who almost exactly resemble humans except for a 1% difference in their DNA, and regarding the similarity one scientist says: "This may point to a common ancestry or parallel evolution." Cannot the latter be so with regard to texts? I think that there is too much haste in pointing to a common origin, inheritance, or a borrowing interaction when textual similarities are found. Cannot certain textual styles develop in parallel? Katz mentions parallel, interdependent traditions, (Katz p.33) but must there be interdependence in the parallel development of texts?

(2)

Reading that “[b]oth the ‘forest-departed’ and the ascetic are denizens of the forest”, (van Buitenen 1975; p.176) I wonder why these two are separated? Perhaps it is to again distinguish between one who has engaged in vanaprastha and the saṃyāsa, as those who are at two different life stages. But, surely, sometimes they are one and the same? I can see 4 possibilities between the two, the ‘forest-departed’ and the ascetic, (the first, the latter, both and neither) but are there 4 possibilities between these two in the Mahābhārata’s “Book of the Forest”?

The introduction to the Rāmāyaṇa suggests that “the epic genre seems to have required such a transitional episode [as the forest book] within the social, political, and ethical problematic they all share”, (p.2) and that the vastly different context of the forest book has been disorienting to contemporary but not traditional readers. Despite my limited exposure to the Rāmāyaṇa and also limited but somewhat greater exposure to the Mahābhārata, I can nevertheless respond to this statement as a contemporary reader of these epics by saying that it is that very transitional nature and vastly different context (as set apart from regular life in the village) that initially drew me to this literature almost 20 years ago. Drawn to them still, now after having spent years pouring over Buddhist, Hindu and Jain scriptures, the tone and setting of these books still fill me with a sense of childlike awe that reminds me of why I was drawn into the world that is India in the first place. No longer driven by childhood parental rebellion, where reading non-Jewish texts was almost blasphemous, my research motivation to find Indian approaches to health and healing brings me back to texts such as these: epics which have historically have not been given enough scholarly attention, and particularly their forest books, specifically because of their unconventional contents that include perspectives on the supernatural, the ascetic and the didactic.

In both introductions, there are parallels drawn to Pali Buddhist works, most importantly stories from the Jātakas, to suggest that the epic versions of these similar stories are recast, re-worked or borrowed from the Buddhist canon. I still find some aspects of this seemingly endless hunt for the non-local origins of religious texts and stories frustrating. To be sure, it is fascinating to consider such trans-local connections as the suggestion that the Indian Bodhisattva became the Arabic Yudasāph and then travelled and transformed yet again into the Greek Iosaph. I even got caught up in the linguistic connections search by thinking that maybe Yudasāph has some etymological connection with the common root from the Hebrew term for for Jews, “Yehudi” becoming “Yuden” in German, but it is taking things too far to suggest that the land of Judah got its name from Buddhist terminology travelling West since about 5 centuries lie between their respective origins (although I am not sure when the terms buddh/bodh originally came to be, and we could very well look at the claims of the infinitely enduring Buddhist past). Even more ridiculous is to try and suggest that any story having to do with generosity, or likewise another quality revered in the Buddhist tradition, must have been originally Buddhist! I am glad van Buitenen put a stop to this by calling generosity an “all-Indian value.” (p.198)

(3)

The wilful death of the ascetic Sharabhanga (Pollock 2006: p.55) is a stunning and truly inspiring display of one type of yogic abandonment of the body. The metaphor of his body abandonment being like the snake leaving off its skin shows his placement of the body as one of many vehicles of consciousness, sloughed off for another existence when no longer useful, and his matter-of-fact confidence and self-imposed timely entrance into the transition demonstrates his awareness that his divine station afterwards is secured. His re-attainment youthful radiance during the immolation in the sacrificial fire is a powerful paradox that in the purity of a yogic death there is the youth and vigour which is most cherished in life. His passing beyond the status of brahmins, seers and gods on his way to the world of Brahma as promised by Indra himself, leaves no doubt that this is no ordinary death. What is also striking, but goes by without flourish, is Sharabhanga’s invitation to Rāma, specifically, to witness his transmogrified departure and the unmentioned privilege Rāma has in doing so. Later, the ascetic Sutīkshna mentions that he too has awaited a meeting with Rāma before “leaving my body behind on the earth” (p.61) to ascend to the world of Brahma, but in this case following a different kind of yogic death than Sharabhanga in that it does not seem to involve self-immolation in a sacrificial fire but, rather, sloughing off the mortal frame and leaving dust with dust. The last mention in “The First Ten Years of Exile” of the special death undertaken by ascetics is in reference to the abode of the sage Agāstya where “great beings cast off their bodies and in new bodies ascended to heaven.” (p.91) The nature of this ‘new body’ requires further investigation. Is it an intermediary form, cast off when reaching heaven? Is it a new and lasting from the time of leaving off the human form? Is it a celestial body like the gods, free of impurities?

I was taken by two other matters regarding ascetic practice shown in the first chapter of the Rāmāyaṇa. One was the transformation of the environment by the power of asceticism. Trees and animals alike flourish in the area surrounding a sage, and beasts have gentle temperaments. This is remarkable. Another fascinating mention of the fruit of ascetic practice is the offer of Sutīkshna to the three travellers for them to “enjoy yourself in the worlds won by my asceticism” and that it would be by his grace. (p.61) That this sort of transfer of merit, or the accrued benefits of austerities being passed onto or shared by those other than the practitioner themselves has many implications. What is this ‘grace,’ exactly? As happens during discussions on karma, wouldn’t the compassionate who have such benefits coming to them share them, through their grace, with as many as possible? Wouldn’t it be given especially with the most desperate? Does the recipient require accrued merit themselves to warrant such grace? In that case, would it not be the result of their own efforts, and not a transfer as such?

Time and again, the treatment of (or lack of engagement with) Sīta is pronounced. Sutīkshna does not offer food to her (p.63), addresses only the brothers and refers to her as “a shadow” (p.65) and she bears the weapons of the brothers as a servant would. (p.67) The sage also doesn’t embrace Sīta as he does the brothers, but this and not addressing her directly might be a custom that follows with ascetic celibacy protocol and not necessarily discrimination. The narrator describes her appearance often, such as her large eyes (p.67) and her fair waist (p.77). Aside from one mention of Rāma’s lotus eyes (p.89), he is most often described not by way of his appearance but by way of the qualities of his character, such as his righteousness.

“The Forest Teachings” chapter of the Mahābhārata also denigrates females, by reifying the male. Draupadi feeds Yudhiṣṭhira first then herself (van Buitenen 1975, p.229). The examples Vidura gives for his brother not being influenced by his advice are “like leading a corrupt woman to a scholar’s house,” or an old man being displeasing to a girl. (p.233) These metaphors are hardly flattering to women. Later, Dhrtarāṣṭra thinks that “no other property, however valuable, prevails over a son” and that a “son is even greater than life itself.” (p.237) Without addressing the mention of children as possessions, an entirely different but important concern, it is clear from these statements that the king places more importance on males than females.

(4)

There are striking parallels in the two epics when the forest books of the Rāmāyaṇa and Mahābhārata are read side-by-side, some of which are hard to see as mere coincidences. Particularly, major events involving rākṣasas appear in almost the same location of the forest books of both epics, within the first several chapters, and they are described similarly as resembling clouds, causing environmental and wildlife disturbances. In the second major chapter of the Rāmāyaṇa forest book (separated from the first only by a slim chapter containing the meeting with the sage Agāstya), “Shurpa-Nakha’s Punishment and Revenge,” the brothers and Sīta meet the rākṣasa that the chapter is named after. Instantly falling in love with Rāma, in introducing herself she self-proclaims as a shape-shifter. (Pollock 2006: p.129) After being teased by the brothers when she professes her love, and mutilated by Lākṣmana after unsuccessfully attacking Sīta, she runs to her mighty brother Khara who is confused as to how one such as herself who is adept at “taking on any form you please” came to be in such a state. (p.135) Angered, the rākṣasa brother sends out a horde of rākṣasas on behalf of his sister to destroy the three forest-dwellers, and the horde is described as being “like clouds driven by the wind.” (p.137) They are slain, and as a bigger and “dreaded troop set forth, a rumbling, mule-gray storm cloud ominously showered down water red as blood.” (p.149) The sun is covered, inauspicious beasts start to clamour, and the environment withers in polar opposition to the flourishing flora and fauna earlier described around the ashrams of seers. In the second chapter of the Mahābhārata’s forest book, “The Slaying of Kirmīra,” a battle with a rākṣasa occurs also. But this may not be enough to warrant mention. As with Shurpa-Nakha, Kirmīra is described as one “who could assume any shape at will.” (van Buitenen 1975: p.241) Similar to the horde in the Rāmāyaṇa, this rākṣasa is “like a monsoon cloud” (p.240) and a “cloud carrying rain.” (p.241) As Kirmīra moves “a gusty wind began to blow, and the sky, overcast by dust, lost its Bear” (p.241) and many animals and plants are terrified by him, an almost identical sequence of poetically described circumstances as with the rākṣasas in the Rāmāyaṇa. Have the texts influenced each other, or can this be explained away by surmising that rākṣasas are typically and symmetrically described in the same way wherever they appear in Indian storytelling? The descriptions are so incredibly similar in manner and locational placement in the respective texts as to raise suspicion of there being some relationship between the texts that brought this about, rather than these aspects appearing in parallel independently.

Another minor parallel between the epics, also involving rākṣasas, is the metaphor of an enemy of those of this class of existence being likened to a thorn. We find such a reference in the Mahābhārata with Kirmīra pledging to destroy Bhīma (who had killed his brother and other close ones) by “excising this thorn of the Rākṣasas!” (p.242) and in the Rāmāyaṇa with Shurpa-Nakha asking her brother to “pluck out this thorn in the side of the rākṣasas, [Rāma] who has made Dāndaka wilderness his home.” (p.145)

In both epics a specific result of a particular negative action is almost exactly replicated, with deceit being said to lead to death in the future. The Rāmāyaṇa has Agāstya tell his visitors that “an ascetic who mistreats a guest is destined to feed on his own flesh in the other world, like the man who bears false witness.” (p.99) Not quite as extreme, the Mahābhārata has Kṛṣṇa stating that “[o]ne who serves with trickery deserves to be killed!” (p.246)

Lastly is just to mention an interesting technique in the Rāmāyaṇa that I anticipate to be repeated, and that is the foreshadowing of impending doom. When Shurpa-Nakha returns to her brother again, after the first horde is defeated, the text says her return is “to Khara’s ill luck.” (p.143) Surely this is pointing to her being the cause of his eventual demise, a technique which seems not to reduce anticipation by spoiling the surprise. Typically such ignorance of the movement of the narrative can cause guessing which some audiences rely on to build excitement, but in this case, knowing the nature of the outcome could very well build just as much excitement.

(5)

With the completion of the Rāmāyaṇa’s “Shurpa-Nakha’s Punishment and Revenge” section of the Book of the Forest, what has piqued my interest are the use of multiple nature similes, repetition as a literary/storytelling device, some concerning aspects of Rāma’s nature (particularly his fury, boastfulness and taunts), and divine weapons in both the Rāmāyaṇa and Mahābhārata (starting with their appearance in the second part of “The Mountain Man” section). I will address the first and last areas of interest here, and save the others for another time.

The approach of Khara and his battalion to destroy the brothers, brings about many environmental portents such as an early twilight, a solar eclipse, stars appearing in daytime, a pervasive tremor and the rather amazing appearance of a meteorite shower. (Pollock 2006: p.151) I distinguish between meteor and meteorite, unlike the translation which glosses the event as having only to do with meteors, since the former typically means that which burns up in the atmosphere and does not reach the ground and the latter refers to non-terrestrial material that actually makes contact with the ground. In this case, as they “come crashing down,” these materials actually land. The tremor is an interesting occurrence which, like the other environmental signs, at first seems to be caused by the horrible movement by the rākṣasa hordes but is interpreted as an ill-omen signalling Khara’s upcoming demise at the hand of Rāma. Contrastingly, a similar Earth-wide tremor appears in Buddhist accounts of the moments following the enlightenment of Shakyamuni Buddha with the defeat of Mara and the Earth-touching mudra, and yet this is not seen as ominous but as an auspicious good sign. It is a defeat of an altogether different kind, that of inner demons rather than wily external troublemaking rākṣasas of the forest. What is particularly powerful in this section are the multiple nature similes. Effective and affective, they paint a clear picture while also tugging at the listener’s emotions to bring out feelings of suspense, horror and awe. Rāma is like a “smokeless flame in the dark (p.157) and his arrows are “like smoky tongues of fire” (p.167); his bloody wounding is “like the sun at twilight enveloped by coulds” (p.161), while enraged he blazes “like the fire at the end of a cosmic age” (p. 159) and his attack is “like fire in a dry forest” (p.163); an evil person who takes no account of the deeds done with contaminated motivations is “like a lizard that feeds on hailstones” (p.177); in regard to bad actions, “savage creatures…are…like trees cut off at the root;” an agent suffers the results of negative actions “just as trees come into flower with the passing of the seasons” and committing them is “[l]ike eating poisoned food.” Even horrifying events are described with nature similes, such as the state of a rākṣasa felled with arrows to the eyes being described as like “a tree with newly sprouted twigs.” (p.167) Such a stirringly beautiful image applied to such a grave matter! This juxtaposition of life and death brought together is a functionally useful technique both to provide a visceral image in the mind of the reader/audience, and also to set the horror of a murderous death against the calm backdrop of nature. A corpse is indeed imbued with stillness like so much of what one would find in the forest, animate and inanimate. Other similes are almost too many to mention, as they occur in droves in almost every verse. Comparisons to similar events in the past are also used to flesh out the storytelling. It appears, too, that the more important the event, the more comparisons that are made, such as with the death of Khara. Finally succuming to Rāma’s arrows, the moment is compared to three different momentous mythological defeats (p.185). This also shows the assumed background knowledge of the audience by the narrator.

In the climactic battle of “Shurpa-Nakha’s Punishment and Revenge,” the Rāmāyaṇa shows the implementation of divine weapons. After several significant blows from Khara, another desperate moment like the initial moments of the battle where Rāma is alone and seems doomed to the reader and even to the various far-sighted holy beings, Rāma deploys “the mighty bow of Vishnu” (p.173). It does not entirely do the trick, as Khara is left lacking his standard, weapons and chariot but remains alive, and it is for the final death-blow that Rāma “took up the fiery arrow…the arrow given by the wise king of the gods, Indra the munificent.” (p.185) In those dire moments when Rāma’s demise seems certain, with the celestials and other holy beings watching the battle with concern and eagerness but without getting involved, Rāma’s otherworldy skill with arrows (showering thousands of them at a time!) is outdone by the use of divine weapons at turning-points in the battle. Are these weapons, both given by gods and imbued with vast power, vicarious interventions from the god-realm?

In the continuing saga of ‘The Mountain Man” in the Mahābhārata, split up by “The Razing of Saubha” section, we see divine weapons featured prominently as well. Here, though, instead of their implementation we see the beginnings of a journey towards their acquisition by the exiles, a task recommended to Yudiṣthira by the yogin Vyāsa and to be performed by Arjuna. (van Buitenen 1975: p.295) Yudiṣthira requests Arjuna to “[y]oke yourself to awesome austerities” and since “with Indra are all the weapons of the Gods,” he must “[g]o to Sakra, and he shall give you the weapons.” (p.296) Later, while practicing austerities and based on his display of unwavering resolve, he is granted a boon by Indra. Arjuna’s request for divine weapons is met with a condition on the boon to meet Shiva first. (p.297) Here, the gods are clearly involved in the affairs of humans, again, as in the Rāmāyaṇa, intervening indirectly by way of supernatural weapons distribution. However, whereas Rāma seems to receive such weapons as a result of his overall good qualities, in this case in the Mahābhārata the weapons are only granted after much effort is exerted through austerities for the specific purpose of gaining weapons, and then only after certain conditions are met as well.

(6)

In “The Session with Mārkaṇḍeya” section of the Mahābhārata, Mārkaṇḍeya’s answers to the questions put to the seer by the Pāṇḍavas reveal much about cosmology and his views, as placed in his mouth by the storyteller, on how results come about. Some more questions can arise from Mārkaṇḍeya’s descriptions. First, it is said that “The Lord of Creatures in the beginning created immaculately pure bodies” and that “[t]hose ancient men…observed good vows, they spoke the truth, they were holy as Brahmā.” (p.575) In the context of beginninglessness, there being infinite past cycles of time and deaths, births and re-deaths of both beings and the universe itself, this ‘beginning’ must surely be referring to the onset of a new cycle. The phrase ‘in the beginning’ here must be referring only loosely to one of many beginnings, one after a cosmic dissolution has occurred followed by a period of quiescence that ends with another beginning. Next, these first humans in the beginning of this particular cycle are abundantly pure in all ways: in their bodily form and in the actions of body, speech and mind. What is odd is the mention of the holding of vows by these men. The nature and content of these vows is not clear, as they are only referred to as ‘good vows.’ If these people are pure in every way, including conduct, why would they need vows? If they are already holy, or we could say, acting naturally in accordance with the natural order, there would be no need for restrictions. Vows tend to bind people from committing inappropriate actions, or as a voluntary practice of penance, where one disallows oneself from particular activities that may or may not be considered as negative. Not eating certain types of flavourful foods is a common self-imposed vow by Jains, for the purpose of purifying karma and also to reduce desire towards objects of the senses. But what are the vows mentioned by Mārkaṇḍeya? What is their purpose? It is hard to say. If the vows have to do with ritual activity, perhaps they are an injunction to perform sacrifices, austerities or other types of offerings or vigorous restraint. Again we can ask, if they are holy and in harmony already, and if such activities are those that are a natural part of this well-balanced order, wouldn't every required activity already be performed by these original pure beings without internally or externally imposed vows?

Another curious aspect of Mārkaṇḍeya’s discourse is the mixture of reasoning in his exaplantion on the origin of results. Regarding this, the seer says that "[s]ome comes from fate, some from chance, some from their acts, what men acquire." (p.576) The differentiation of predetermination, randomness and cause and effect is fascinating, but even more interesting is that these are placed side by each as a trifecta to completely explain how things come to be the way they are for beings. Soon after this, Mārkaṇḍeya is made by the storyteller to prioritise lifestyles by establishing if there are benefits to be had by certain ways of life in this life and/or the next. Here, surprisingly perhaps, Yoga, Veda, "[c]ontrolling their senses and helping the creatures" does not bring benefit in this life and the next but only in the future. The highest practice, it would seem, is abiding in dharma, the Law, as it brings about all things in this and future lives. This would be an indication that this seer is made not only to present the Vedic emphasis of former times less significant, but that dharma is even more important than restraint and compassion.

References

Edmunds, Lowell. “Epic and Myth”. A Companion to Ancient Epic. ed. John Miles Foley. Blackwell Publishing. 2005, 31-44.

Katz, Joshua T. “The Indo-European Context”. A Companion to Ancient Epic. ed. John Miles Foley. Blackwell Publishing. 2005. 20-30.

Martin, Richard P. A Companion to Ancient Epic. ed. John Miles Foley. Blackwell Publishing. 2005. 9-19

Pollock, Sheldon L. (tr., 2006); The Rāmāyaṇa Book Three, The Forest, By Valmiki. New York University Press.

van Buitenen, J.A.B. (Ed., 1975); The Mahābhārata Book III, The Book of the Forest. University of Chicago Press. 1975.

Voluntary death in the epics Mahābhārata & Rāmāyaṇa

2011-06-07T21:58:00.000-07:00

Sean Hillman, 2011
M.A. (c) Religion (Buddhist Studies)/Bioethics
B.A. East Asian Studies
Department and Centre for the Study of Religion
Joint Centre for Bioethics
University of Toronto, CANADA

A special category of death finds its way into both the epic Mahābhārata and Rāmāyaṇa, that of voluntary death. Sometimes referred to as “self-willed death”[i], such deaths can be further sub-categorized into suicide, heroic and religious. The first has historically been given much more attention in the mass media and academia. Proof of this can be seen in the abundance of court cases and bioethical research that ponder on suicide, Physician Assisted Suicide (PAS) and euthanasia in contrast to that having to do with heroic and religious voluntary death. Most people, when asked, do not easily recognize these latter two categories, which Young calls mors voluntaria heroica and mors voluntaria religiosa respectively[ii], but would typically have a well-formed opinion about the motivations behind, and results of, suicide. Although both deserve much more scholarly attention, this study will keep religious voluntary death as its primary focus. Among religious voluntary deaths there are various types of such a purposeful and consciously directed end to life. These are: The Great Journey or walking in an auspicious direction until falling dead (Mahāprasthāna), sacrificial self-immolation (Agnipraveśa), regular immolation, drowning in rivers and ponds (Jalapraveśa), fasting to death (Anaśana or Anuśān-parva), on the banks of holy rivers, death while in meditation (samādhimaraṇa), abstaining from food and awaiting the approach of death in a seating posture (prāyopaveśana),[iii] and by yogic manipulation of the breath and inner energies resulting in the projection of consciousness (utkrānti)[iv]. How do such deaths differ from ordinary deaths? This study aims to establish that the epics portray religious voluntary death as specifically counteracting some or all of the themes that accompany ordinary death, namely: fear, fate, causality, pursuit by the Lord of Death, loss of senses and breath, dissolution and embodiment. Firstly we will look at how death (as the end of life) and Death (the personified reaper of souls) are presented in each of the twin epics’ third sections, the forest books in particular, while looking at some of the material beyond these books as well. The analysis of death in the Rāmāyaṇa will be particularly linguistic in nature. Next will follow an outline of the various types of religious voluntary deaths found in both, or one or the other, of the twin epics. Lastly, we will look closely at the voluntary deaths of the main protagonists of the epics, the Pāṇḍavas in the Mahābhārata, and Rāma in the Rāmāyaṇa, to establish whether voluntary death counteracts the above-mentioned themes that accompany ordinary death.

Death and death in the Epic Forest Books

If we are to show how religious voluntary death is utilized in the twin epics, first it is necessary to establish how death is presented and contextualized in each. I will start with the Rāmāyaṇa since I have at my disposal Pollock's line-by-line Sanskrit transliteration to assist in locating terminology.

A rigorous survey of The Forest Book of the Rāmāyaṇa reveals that Death and death are distinguished between each other, and are presented in repetitively particular ways. Death is personified as the taker of life, whereas death is a physiological and psycho-spiritual transformation of the individual.

The personification of Death serves several functions: as a metaphor for attackers/harmers; as an object of fear; and as a representation of the bestower of fate and punishment. Pollock's translation often conflates several Sanskrit terms with the same English terminology, so teasing out these terms will prove useful.

Death is portrayed as male, and his image is evoked in descriptions of attacking enemies in battle. In their first encounter with a rākshasa since entering the forest, Virādha attacks the forest dwelling trio Rāma, Lakśmana and Sīta “…like Death (āntaka) attacking people.”[v]rākshasa Khara describes his sister Shurpa-nakha as one who goes about “like Death (āntaka) himself.”[vi] There are many other instances of rākshasas being described this way in the Rāmāyaṇa Forest Book, as moving about the world in a harmful way like Death himself, with āntaka as the operative term.[vii] In these cases, the usage of āntaka makes sense as it is usually translated as 'destroyer.' The For example, the shared Buddhist and Shaiva tantric deity Yamāntaka is known as 'the destroyer of death', and "Krishna…is famous as śrīśa khacū āntaka, the blessed destroyer of the demon Shankhachuda."[viii] In Pali, āntaka is sometimes translated as Evil One, in masculine form, and made synonymous with māra.[ix] This is a fascinating linguistic connection, since māra is subdivided in both Hindu and Buddhist texts as a harmful force with internal and external aspects. Berzin explains that in Hindu mythology, "[t]o rouse Shiva, Kama shot five arrows from his bow. These arrows were to make one ecstatic,…to make one crave,…to make one stupefied,…to make one thin, emaciated and dried out,…to make one dead. These five are called the five types of troubles that are the work of Mara."[x] In Buddhist mythology, since "[t]he term mara derives from the Sanskrit root mr, to murder…mara is what murders or causes interference to us… Mara is also explained as “what puts an end” (mthar-byed, Skt. antaka) – that which puts an end to spiritual practice. There are four types of mara: the mara of death (the Lord of Death), the mara of disturbing emotions and attitudes, the mara of the aggregate factors of experience (the five aggregates), the Mara who is the son of the gods."[xi] Additionally, the mara of death is further subdivided: "Mara is also considered Yama (gShin-rje), the Lord of Death (‘Chi-bdag)…outer Yama is death itself…inner Yama is the disturbing emotions and attitudes…hidden or secret Yama is the three subtlest conceptual minds.”[xii] Bearing this in mind, as some of these points will prove useful later in this study, the usage of āntaka in our Rāmāyaṇa Forest Book context is clearly Death as an external harmer bringing an end to life, evoked as a metaphor to describe Rāmāyaṇa players who are harmers likewise bringing death to others.

Next is the usage of Death as a fearsome object. With this application, several terms are used: āntaka, mṛtyu, mukta and kāla. The appearance of the rākshasa Virādha is “…as terrifying to all creatures as Death (āntaka) with jaws agape.”[xiii] This fearsome image of Death hungry for the living is recurring, with āntaka as the Sanskrit appearing each time.[xiv]āntaka) with noose held ready”[xv], but these are the only instances where this portrayal of Death as prepared to choke the life from his victim has Death as āntaka. The metaphor of Death as prepared to strike his victim with an implement straddles several Sanskrit terms. Khara is twice at the ready in battle “like Death (The female rākshasa Shurpa-nakhaSīta “like the very noose of Death (mṛtyu)[xvi], and Rāma attacks the rākshasa legion “like noose of Doom (mukta).”[xvii] attempts to strike Here we have the introduction of two additional Sanskrit terms, mṛtyu for Death and mukta for Doom, another English term for Death personified. Mṛtyu is translated as death[xviii] and mukta as liberated[xix], so we have three quite different Sanskrit terms subsumed into the same repeated image. Mṛtyu seems to be the predominant usage to specifically portray the fearsome nature of Death. The rākshasa Khara states that “[i]n my rage I could throw the fear of death (maraṇa) into Death (mṛtyu) himself,”[xx] and while abuducting Sīta, the rākshasaRāvana instills terror since “…seeing him advancing like Death (mrtyu) himself, the spirits of the forest fled overpowered by fear.[xxi] Rāvana also informs Sīta that "…all things born are put to flight by fear of Death (mrtyu)."[xxii] The last Sanskrit term used during portrayals of Death as fearsome is kāla, time: "Then suddenly Rāvana…abandoned the kindly form of a beggar and assumed his true shape, one such as Doom (kāla) itself must have. With eyes flaming bright red, with earrings of burnished gold, with bow and arrows, he become once more the majestic ten-faced stalker of the night."[xxiii] Although Pollock presents Death as 'Doom' with two Sanskrit terms, mukta and kāla, for the one English word, this is not an isolated usage of kāla for Death. Just prior to Lakśmana’s death, Yama the Lord of Death himself, in the form of an ascetic, comes to have a private discussion with Rāma and in the Dutt translation of the Rāmāyaṇa, Yama is referred to as Kāla.[xxiv] The Lord of Death also goes by the name of Yama in The Forest Book of the Rāmāyaṇa, but in all but one instance in relation to his underworldly (and assuredly frightening) location: the “house of Yama”[xxv] and his abode.[xxvi] Our discussion of Death’s title ‘Kāla’, given it’s relation to time and the connotation of impending disaster that comes with ‘Doom,’ makes this an appropriate moment to move to the last major purpose for Death personified appearing in The Forest Book of the Rāmāyaṇa: Death as the bestower of fate and punishment.

Here, too, we start with Death the destroyer, āntaka, who is wont for “…attacking people at their fated hour (kāla).”[xxvii] Here the implications are that life-spans are indeed limited, as time for a person runs out in that final hour, and that that time is predetermined by some means. Whereas Death here is still a personified force external to the individual, kāla, rather, seems to belong to the person. Death is implementing the end of life that is according to a specific timing of the individual. This is unlike the other usages we have seen of Kāla as personified Doom or Yama synonym. While in the clutches of the cursed and disfigured Kabāndha, Rāma bemoans to Lakśmana when it seems that their demise is inevitable: “How great the power that doom (kāla) exerts against all creatures… Is not fate (daiva) too much for any creature to endure…? Powerful heroes expert in arms can be overcome by doom (kāla) and collapse on the field of battle like dikes made of sand.[xxviii] Interesting that the term bhāgya does not appear for doom or fate, but rather kāla, also translated as ‘time’, and daiva,Kāla again is translated as ‘doom’ but without capitalization. sometimes translated as ‘destiny.’ If this is not a mistake, could it be a subtle differentiation between Doom and doom with the former being an objective force and the latter a subjective one, as with Death and death? Perhaps. Suffice it to say that fate and doom/time again give one the sense that the end of life is inevitable, merely a matter of time, and that when that time runs out is predetermined. The personified Death is often referenced as the one who dispenses with life, but here the end of life appears to be the result of deeds: “the power of kings is infinite…they can exact punishment like Yama.”[xxix] We could sum up this section by stating that the end of life coming about by an internal kāla or external Kāla could remain a matter of perspective, as the text seems to point to both.

Moving from the personified Death to the death of the individual, not only does a similar theme of time appear as well, but also some unique aspects: that of the loss of one’s senses and breath in the process of dying.

The rākshasa Khara scolds Rāma for being haughty “…when the hour of his death (mṛtyu kāla ) is at hand…”[xxx] Thus far we have shown mṛtyu and kāla mostly translated as Death and Doom, respectively, and also ‘fated hour’ and ‘doom’ for the latter. Having the two terms together, here, has been interpreted by Pollock as having more to do with the death of the individual, rather than the objective and personified Death. However, given the other usages of kāla, it would not be a stretch to read this phrase as having also to do with fate as well.

The loss of sense faculties and breath also seem to accompany the loss of life in the individual in the The Forest Book of the Rāmāyaṇa. Khara says to Rāma: “You have lost all sense of what to say and not to say, because Death (mṛtyu) has you in his power. For once the noose of Doom (Kāla) is wound around his neck, a man no longer knows what is or is not to be done, and all six senses fail him.”[xxxi] Later, Jatāyus the great vulture proclaims while in the throes of dying that “…everything is swimming before my eyes. I see the golden trees now and their streaming hair of spikenard!”[xxxii] In both examples is mention of the senses failing as death approaches, including the mental faculty. The author has Khara speak of the loss of knowing appropriateness, and Jatāyus seems to be describing the onset of a vision. Is he having a glimpse of his destination after death? Jatāyus also describes the increasing difficulty of his dying experience when he states that “[m]y breath is coming harder…”,[xxxiii] and, alas, his life ends when he “…let go the breath of life and could capture it no more.”[xxxiv] Much later in the epic, outside of the Forest Book, a death is again described in such a way when “Kausalya, Rāma’s mother, breathed her last.”[xxxv] The loss of breath, clearly, is presented as the main indicator of the loss of life of an individual. What indicates death in the Mahābhārata?

Shifting now to the other of the twin epics, the Mahābhārata, the analysis of the presentation of death will be based less on linguistics since I do not have a line-by-line Sanskrit transliteration of this text. Regardless, we will take what we have gleaned from the Rāmāyaṇa’s presentation of Death and death in The Forest Book and see what differences and similarities we can find in the Mahābhārata’s Forest Book.

One key feature of the Mahābhārata’s unique presentation of death is an emphasis on the body as the physical embodiment of the soul that is absent from the Rāmāyaṇa. In questioning the ascetic Mārkaṇḍeya on the nature of actions and their results, Yudhiṣṭhira refers to death as the “…embodied soul…shedding his body…”[xxxvi] We see this in the Santi Parva Book also when Brigu states that “The body alone dissolves away. The living creature, though depending upon the body, does not meet with destruction when the body is destroyed.”[xxxvii] Again, in the same book, Bhishma is made to say that death is when “[t]he embodied soul…[is] divested of Rajas.”[xxxviii] This ‘Rajas,’ according to the Samkhya school, is “one of the three gunas” or qualities and is specifically “[that which] is responsible for motion, energy and preservation.”[xxxix] This points to another aspect of death that the Mahābhārata marks as important, that of the departure of the animating force. In the same Santi Parva book, the ascetic Parsara says this of death: “Abandoned by the owner, the body becomes inanimate and motionless. Indeed, when the primal ingredients return to their respective natures (merge into the five elements), the body mingles with the dust… Jiva (the embodied soul), after dissolution of the body it inhabited…”[xl] This loss of animating life-energy accompanies the body’s dissolution at death which Bhishma calls “the destruction of this gross body”[xli] and of which Mārkaṇḍeya states that “[a]t the end of his life he abandons his mostly deteriorated carcass…”[xlii] What is it that abandons the body at death? We can safely assume that it is the soul referred to in the other passages. Dissolution upon death is even mentioned in the Mahābhārata’s telling of Rāma’s story with the death of Rāvaṇa: “The five elements departed from the lordly Rāvaṇa, for he was toppled…”[xliii]

With these excerpts we have shown several themes that sets the MahābhārataSanti Parva, apart from that in the Rāmāyaṇa’s Forest Book. There are, however, some commonalities. presentation of death, in the Forest Book and the

We saw earlier that the Rāmāyaṇa considers death as every being’s fate, an inevitable end that comes with having life, and we find this in the Mahābhārata as well. Parsara states that, necessarily, “…[d]eath follows birth in respect of all men…”[xliv] and even Rāma himself, in the Mahābhārata, is made to say that death is “…the final destination of all creatures.”[xlv] But before we get the impression that the Mahābhārata holds death as unpredictably inevitable, the text also seems to reinforce the Rāmāyaṇa’s consideration of death as set, predetermined, fated. In the Mahābhārata’s Rāma section, “King Daśaratha succumbed to the body’s Law of the passing of time.”[xlvi] This seems to resemble the internally-driven fate of the individual, but Mārkaṇḍeya proclaims this verse: “Behold, O King, all the various creatures, [h]ow all according to kind with force, [a]ct out what the Ordainer ordained for them”[xlvii] Although we have here an ‘Ordainer’ which we do not find in the Rāmāyaṇa, we nevertheless can see the parallel with there being an objective, external force that brings about the various circumstances of beings, including death. In the Rāmāyaṇa we have shown this to be Death and Doom personified, interchangeably āntaka, mrtyu, mukta,Yama and Kāla. Not the omnipotent ‘Ordainer’ of the Mahābhārata, but functioning in the same way in both epics as an objective bestower of death.

Lastly, a major point of departure from the Rāmāyaṇa is the Mahābhārata’s venturing beyond mere fate as the cause of circumstances, death included, and adding the cause and effect of actions into the formula. Actually, Mārkaṇḍeya gives three contributing causal factors to the circumstances that beings find themselves in: “Some comes from fate, some from chance, some from their acts.”[xlviii] With regard to death specifically, Mārkaṇḍeya seems to outright reject death by fate when he states that “[t]hose who lack the eye of insight believe that this creature is governed by the rule of death and is unaffected by either good or bad markings; but this has been declared to be the course of the stupid.”[xlix] As this particular dialogue is prompted by a question put to the ascetic concerning the way in which actions follow beings, the ‘good and bad markings’ which affect the type of death one has can confidently be said to be from previous actions. Thus, the text here shows tension between different positions on what influences death: that of predetermination by an objective supernal being, and self-determination by way of actions. We see this tension even within the confines of the discourses of one individual ascetic, Mārkaṇḍeya, without even addressing the third contributing causal factor he presents, that of events being undetermined and randomized, or by ‘chance.’ This sort of tension appears absent from the Rāmāyaṇa, since the death fate of the individual and the objective implementation of that fate by Death personified seem to harmonize quite well. The external Death is merely the means by which the death fated to the individual is brought about.

Given the various themes that occur around Death and death, and in light of our upcoming sections of religious voluntary death, I will suggest that it is these very things that such a unique mode of dying is utilized to counteract. In other words, does religious voluntary death aim and/or succeed in counteracting: fate; causality; the attacks of Death and Doom or the Lord of Death; the fear of Death and death; and the loss of senses and breath? What about embodiment and the inevitability of death? Does voluntary death lead to an end to embodiment and death itself, bringing about an entirely new status for the soul? Let us see.

Voluntary Death(s) in the Epics

Religious voluntary death is a known phenomenon to the cast of the Rāmāyaṇa. While approaching the abode of the sage Agāstya, Rāma notes that this is a particularly auspicious location where “great beings cast off their bodies (tyaktvā dehān) and in new bodies ascended to heaven as supreme seers.”[l] In the Mahābhārata too, religious voluntary death is presented as a particular way of dying that does not require much explanation. Mārkaṇḍeya states during his cosmological discourse that “in the beginning…men died when they wanted…”[li] Precisely how are these death practices performed?

A book by Śreyas on Jain Voluntary Death[lii] gives a fairly thorough survey of voluntary death as found in traditions other than Jainsim, including those found in Hindu texts. I will use this, in part and with qualifications, in order to establish which types of voluntary death are uniquely found in one or the other of the epics, and which are found in both texts. There are a few voluntary deaths that Śreyas fails to mention, and one which I feel is misconceived. I will address them each.

Starting with the Rāmāyaṇa Forest Book, the Vedic sacrificial self-immolation of Śarabhaṅga Ṛṣi,[liii] which Śreyas calls Agnipraveśa,[liv] seems to be the only type of voluntary death that occur solely in this epic and not in the Mahābhārata. One might be inclined to include Dhritrashtra’s voluntary death by fire in this category, but I am not so inclined since the fire was not sacrificial. Rather, it was a “fire in the forest, which slowly envelop[ed] the hermitage. Dhritrashtra knew it was time to leave the body and travel further on. He sat down…facing eastwards in yogic posture and calmly gave himself up to the flames. Thus ended the life of the elder son of Vichitravirya and Ambika, born blind.”[lv] This assuredly is a voluntary death by immolation, but not Agnipraveśa. We can give this voluntary death its own category, voluntary death by naturally arising fire, and say that it occurs only in the Mahābhārata. Also in the Rāmāyaṇa Forest Book we find two indeterminate voluntary deaths, those of the ascetic Sutīkshna who, like Śarabhaṅga, also awaited a meeting with Rāma[lvi] and the female ascetic Shābari who “had gone to heaven by her own act….”[lvii] before “leaving my body behind on the earth”,

By the account of Śreyas, there are three types of religious voluntary death that occur only in the Mahābhārata, but I contest one of them as being not exclusive to this epic. The first is the “irrevocable last great journey (Mahā-prasthāna) [f.9: Mahābhārata Vanaparva, 85.85]…[where one is] subsisting on water and air alone and walking on in an auspicious direction until the end of one’s life…”,[lviii] which the Pāṇḍavas engage in, an the second is “fasting to death (Anaśana) [f.12 Mahābhārata (Anuśān-parva) 25.63,64].”[lix] What I contest is Śreyas’s position that voluntary death on the banks of holy rivers only occurs in the Mahābhārata. I consider the voluntary death of Lakśmaṇa to be of this type (but not exclusively of this type) and, therefore, I also disagree with Śreyas including Lakṣamaṇa’s voluntary death among those that are by drowning in rivers and ponds. His death was on “the banks of Saraju”[lx] and had a yogic component that Śreyas does not mention. I will discuss this when I come to the third type of voluntary death that occurs in both epics.

Of the three types of voluntary death that occur in both the Rāmāyaṇa and Mahābhārata, Śreyas only recognizes one: that of “…drowning in rivers and ponds (Jalapraveśa) as in the cases of…Lord Rāma accompanied by Bharat, Śatrughna, his subordinate kings and the citizens of Ayodhya. [f.3: Rāmāyaṇa, Uttara Kāṇḍa, 110.2] By drowning in the confluence of three holy rivers at Prayag [f.4: Mahābhārata Vanaparva, 85.85]”[lxi] As I mentioned, Śreyas includes Lakṣamaṇa’s death here (and I do not), and excludes his death also from the following: “…embracing voluntary death on the banks of holy rivers… [f.6: Mahābhārata, Śalyaparva 39.33].[lxii] Since I include Lakśmaṇa’s voluntary death here (Rāmāyaṇa, Uttara Kāṇḍa, 106.8), it is another type of voluntary death seen in both epics. The third type of voluntary death that I see occurring in both epics we can call a yogic death, which White calls utkrānti.[lxiii] I include the voluntary deaths of both Lakśmaṇa and Bhishma[lxiv] in this category. Allow me to justify this category, and also why I exclude Lakśmaṇa from that of drowning and have him straddling two categories, voluntary death by yogic means and that on the bank of a river.

According to Dutt’s translation, Lakśmana clearly chose to die. “Lakshmana thought within himself: ‘My own destruction is far more desirable then that of all.’”[lxv] He then “reached the banks of Saraju and rinsed his mouth he stood there with folded palms.”[lxvi] There is no indication here that he entered the water, so we cannot call this voluntary death by drowning. As for the yogic component, “having obstructed all passages he did not breathe any more…being thus engaged in penances, having obstructed his breath, Apsaras, Indra and other deities and Rishis showered flowers upon him. Thereupon beyond the sight of men, having taken the highly powerful Lakshmana within his body, the king of celestials enetered his own city. Thereupon beholding Lakshmana, the fourth portion of Vishnu arrived at their city the celestials were greatly delighted and engaged in his worship.”[lxvii]Mahābhārata, Bhishma “held forth his life-breaths successively in those parts of his body which are indicated in Yoga… The life-breaths, restrained and unable to escape through any of the outlets, at last pierced through the crown of the head and proceeded upwards to heaven.”[lxviii] Although the internal processes are explicitly mentioned in the case of Bhishma and not in the description of Lakśmana’s death, the parallel is striking. Similarly, in the White specifically mentions “Bhīmṣa…as one who had died spontaneously, of his own free will”[lxix] and states that when “Abhinavagupta invokes a precedent for the practice of utkrānti [upward advance], he refers to Bhīmṣa.”[lxx]

The Voluntary Death(s) of the Epic Heroes

Lastly, we will look closely (but briefly) at the voluntary deaths of the major heroes of the two epics, Rāma and the Pāṇḍavas, to try and answer our questions about whether voluntary death serves the function of counteracting the various aspects of ordinary death that we outlined earlier. Specifically we aim to see if voluntary deaths contravene: fate; causality; the attacks of an objective, personified Death; the fear of Death and death; the loss of senses and breath; embodiment and, death itself.

First we will look at the voluntary death of Rāma. “Having forsaken Lakshmana and being stricken with sorrow and grief Rāma said to his citizens and ministers: ‘I shall to-day repair to woods… I shall follow the way which has been wended by Lakshmana.’”[lxxi] In following the way of Lakśmana, Rāma proceeds to the same body of water to abandon the body but I do not take this to mean that because Rāma enters the water, that this retroactively reinforces the idea that Lakśmana entered the water since the text does not indicate this. Following Lakśmana also indicates that Rāma knows that he will have the same ultimate destination as his brother as shown by “…Rāma`s determination of going to heaven…”[lxxii] Although Rāma feels grief over his brother, the parade of those accompanying Rāma to either join him or merely witness his departure, it is not an event marked with sorrow. “There was none poorly, aggrieved or miserable – all of them appeared wonderfully happy and delighted.”[lxxiii] The communal mood, Rāma’s determination and confidence in knowing he will ascend could all indicate that there is no fear on his part in following this voluntary death. Next, “the descendent of Raghu espied Saraju of holy waters flowing towards the west. And… Rāma, with his followers arrived at the place where he should give up his person. Thereupon at that moment, Brahmā…arrived there where Kākuthstha had addressed himself to repair to heaven… Thereupon the Patriarch gave vent… ‘Come O Vishnu…do thou enter here with thy brothers, resembling the celestials in brilliance in whatever form thou likest – either in that of the sky or in thy own Vishnu form…’ …Hearing the words of the Patriarch and determining everything the high-minded Rāma entered there bodily with his brothers in his Vishnu form.”[lxxiv] From this description, we also note that there is no presence of Death personified, or fear of such. Even though Rāma and Kāla/Yama engaged in conversation earlier, there is no indication that Death is in any way involved in Rāma’s chosen death. Nor is there any mention of fate or causality, so it is difficult to say whether this voluntary death has counteracted the force of either. Finally, as Rāma’s voluntary death is followed by bodily entrance into the celestial realm, albeit in his supreme form, it would be difficult to say that Rāma sloughed off the gross body in an ordinary way since the transition is a seamless one from human to divine form with no apparent residual, nor the loss of senses or breath. This death is not only extraordinary because of its voluntary nature, but also because there seems to be no gap during which the human body would perish by drowning and shift into a divine form. Even though we include this voluntary death in the category of drowning, we could say that this is indeed a transcendence of death itself since this translation of the text shows none of the typical signs of death, such as dissolution and the end of breath, but rather an instantaneous movement from human to god.

Moving to the Mahābhārata for our last inquiry into voluntary death, the Pāṇḍavas "[h]aving heard the particulars of the great slaughter of the Vrishnis… and having been informed also of Krishna’s ascension to Heaven…the Kaurava king set his heart on leaving the world… His brothers also formed the same resolution. Then Dharma’s son, Yudhishthira, the king of the Kurus, casting off his ornaments, wore barks of trees. Bhima and Arjuna and the twins, and Draupadi also of great fame, similarly clad themselves in bark of trees… The five brothers, with Draupadi forming the sixth, and a dog forming the seventh, set out on their journey. Setting themselves on Yoga, those high-souled ones, resolved to observe the religion of Renunciation, traversed through various countries and reached diverse rivers and seas.”[lxxv] Right off the bat, we see that, like Rāma, the entrance of the Pāṇḍavas into the Great Journey is triggered by grief. Rather than the fear of death, we could say that they fearlessly enter into this voluntary death practice because they cannot bear to be without Kṛṣṇa and, also like Rāma, know that they will be reunited. Then each of the troupe begin to fall down, one by one. “Yajnaseni, falling of from Yoga, dropped down on the Earth… Yudhishthira said: ‘O best of men, though we were all equal unto her she had great partiality for Dhananjaya. She obtains the fruit of that conduct today, O best of men…’ Then Sahadeva of great learning fell down on the Earth… Yudhishthira said, ‘He never thought anybody his equal in wisdom. It is for that fault that this prince has fallen down.’”[lxxvi] As each of the Pāṇḍavas fall, an explanation is given as to why they drop when they do. Here, with the repetitive mention of causality, we see one of the major differences between the voluntary deaths of Rāma and the Pāṇḍavas. Although the Pāṇḍavas all ascend, the exact time of the deaths of all but Yudhishthira is causally determined. It is the function of their voluntary deaths to attain a heavenly state, an end which we see no indication being determined by fate, causality or the reckoning of the Lord of Death. With all but Yudhishthira, also, we can safely assume that there was an actual death process involving the loss of breath and dissolution of the elements and therefore not being an embodied ascension. They died, “[h]aving cast off their human bodies”,[lxxvii] but it is not clear whether there was any accompanying delirium or what we have been calling a loss of senses. Although they attained heavenly status, it cannot be said that the Pāṇḍavas transcended death as we might consider of Rāma. Yudhishthira, however, is told by Indra that “it is ordained that thou shalt go thither in this very body of thine.”[lxxviii] As with Rāma, Yudhishthira’s has a divinely escorted embodied ascension. However, unlike both Rāma and his family members, Yudhishthira’s transition is ‘ordained.’ He may have side-stepped causality, the attacks of personified Death, the fear of Death and death, the loss of senses and breath and even the sloughing off of the body that accompanies a typical death, but Yudhishthira is bound by fate, or the predetermination of the Ordainer, even if the end result is a fortunate one.

In closing, after establishing various themes that come with death in both epics, and the various types of voluntary deaths in each, looking at the religious voluntary deaths of the heroes of both the Rāmāyaṇa and the Mahābhārata has shown some variation in the process of such deaths between and within each of the epics. In each case grief motivated the players, and yet fear did not seem present. Nor did the dreaded Lord of Death make an appearance in either epic with the voluntary death of the heroes. Rāma and Yudhishthira both attained embodied ascension, apparently without the loss of senses, breath or a dissolution process. Yudhishthira’s was fated, Rāma’s not. We can say that they transcended death. The remaining Pāṇḍavas, however, did not have embodied ascension nor transcend death, and so the loss of breath and dissolution most likely came with death but further investigation is needed to know whether they had delirium or not. The time of their moment of death was determined by causality, based on former actions. They were reunited, all.

Endnotes

[i] Young 1989

[ii] Ibid.; p.75

[iii] Śreyas 2007 pp.293-303; Young 1989 p.75.

[iv] White 2009; p.114.

[v] Pollock 2006; p. 41.

[vi] Ibid. ; p. 135.

[vii] Ibid.; pp.137, 149, 281.

[viii] Goswami 2002.

[ix] English Pali Dictionary 2010.

[x] Berzin 2006.

[xi] Ibid.

[xii] Ibid.

[xiii] Pollock 2006; p.41.

[xiv] Ibid. ; pp. 47, 191.

[xv] Ibid. ; pp. 173, 179.

[xvi] Ibid. ; p.133.

[xvii] Ibid. ; p. 163.

[xviii] English-Sanskrit Mico-Dictionary.

[xix] Bhaktivedanta VedaBase Network.

[xx] Pollock 2006; p. 153.

[xxi] Ibid. ; p.281.

[xxii] Ibid. ; pp. 273-274.

[xxiii] Ibid. ; p.279.

[xxiv] Dutt 1892; p.1919.

[xxv] Pollock 2006; pp. 87, 221, 389.

[xxvi] Ibid. ; p.145.

[xxvii] Ibid. ; p. 41.

[xxviii] Ibid. ; p.385.

[xxix] Ibid. ; p. 227.

[xxx] Ibid. ; p.179.

[xxxi] Ibid. ; p. 183.

[xxxii] Ibid. ; p.373.

[xxxiii] Ibid. ; p.373.

[xxxiv] Ibid. ; p.375.

[xxxv] Dutt 1892; p.1914.

[xxxvi] van Buitenen 1975; p.574.

[xxxvii] Ganguli; Santi Parva [book 12], Section CCXVII.

[xxxviii] Ibid.

[xxxix] Yogananda 1973; p.22.

[xl] Ganguli; Santi Parva [book 12], Section CCXVII.

[xli] Ibid.

[xlii] van Buitenen 1975; p.575.

[xliii] Ibid. ; p.756.

[xliv] Ganguli; Santi Parva [book 12], Section CCXVII.

[xlv] van Buitenen 1975; p.742.

[xlvi] Ibid. ; p.733.

[xlvii] Ibid. ; p.272.

[xlviii] Ibid. ; p.576.

[xlix] Ibid. ; p.575.

[l] Pollock 2006; p.91.

[li] van Buitenen 1975; p.575.

[lii] Śreyas 2007.

[liii] Pollock 2006; p.55.

[liv] Śreyas 2007; p.296.

[lv] Exotic India 2010.

[lvi] Pollock 2006; p.61.

[lvii] Ibid. ; p.409.

[lviii] Śreyas 2007; p.296.

[lix] Ibid. ; p.295.

[lx] Dutt 1892; p. 1924.

[lxi] Śreyas 2007; p.296.

[lxii] Ibid. ; p.296.

[lxiii] White 2009; p.114.

[lxiv] Ganguli; Anusasana Parva [book 13], Section CLXVIII.

[lxv] Dutt 1892; p.1923.

[lxvi] Ibid. ; p.1923.

[lxvii] Ibid. ; pp. 1924-1925.

[lxviii] Ganguli; Anusasana Parva [book 13], Section CLXVIII.

[lxix] White 2009; p.114.

[lxx] Ibid. ; p.114.

[lxxi] Dutt 1892; p. 1925.

[lxxii] Ibid. ; p. 1927.

[lxxiii] Ibid. ; p.1929.

[lxxiv] Ibid. ; p. 1930.

[lxxv] Ganguli 1883.

[lxxvi] Ibid.

[lxxvii] Ibid.

[lxxviii] Ibid.

References

Berzin, Alexander (2006); The Four Maras (The Four Demonic Forces); The Buddhist Archives of Dr. Alexander Berzin (2010); http://www.berzinarchives.com

Bhaktivedanta VedaBase Network, Sanskrit-English Dictionary; The Bhaktivedanta Book Trust International, Inc.; http://vedabase.net/

Dutt, Shri Manmatha Nath (1892); The Ramayana; Girish Chandra Chackravarti, Deva Press; Calcutta.

English-Sanskrit Micro-dictionary; India (damaged; publisher and date unknown)

Exotic India 2010 http://www.exoticindiaart.com/product/OP95/

Ganguli, Kisari Mohan (translator, published between 1883 and 1896); The Mahabharata of Krishna-Dwaipayana Vyasa; Internet sacred text Archive; 2010, John Bruno Hare. http://www.sacred-texts.com/hin/maha/index.htm

Goswami, Srila Rupa (2002); The Demon Shankachuda (From Lalita-mādhava-nā akam); Sri Krishna Kathamrita Bindu magazine; Gopal Jiu Publications, Issue No. 34.

Pollock, Sheldon L. (tr., 2006); The Rāmāyaṇa Book Three, The Forest, By Valmiki. New York University Press.

Śreyas, Dr. D.S. Baya (2007); Samādhimaraṇa - Death With Equanimity: The Pursuit of Immortality; Prakrit Bharati Academy, Jaipur.

van Buitenen, J.A.B. (Ed., 1975); The Mahābhārata Book III, The Book of the Forest. University of Chicago Press. 1975.

White, David Gordon (2009); Sinister Yogis; Chicago; London: The University of Chicago Press.

Young, Katherine K. (1989); Euthanasia: Traditional Hindu Views and the Contemporary Debate; Hindu Ethics: Purity, Abortion, and Euthanasia; Albany, State University of New York Press.

Health Care in the Tibetan Refugee Community of Dharamsala (Kangra District, Himachal Pradesh, North India)

2011-04-11T13:59:00.000-07:00

Sean Hillman, 2011
M.A. (c) Religion (Buddhist Studies)/Bioethics
B.A. East Asian Studies
Department and Centre for the Study of Religion
Joint Centre for Bioethics
University of Toronto, CANADA

The Tibetan Refugee Community in Dharamsala, India: Background

After going into exile in 1959, due to the heightening oppression of the occupying Chinese Communist regime in Tibet, His Holiness the Dalai Lama was followed to India by approximately 80-100 000+ Tibetans. According to the International Institute for Sustainable Development (IISD), “[t]he beginning years were expectedly the most difficult. Many Tibetans, coming from the high Tibetan plateau, succumbed to tropical diseases and heat. They were divided into road construction groups and lived in tented camps. With help from the Government of India and others, 54 agricultural and agro-industrial based refugee settlements were gradually established. The idea was to resettle the Tibetans in compact homogeneous communities where they would be able to preserve and perpetuate their culture and traditions, while at the same time enabling them to become self-sufficient in livelihoods.”[i] The majority of Tibetans settled in the Karnataka State of South India. There, the landscape is very flat, and this with the heat and drought make it as unlike their homeland as can be. Agriculture also proves to be quite difficult. The most significant of the many Tibetan communities throughout India, however, is in Dharamsala, a beautiful “hill station lying on the spur of the Dhauladhar range [of the Himalayas and]…wooded with oak and conifer trees and snow capped mountains [which] enfold three sides of the town while the [Kangra] valley stretches in front.”[ii] An environment much more suited to the Tibetans “lying 526-km northwest of New Delhi, Dharamsala[, it] is the headquarters of the Kangra District in the Indian state of Himachal Pradesh,”[iii] is the seat of the Tibetan Government-in-Exile, and houses the residence of His Holiness the Dalai Lama. The presence of the Tibetan leader and the region’s beauty, some parts so highly elevated (between 1250 m to 1550 m)ii that one is literally in or above the clouds, bring a myriad of Indian and foreign tourists every year. Birds of all kinds enjoy the area too, as it is a major migration route. Most of the settlement is built on steep inclines, and is subdivided into: (1) an upper region of Tibetan institutions (such as the Tibetan Institute for Performing Arts, TIPA), residences and markets called MacLeod Ganj which ends slightly further down the mountain at the main Temple complex and the Dalai Lama residence (surrounded entirely by a circumambulation route); (2) a mid-region even further down where the Central Tibetan Administration (henceforth referred to as CTA) offices (including the Paliament-in-Exile and Department of Health, henceforth referred to as DoH) and Library of Tibetan Works and Archives (LTWA) research library can be found; and (3) a lower region of Indian residences, offices and markets which splits off towards the Lower Tibetan Children’s Village school in one direction, and towards the Kangra Valley in the other. For the convenience of our purposes here we will subsume the entire area under the name “Dharamsala.”

What is provided collectively? What types of health care goods, other social goods & consumer goods?

Having provided some necessary background to the Dharamsala Tibetan settlement, we can now look at the goods available to the refugees. Let’s divide them broadly into the necessities of life (water, food, clothing, shelter, electricity), and essential services such as refugee intake and placement, health care, security, sanitation, education and transportation. Of course, many of these fall under Daniel’s categories of “[h]ealth-care needs…[which are] those things we need in order to maintain, restore, or provide functional equivalents (where possible) to, normal species functioning…[and which] can be divided into (1) adequate nutrition, shelter; (2) sanitary, safe, unpolluted living and working conditions; (3) exercise, rest, and other features; (4) preventive, curative, and rehabilitative personal medical services; (5) non-medical personal (and social) support services.” [iv] Looking at this list, we will add recreation to ours (including exercise and entertainment), and we will look particularly at medical (allopathic and traditional) health care and treat it separately.

The Tibetan refugee community in India almost entirely depended on the kindness of the Indian government when they first arrived in 1959, physically and emotionally destitute. “With help from concerned governments, the UN High Commission for Refugees, humanitarian organisations, and philanthropic individuals on the one hand and the sheer tenacity of the Tibetans themselves on the other hand,”ⁱ over the next 50 years an infrastructure has been built on the basis of a “democratic administration in exile…to manage the affairs of the Tibetan refugees”ⁱto the point where the Tibetan community in Dharamsala has become autonomous and self-sufficient to a very high degree. Some of the goods mentioned above are provided/regulated by the Indian Government, some are collaborative between the Tibetan and Indian communities, and some are entirely provided by Tibetans for Tibetans. Some of the necessities of life are only available through the Indian governmental agencies, such as those which regulate water and electricity/gas distribution. A certain amount of land was initially given to the Tibetans, but building in other areas requires both permission from the government and collaboration with Indians since non-Indians cannot own land in India. An exmple of such a negotiation is the process of acquiring land in an area close to Dharamsala for another important Tibetan religious leader, His Holiness the 17^th Gyalwa Karmapa. Although the mountainous terrain of Dharamsala prevents the Tibetans from engaging in much agriculture, they do produce their main staple from ground barley, known as tsampa. Many goods are also brought from Tibet, such as bricks of tea, yak jerky and dried cheese. As expert crafts people, the Tibetans make much of their own traditional clothing, and sell them, as well as generating income by way of tourism and hospitality, crafts such as carpet weaving, wood and metal carving and sculpture, thangka (religious iconography) painting, book publishing, and traditional Tibetan medicine. This income allows for the purchase of food and clothing they cannot produce themselves, individual roof-top water tanks (beyond that which is available communally, such as the water that comes from local water-pumps) and electricity/gas supply.

As for essential services, the only areas where the Tibetans are for the most part dependent on the Indian government are security and transportation. Although there is a private security force surrounding the Dalai Lama at all times, which is reasonable for someone who is considered to be like a head of state (despite there being a democratically elected prime minister and parliament of Tibet-in-exile), the police and military are Indian-run. Although many Tibetans own private vehicles, including a great many motorcycles for their convenience and cost-effectiveness, the bus services (save some Tibetan-run tourist buses) and taxis are state-controlled. The remaining essential services, refugee intake and placement, health care, sanitation, and education, are collaborative overall, but Tibetan health care and education are predominantly internal within the Tibetan community. When Tibetans arrive from Tibet, exhausted, impoverished, frost-bitten from walking over snowy mountains and sometimes at death’s door, the Tibetans have everything in place to assist them (including a Tibetan Torture Survivors Program, TTSP, a “multi-disciplinary program…[to] reduce physical, psychosocial and psychological problems as a result of violence and politically motivated torture in prisons in Tibet”)[v], but eventually the new refugee will need to get permission to stay from the local police superintendent. There are identity papers that a Tibetan may acquire from the Indian administration, but they are not the equivalent of our landed immigrant documents. They may potentially be sent back to Tibet, but this does not happen as frequently as in Nepal since India does not relent to bullying by China whereas Nepal is heavily influenced by the regime. Tibetans even have the freedom to protest the Chinese occupation in India, but in Nepal it is forbidden (which I learned the hard way when I was arrested in Kathmandu in 1996 for being on a bus that was merely heading towards an Amnesty International sponsored rally). As for education, “[w]ith assistance from the Government of India, Tibetan schools were established to impart modern secular education to the Tibetan children while also emphasising the learning of Tibetan language and literature, history, culture, religion, arts and crafts,”ⁱ and now it is safe to say that there are no Tibetan children not attending one of the Tibetan Children’s Village schools (which also serve as orphanages). In theory, the Indian government schools are open to Tibetans, but that option is not usually taken. Tibetans also have the option to attend secondary and post-secondary institutions, such as the College for Higher Tibetan Studies (where I had the fortune to studied logic and philosophy in the Institute of Buddhist Dialectics division). It is important to note that monastic community life and education is available as well, with more monastic colleges for males but still enough available for nuns to pursue such training also. Sanitation is an ongoing struggle for both the Tibetan and Indian administrations and communities. Both have made attempts to slowly develop recycling and garbage pick-up programs and install public washrooms in key locations, such as the main religious hub of the Temple complex of the Dalai Lama. Open sewers remain, as does the phenomenon of outdoor human waste elimination at the side of the road, or even during mass gatherings with the side of a hill demarcated in lieu of porta-potties. Garbage is still thrown into the environment, and collected waste is brought to open dumps at some distance from residential areas. Tibetans must pick up the slack in areas where the Indian government falters, and their recycling in the Tibetan institutions is quite admirable. The stray dog overpopulation problem, with rabies and mange quite rampant, is dealt with either by removing them to other areas, isolated sterilisation projects (such as volunteer Danish vets brought in the early 2000’s) and a relatively new animal welfare association. Lastly, touching briefly on recreation will suffice with mention of basketball courts being an essential part of every Tibetan school’s yard, and a public swimming pool built by the regional authorities at the site of a natural spring, which keeps the pool constantly full of fresh (and bone chilling!) water.

Next we come to health care. India has, in general, a two-tiered health care system. Both Indian government hospitals and private clinics exist, the latter including physicians, labs, diagnostic imaging, oncology and so on almost endlessly. Tibetans have access to both, but would sooner visit a traditional Tibetan doctor who approaches health with a 3-humours model, placing emphasis on pulse and urine analysis and including religious explanations and activities in response to health concerns. They may also simply buy herbal remedies, or blessed substances such as ‘mani pills,’ from the Tibetan Medical and Astrology Institute (TMAI, Men-Tsee-Khang). Both Men-Tsee-Khang and the Tibetan Delek Hospital are located mere steps away from the Central Tibetan Administration complex, and the hospital would be the next place to visit when addressing more serious conditions. The “45-bed…hospital provides general medical care with a special focus on Tuberculosis, the single most serious infectious disease that threatens the Tibetan population and new arrivals from Tibet. Delek also has strong maternal and child health care programs, a service sorely lacking in the area.”[vi] Since Delek’s “hospital services are limited to primary health care…as we cannot provide advanced medical facilities in our settlement hospitals due to lack of qualified and duly skilled staff and also because of financial constraints” patients are sometimes sent for “advanced…treatment in referral hospitals in various parts of the country…[hospitals] that cover major surgeries and other allied health services, which are currently not available in our settlement hospitals.”^vThe hospital does have a single, small ‘ambulance,’ a converted van of the type used by local taxi drivers. A co-ed old age home for the Tibetan elderly, Jampa Ling, is located behind the residence of the Dalai Lama, strategically placed because it is on the circumambulation route around the residence and older Tibetans are quite fond of circumabulating for health and social chatting, in addition to the karmic merit that is thought to be accrued. At any point in the development of health concerns, from the most minor to the most major for oneself or a loved one, a Tibetan may also consult a religious professional (either monastic or not). In addition to astrological advice that can also be accessed at the Men-Tsee-Khang, a client may ask for: a divination (by dice, tsampa balls, or drum); an assessment for potential spirit harm as the cause of disease or obstacles; or even an exorcism (though this is less frequent in contemporary India, or kept more quiet). The Central Tibetan Administration’s Department of Health is “working towards the integration of traditional system of Tibetan medicine with the allopathic Primary Health Care system in order to avail maximum benefits. The two systems of medicine run in parallel to each other and are used equally by the people; increasing the frequency of referral process between the two health care systems.”^v It has also, over the years, implemented programs for: potable water, improved sanitation, substance abuse rehabilitation, helping those with disabilities and special needs, and health education including HIV/AIDS campaigns.^v

The nature of the provision for each of these types of goods.

Upon arrival to India as refugees, the Tibetans lived in tent camps and the basic necessities of life were provided for by the Indian government. Since then, the Tibetans in Dharamsala have become organized enough to not have to rely entirely on the generosity of India and can afford the costs of individual household water-lines/tanks (although some families still access local unfiltered well-water via pumps, which are unreliable at best but available at no cost) and electricity, food and clothing (so much so that new refugees can be taken care of by the community) and land beyond the areas initially given to the Tibetans. Although private taxi-drivers and tour buses abound, generally bus and taxi transportation service and fees are regulated by the government which makes for low ticket prices and reliable schedules. The extra efforts to improve sanitation in Dharamsala are borne by the community and donations from abroad. Almost every area of Tibetan society is in some way touched by international financial support, but predominantly it is found in support of: refugee services, education, environment (sanitation, roads, building), monasteries/nunneries and health care. As mentioned earlier, Tibetans can access free education and health care provided by the Indian government but mostly opt out in favour of Tibetan-run services. Education and health care are two areas where needy Tibetans can get what they need at no cost, but, in addition to international donations, the Tibetan community itself bears the financial burden to some degree.

The Tibetan Children’s Village is a case-in-point regarding the Tibetan community investing in education to ensure access and quality. “On 17 May 1960, fifty-one children arrived from the road construction camps in Jammu, ill and malnourished. Mrs. Tsering Dolma Takla, the elder sister of His Holiness, volunteered to look after them. Initially these children were assigned to members of the Dalai Lama's entourage, but before long the Government of India offered its assistance, renting Conium House to accommodate all the children together… Originally, the Nursery for Tibetan Refugee Children provided only basic care for children. When they reached the age of eight, they were sent to other residential schools established by the Government of India. But eventually this arrangement could not be continued as all the residential schools filled to capacity… A massive re-organization plan was set into motion. This included seeking help from private donors and international aid organizations. A period of hectic construction work ensued to provide for more houses and classrooms for children. The Nursery slowly took the shape of a small village with its own school and homes… [Started in the 80s during a great influx of refugees, t]oday, TCV School Lower Dharamsala is a high standard school with both primary and secondary school. It is entirely funded by Tibetan parents in exile.[vii] Initially the Government of India provided both land for refugee orphan housing and access to Indian schools, but proving inadequate, the growth required depended instead on international support and eventually the Tibetans could support their main school themselves. The monastic life, too, is invested in by both international supporters and the Tibetans-in-exile such that any Tibetan who can follow the discipline can be assured of a lifetime of support by the institution. This includes the necessities of life and extensive religious (and some secular) education.

Health care is another example of a good invested in by both international supporters and the Tibetans-in-exile themselves to ensure access and quality. It is free for both Tibetans and local Indians who cannot afford the low fees. “In its basic health care policy, the DoH has adopted the goal of ‘Health For All,’”^v and as an example, Delek Hospital is a charitable institution where “[u]ser fees are kept exceptionally low so that the poor can afford treatment in this hospital.”^vi The CTA is responsible for maintaining free access to health care for the poor: “Under the guidelines issued by the Kashag (Apex Executive Body), the Central Poverty Alleviation Committee has conducted an intensive survey on poor and needy among the exile Tibetan Community… As per the Kashag’s policy and guidelines, the Department of Health is providing monthly stipend and bearing all the medical expenses of all the needy and poor Tibetan people identified by the Central Poverty Alleviation Committee.”^v An Emergency Medical Relief Program allows for Tibetans to pay what they can (even if it is zero), and to buy into health insurance: “advanced treatment…can be classified into two categories: emergency medical relief for the staff members of Central Tibetan Administration who make a monthly contribution of 1% of their monthly gross salary towards CTA medical fund. The other category is the poorest of the poor who are selected and duly registered by the three concerned CTA Departments, i.e. Department of Home, Education and Health. We look after the health of the poorest of the poor category and bear cent per cent of their medical cost including medical services, surgery and other operational cost. As for the remaining category of patients, the percentage of DoH medical relief assistance is based primarily on the scrutiny and recommendation of the settlement heads, camp leaders and the DoH hospital Executive Secretaries of various settlements.”^v

What types of health care goods are and are not provided collectively (or where the type of provision is different)?

There is a difference in the distribution of Tibetan traditional medicine and the operation of freelance religious professionals that address health concerns by way of traditional medicine or by religious methods. The Tibetan Medical and Astrology Institute (TMAI, Men-Tsee-Khang) supports their own staff and their families, and students from funds generated by their services and from international support. “To involve children in the community of TMAI, housing, child care and other resources are provided to staff and their families. To ensure that the children of staff receive adequate medicine, food, clothing and school supplies, we seek individuals willing to sponsor a child… As part of its charity work, Men-Tsee-Khang also provides free education for its medical and astrological students.”^viii Additionally, the elderly, new refugees, the poor, monastics and students are granted special consideration: “Charitable Health Care: As a registered charity, it is Men-Tsee-Khang policy to provide free medicine to Tibetans over the age of seventy, to new Tibetan refugees for the first six months, and to poor or desitute Tibetans (the respective Settlement/Welfare Officer in the refugee settlement determines whether a Tibetan is poor or destitute). Concessional medicine is provided to monks, nuns and students.”[viii] It is noteworthy that the last category of Tibetans are not given free medicine, but rather that which is “concessional” (some degree of subsidy), likely because the institutions to which they belong provide on-site medicine and basic nursing care, monetary support for health care external to the institution, and monetary stipends. It is also worth noting that the elderly are given free medicine regardless of their financial standing.

As freelancers, religious professionals control the distribution of their own services. As they may or may not be monastics, they may or may not be receiving financial support from a monastic institution or individual lay Buddhist devotees. As a dependent themselves, it would be difficult for a monastic to deny helping someone who could not afford their services but as there is no regulation of their vocation as a healer, herbalist, diviner, astrologer, exorcist or ritual specialist, their own discretion determines how they deliver services. If they are a graduate of the Men-Tsee-Khang, as many monks are in fact trained traditional Tibetan medical doctors, there may be some systemization of their delivery of service despite having their own clinic. This requires further investigation.

What rationale(s) is provided (or implied) in all of this? What appears to be the nature of the entitlement(s)?

Here we have several types of distribution: the Indian governmental support of the Tibetan refugee community, Tibetans helping other Tibetans, Tibetans investing for entitlements for themselves and the younger generation, Tibetans helping the impoverished regardless of their ethnicity, and Tibetans giving special entitlements to certain groups within the Tibetan community: new refugees, the elderly, the destitute, students, and monastics.

As for the initial and ongoing Indian governmental support of the Tibetan refugee community, I think there are several layers of rationalization behind it. The first could be the particular situation of the Tibetans as refugees. As such, they are particularly needy, disadvantaged and unprotected. Not only this, they are a neighbouring people who consider India as their spiritual homeland from which their religion has come, as the majority of Tibetans are Buddhists who practice Indian Buddhism (as opposed to Chinese Buddhism). Plus, India is sympathetic to the Tibetan cause in opposition to the Chinese communist viewpoint that Tibet is a part of China therefore their occupation is legitimate. This is shown by 50 years of India not bowing to Chinese pressure to not host the Tibetans, and could be reinforced by the fact that India has had its own troubles with China where their borders meet. For both the Indians and Tibetans who are in a position to help new refugees, both can see them as special claimants, and be motivated to meet their needs because they are especially needy. They may also be motivated to prevent harm, and also driven by charity and beneficence. The reasoning of fulfilling the needs of others by virtue of their being special claimants can also be behind the Tibetans’ demarcation of certain groups: the poor in general, and the elderly within their own community. These groups are vulnerable and especially needy, and so helping them can be motivated by the same reasoning as for helping refugees (harm prevention, charity, beneficence). Alternatively, the students and monastics would not have special entitlements because of being especially needy and vulnerable, but rather due to their particular lifestyle requiring them not to work and the value placed on these groups by Tibetan society. Students, in order to fully participate in society as a wage-earner, need to spend a certain amount of time focusing on their studies and not working. Similarly, but in an ongoing way, monastics need to focus on their religious studies and practice and in observing the ascetic discipline they do not do wage-earning work in that trade or commerce increases attachment to wordly activities and possessions. Highly revered in Tibetan culture, the role of a monk is in reciprocity with the Buddhist householders: the monastics offer teachings and guidance, and the householders support them by providing the requisites of food, shelter, clothing and medicine (either directly or by way of making donations to the monastery/nunnery). It would be remiss to not mention that Buddhists see any help offered to monastics as one cause for the accumulation of meritorious karma that will benefit the practitioner in this and future lives, so religiously-oriented motivations also influence entitlements granted monastics. Lomasky’s statement that “[e]ven on coldly economic grounds, it is irrational not to invest a sum that will be returned many times over in a life of increased productivity” [ix] can apply to the entitlements given to refugees, students and monastics. Even though wage-earners and non-wage-earners have different outputs from their training and development, both are valid and valued by Tibetan society for their contributions. As well, both refugees and students will eventually, it is hoped, no longer be at all dependent on special entitlements and so their initial and limited supported can be seen as the fair equality of opportunity principle in operation.

According to these policies and practices, is health care different? How is health care different?

Buchanan’s approach of using the “combined weight of arguments…[as] justification for an enforced principle guaranteeing a decent minimum of health care to everyone…[rather than a] universal right to a decent minimum of health care”[x] might give us a glimpse at the reasoning behind the Indian government and the Tibetan community in India treating health as paramount in refugee support. The first are the “Arguments from Special Rights^ixwhere “[s]pecial right-claims…restrict the right in question to certain individuals or groups."[xi] One type of these arguments is "from the requirements of rectifying past or present institutional injustices… on the grounds that these injustices have directly or indirectly had detrimental effects on the health of the groups in question...[from a] history of unjust treatment by government or other social institutions."^x The Tibetans as new refugee claimants escaping from an oppressive regime certainly makes them an especially needy group health-wise, suffering from such things as: injuries, malnourishment and post-traumatic stress from torture, underlying illnesses exacerbated by not receiving proper care in Tibet, frost-bite from the trek to India and so on. The legitimacy of the claim is strengthened by India’s first-hand experience with China’s strong territorial movements to surrounding areas. In this case, the rectification would not be because of injustices perpetrated by India, but rather those perpetrated by the occupying Chinese and recognized as such by India. Another line of reasoning comes from Buchanan’s “Arguments from the Prevention of Harm” which will "protect the citizenry from certain harms arising from the interactions of persons living together in large numbers… Examples include sanitation and immunization. The moral justification of such measures, which constitute an important element in a decent minimum of health care, rests upon the widely accepted Harm (Prevention) Principle, not upon a right to health care."^x Since the Tibetans have, at various times (particularly 1959 and the mid-80s), come to India in droves, such a principle would inform the actions of the hosting nation in relation to refugees to ensure not only that the Tibetans would not be harmed by being put together while their susceptibility to illness is high (taking as a given that the majority will not be in good health upon arrival), but also so that Indians in the surrounding areas will also not be harmed by the spread of disease out from the refugee community.

Earlier it was shown that education and health care are the two social goods that Tibetans buy into for themselves: Lower TCV school is entirely funded by Tibetans, and some Tibetans have the option to give a percentage of their income as health insurance. Health care is approached differently in that it relies on support from the CTA and donations both local and abroad and a sliding-scale based on the ability to pay because (1) the needs are so great and, because (2) the Tibetans are committed to providing health care to every Tibetan. It cannot be said that the Tibetans ensure that every Tibetan gets an education, since it is only for Tibetans of schooling-age that this is done. But it can be said that the Tibetans ensure access to health care for every Tibetan.

A major influence on the Tibetans treatment of health as special comes from the Buddhist conception of suffering and its alleviation as the fundamental human challenge. When Daniels says that “[s]ome might say health care in a direct and simple way reduces pain and suffering,”[xii] the Tibetans would belong to this group. There are many principles from Buddhist doctrine and practice that might influence Tibetan decision-making: generosity, the wish to benefit others, the wish to become fully developed in order to be most effective in helping others do the same, love (the wish for others to have happiness), compassion (the wish for others to be free from suffering), the technique of imagining taking on other’s suffering and giving them happiness in return, and so on.. All of these can be engaged in with the idea of accruing karmic merit for oneself or, alternatively, with no hope for reward, purely for the sake of the other. With these as a foundation, an “enforced beneficence argument for a decent minimum of health care”[xiii] might not be seen as interference in a person’s autonomy but rather as a co-ordinated effort to act in accord with Buddhist principles as a group which must necessarily lead to a positive outcome.

It might be said that Tibetans overemphasize health. This, however, might be perceived by an observer as due to the Tibetans’ not holding to a “ ‘biomedical’ model of disease and health…[where health is the] absence of disease…[and illness is from] deviations from the natural functional organization of a typical member of a species.”[xiv] Tibetans, rather, adhere to a bio-psycho-spiritual view of health, which means that many things are included that would not be typically seen as falling under the binary of health/disease, such as very subtle conceptual positions and emotions. Also, contrastingly, because the end goal of the Buddhist path is seen as total mental health (which will necessarily be coupled with perfect physical health), a heavy emphasis is placed on mental development to the detriment on some crucial components of health, such as exercise.

Are these policies and practices appropriate?

The historical support of the Tibetans-in-exile by the Indian government in providing refuge, the necessities of life and essential services up to the point where the community could support themselves, to the detriment of the country’s relationship with China, is very admirable and garners ongoing gratitude from the Tibetans. Treating refugees as a special group, especially when most have been subject to abuse, is appropriate, as is harm protection for the Tibetans as a group and in relation to pre-existing neighbouring communities. The Tibetans utilize these two principles (special entitlements and harm protection) themselves when dealing with new refugees. The only problem is see with this is in finding the threshold where a new refugee is no longer ‘new’ and has achieved a certain level of stability where his entitlements should change because they require less dependence. The Tibetans make this distinction, but I do not know how they come to the determination that a refugee is no longer ‘new.’ I also am not sure how or if the Indian government makes the distinction between a new or more settled refugee. My concern extends to the support given by international donors and fundraisers. For example, in South India some monastic institutions receive monetary support beyond their needs and, in the expressed opinion of the Dalai Lama, it is wasted on buildings that are too big to fit all of their monks and would be used more effectively if given to the local farmers who struggle with drought. Also, in every Tibetan community in exile there will be some who try to retain multiple sponsors, on the basis of being a refugee and each without the knowledge of the others, and resulting again in there being resources beyond needs. The potential to subsume new refugees with those that are more settled, and the accumulation of benefits and donations from multiple sources, can endanger entitlement claims as well as charitable assistance.

In my opinion, the biggest concern with the reasoning behind health care provision in the Tibetan refugee community in Dharamsala is the lack of some degree of personal responsibility affecting distribution. As Gutmann states, when we consider the various “choices of lifestyle among the population[xv]…[a]n equal access principle seems to neglect the distinction between voluntary and nonvoluntary health risks…”[xvi] The Tibetan community is notorious for certain types of behaviour statistically leading to certain health outcomes: a diet relying heavily on butter and salt, leading to high prevalence of diabetes; snuff usage, even (maybe even especially) in monastic community, leading to nasal problems and cancer; long periods of meditation while immobile in meditation retreat boxes causing crippling joint problems; lack of exercise in monasteries leading to obesity and heart problems;

and some may point to almost perpetual usage of incense as a risk for sinusitis. Not unique to the Tibetans, of course, but alcohol and drug abuse are problems particularly among new and young Tibetan refugees. Like Gutmann, in this community where access to health care is guaranteed for all, I would “…ask whether it is fair to provide the same level of access for all people, including those that voluntarily adopt bad health habits, and who quite knowingly and willingly take greater-than-average risks with their lives and health.”^xvi The question is: are Tibetans all able to recognize certain activities as health risks? I agree with Dworkin (1979), quoted by Gutmann, who states that it would “not be unfair to force individuals to be financially liable for voluntarily undertaken health risks, but only under certain conditional assumptions…[the] ability…1) to determine…causal role of voluntary versus nonvoluntary factors in genesis of illness; 2) to differentiate between purely voluntary behaviour and…compulsive; and 3) to distinguish between genetic and nongenetic predispositions to illness.”[xvii]

If it is determined that a behaviour that is a risk to health is voluntary, the question then becomes: what health care entitlements are owed to this Tibetan by the Tibetan community, as decided by the CTA DoH? This is a difficult question in the context of a community committed to “health for all.” I would, however, suggest some new methods of health education and some deterrents to behaviours that pose health risks. Until now, according to the DoH, health education has been limited to “various health awareness programs in the settlements, schools and monasteries…[by way of] newsletters…pamphlets, books, comics, posters and films.”^v What education is done by health professionals at the bedside or in clinics? And do foreign volunteer health providers have the freedom to explore approaches to health that may have never been broached with a Tibetan before? As for risk behaviour deterrents, since threats to access would not fit the Tibetan “health for all” model, providers could discourage those who consciously engage in behaviour that risks health by: increasingly burdening them with accountability exercises; providing explicit reference to the strain on the community, caregivers and resources (cost per visit or procedure); and making them aware of the increasing barriers to their own ability to access health services that would come with deteriorating health (such as not being able to make it to the hospital in time when in crisis).

Notes

[i] International Institute for Sustainable Development (2011); We the Peoples: 50 Communities Awards (A summary of exemplary communities by category of UN activity); http://www.iisd.org/50comm/commdb/desc/d46.htm

[ii] Department of Tourism & Civil Aviation, Government of Himachal Pradesh, Shimla (2008); Himachal Tourish: Unforgettable Himachal; http://himachaltourism.gov.in/post/Dharamshala.aspx

[iii] An Informative, Travel and Community Website of Dharamsala, Mcleodganj and Kangra Valley (2011); http://www.mcllo.com/mcleodganj%20%5BMcllo.com%5D.html

[iv] Daniels, N. (1981); Health-care Needs and Distributive Justice. Philosophy and Public Affairs; Spring. 10(2): p. 158.

[v] Central Tibetan Administration Official Website (2009); http://www.tibet.net/en/index.php?id=25&rmenuid=12

[vi] Friends of Delek Hospital (2010); http://www.delekhospital.org/index.htm

[vii] Tibetan Children’s Village (2004); http://www.tcv.org.in/

[viii] Men-Tsee-Khang: Official Website of the Tibetan Medical and Astrology Institute of H.H. the Dalai Lama (2011); http://www.men-tsee-khang.org/

[ix] Lomasky L. (1981); Medical Progress and National Health Care. Philosophy and Public Affairs. 1981; 10(1): p.85.

[x] Buchanan, Allen E. (1984); The Right to a Decent Minimum of Health Care; Philosophy and Public Affairs, Vol. 13, No. 1, Princeton University Press. p. 66.

[xi] Ibid.; p.67.

[xii] Daniels 1981; p.169.

[xiii] Buchanan 1984; p.76.

[xiv] Daniels 1981; p.155.

[xv] Gutmann A. (1981); For and Against Equal Access to Health Care. The Milbank Memorial Fund Quarterly. Health and Society; 59(4): p.553.

[xvi] Ibid.; p.554.

[xvii] Ibid.; pp.554-555.

References

An Informative, Travel and Community Website of Dharamsala, Mcleodganj and Kangra Valley (2011); http://www.mcllo.com/mcleodganj%20%5BMcllo.com%5D.html

Buchanan, Allen E. (1984); The Right to a Decent Minimum of Health Care; Philosophy and Public Affairs, Vol. 13, No. 1, Princeton University Press.

Central Tibetan Administration Official Website (2009); http://www.tibet.net/en

Daniels, N. (1981); Health-care Needs and Distributive Justice. Philosophy and Public Affairs;

Spring. 10(2).

Department of Tourism & Civil Aviation, Government of Himachal Pradesh, Shimla (2008); Himachal Tourish: Unforgettable Himachal; http://himachaltourism.gov.in/post/Dharamshala.aspx

Friends of Delek Hospital (2010); http://www.delekhospital.org/index.htm

Gutmann A. (1981); For and Against Equal Access to Health Care. The Milbank Memorial Fund Quarterly. Health and Society; 59(4).

International Institute for Sustainable Development (2011); We the Peoples: 50 Communities Awards (A summary of exemplary communities by category of UN activity); http://www.iisd.org/50comm/commdb/desc/d46.htm

Lomasky L. (1981); Medical Progress and National Health Care. Philosophy and Public Affairs. 1981; 10(1).

Men-Tsee-Khang: Official Website of the Tibetan Medical and Astrology Institute of H.H. the Dalai Lama (2011); http://www.men-tsee-khang.org/

Voluntary death as found in the epics Mahābhārata & Rāmāyaṇa

2011-04-11T13:57:00.000-07:00

COMING SOON

Thoughts on the Rāmāyaṇa & Mahābhārata

2011-02-09T23:55:00.000-08:00

COMING SOON

Short pieces on the great Indian Sanskrit epics Rāmāyaṇa and Mahābhārata.

Buddhist Deaths in Hospital: Narratives and Case Analyses

2010-12-19T20:30:00.000-08:00

I am in the process of collecting anonymized narratives of Buddhist deaths occurring in hospitals. My aim is to look at the challenges and triumphs of such occurences, to assist with future problem-solving when caring for diverse populations in end-of-life care in general, and dying Buddhists in particular.

This is a work-in-progress so any contributions and feedback are most welcome. No identifying information will be posted and some details may be altered to ensure confidentiality.

Below is one case run through an ethical framework.

A Brief Case Analysis of a Dying Tibetan Buddhist of Canadian Descent utilising Dr. Robert Butcher’s “Framework for Ethical Decision-Making”

Applying Dr. Robert Butcher’s “Framework for Ethical Decision-Making” to the case of Ms. T, a patient with a brain-tumour in a Toronto Catholic hospital palliative care unit, will involve outlining the details of the case to be examined, followed by: (1) determining the problem, (2) finding the issues involved, (3) pinpointing the stakeholders, (4) pointing out the options and making assessments, (5) making a decision, and (6) the implementation of that decision.[1] Subsequently, the strengths and limitations of Dr. Butcher’s framework will be compared and contrasted to the the IDEA: Ethical Decision-Making Framework.[2]

Setting the stage and determining the problem

Ms. T is a Canadian-born, 40-year old female with an inoperable brain-tumour and a prognosis of two months to live. She was admitted to the Medicine Unit of a Toronto hospital with vertigo and headache symptoms, and rapidly deteriorated. Her speech underwent periods of dysphasia, neuropathy and reduced motor control led to unsteady gait and reduced mobility and a general lack of ability to perform activities of daily living. This combined with dementia led to incontinence and periods of disorientation. Noteworthy, however, were frequent but unpredictable periods of lucidity where the patient was oriented to person, place and time and also had clear access to short and long-term memory. Despite the onset of dementia and worsening agility, she did not suffer from agitation nor complained of pain. She was moved to the palliative care unit several weeks ago, on the recommendation of the interdisciplinary team, particularly the primary physician, some key nurses, the social worker and chaplain. Deemed incompetent to make the decision herself, the decision to move Ms. T was done in collaboration with several people close to the patient, two of whom are substitute decision makers. Ms. T is unmarried, and has no family save an older brother who visits often but he has a history of mental health problems and his visitation has been restricted due to his erratic behaviour and verbal abuse of staff. The brother, along with a close female friend of Ms. T, are the substitute decision makers and there is a “Power of attorney for personal care” document in the chart which contains robust information regarding Ms. T’s decisions for advance care planning in almost every area, from the non-usage of such heroics as CPR to funerary arrangements.

Although from a Christian family, Ms. T has been a Tibetan Buddhist practitioner for the last 20 years. She is close with her teacher in the city, a monk, and has made many trips to India, Nepal and Tibet and regularly attends temple activities. She also practices at home, meditating, chanting and reading texts in front of her shrine. Her teacher, Lama Tsultrim, visits her every day and her close friend and brother know that although he is not a substitute decision maker, Ms. T puts great stock in his views and advice as she has trust and faith in him. Additionally, a hospital staff member who is a nursing assistant on another unit that is managed by the same nurse who manages the palliative care unit happens to be a Tibetan Buddhist monk also of Canadian descent, and the nursing staff have requested for him to visit Ms. T since she is often alone. Both monks would talk and chant together with Ms. T, and reads texts to her. All of this is indicated in the chart.

Two weeks into her stay, one of the hospital chaplains (who is also a Catholic priest) started to wheel Ms. T to daily Mass in the hospital chapel. It is unclear how this came about but the nursing staff certainly participated in this activity, since their permission is required for the patient to leave the unit, even if there is no way of knowing if it was their idea initially.
The nursing assistant monk, (Ven./Br.) Tyler, who was hospital staff but previously visiting Ms. T in the capacity of clergy was sent to the palliative care unit one day to do a shift. Shared staffing is a common occurrence given that there is one manager for both units. While the nurses and aides listened as a group to the morning taped-report in the staff lounge, Ms. T’s night nurse said, “Ms. T has re-embraced her Catholic faith,” indicated that she was attending Mass with the chaplain-priest and advised to “not inform the Buddhist clergy.” One nurse nudges Tyler, fully knowing the context, and says “don’t take it personally.”

Specifically, the problem that requires solving is the manipulation of the vulnerable patient by having her engage in religious activities that she would not choose to be a part of were she competent. This problem survives both by the inaction of those who do not see the ethical dilemma, and the deception of those who collude to keep this breach of trust under wraps from those who will recognize it as such. Because it is hard to say if other nursing staff know about the patient’s incompetency and the incongruency between actively involving her in religious activities that are at odds with her own faith, at this moment Tyler is responsible for taking action since he is the only one who has an active and vested interest in fulfilling the patient’s particular spiritual needs. He needs to openly point to the problem, but the question is: in what manner and to whom is he to make the problem known?

Issues

Formulating an ethical context requires teasing out the ethical issues and relevant hospital policies or goals at play in this problem. Autonomy, beneficence, non-maleficence, integrity, dignity, diversity, conflict of interest, and transparency are all weighing in with this situation. Ms. T’s beliefs and autonomous wishes with regard to spiritual care are clearly known despite being out of the ordinary and her lacking in capacity, and they are not being respected. The diversity demonstrated by such a unique worldview being held by a Western Buddhist is trampled by wheeling her to a church service involving sacraments, a major conflict of interest for the healthcare providers who are caught between injunctions to care for patients on their own terms and the missionary push in Roman Catholicism. Their integrity is in jeopardy since a strong missionary drive might override giving priority to ethical considerations, and allow violations of ethical requirements to pass unnoticed. In this way she is being harmed by those who are actively going against her wishes, and she is unprotected from harm (a requirement of beneficence) by those who passively observe such treatment and do not interfere. Although brought up in report, and most likely documented in the chart, the process that led to the patient being brought to church is opaque because someone surely would have done something to interfere if they had all of the pieces of this ethical puzzle: the patient’s current inability to make decisions, her history which includes her religious orientation, the presence of formerly expressed wishes and the support of her advocates (brother, friend and clergy).
Institutionally, this hospital’s operation is guided by the Catholic Health Association of Canada’s Catholic Health Ethics Guide. In Section I, The Communal Nature of Care, we see the following articles under Health and Healing:

2. …determinants of health include biological and psychological (mental and emotional) factors, the physical environment, lifestyle, spirituality and religious belief, social interactions and support, economic status, and working conditions. Together, these factors influence the health of an individual or community.
3. Healing is more than simply curing a disease. Healing takes into account the wholeness of the person, recognizing the interrelationship of body, mind and spirit. It involves a restoration of balance and acknowledges the role spirituality and/or religious beliefs can play in the healing process. A particularly important way to nurture health is to foster prayer, forgiveness and reconciliation.[3]

The opening section of the document places great importance on an individual’s spirituality, and see it as a crucial component in promoting and restoring health. In the same section, we see the following article under Mission of Catholic Health and Social Service Organizations:

7. Every Catholic health and social service organization proclaims a religious identity that reflects a vision of life and of the world that is in accord with human values and is faithful to the Roman Catholic tradition. The organization’s mission should be articulated clearly in a mission statement. Such statements should be reviewed regularly, with opportunities for input from all members of the organization. A regular audit to ensure compliance with the mission is necessary. [4]

Here we may become concerned that ‘spirituality’ has now become too narrow. It is important to note here that the staff demographic at Catholic hospitals is as diverse as the patient population. However, what about the healthcare provider working at such an institution who also happens to be Catholic, such as the priest who is stealing away Ms. T? His ‘vision of life’ may be something kept in check within his mind and among his flock, but in his ‘vision of the world’ is there a compulsion to save lapsed Catholics from themselves by returning them to the faith? Again from Section I, The Communal Nature of Care, under Primary Purpose:

8. Whatever its particular objectives, every Catholic health and social service organization aims primarily at the relief of suffering and the promotion of health…[5]

The guide, here, allows for various agendas but brings the objective of Catholic healthcare back to reducing suffering and increasing health, for which spirituality is recognized as a crucial component. Not just any spirituality, mind you, but that which is in accordance with the individual. In section V, Care of the Dying Person, we see these relevant articles with regard to Decision-making and the Dying Person:

89. In making decisions about the treatment of the dying person, the needs, values and wishes of the person receiving care should be the primary consideration. Treatment decisions should reflect an agreement among all those involved in the care of the person, including family members and those who are significant in the person’s life.
91. When a person is not competent, that is, lacks adequate decision-making capacity with respect to treatment, every effort is to be made to ensure that the choice of health care treatment is consistent with the person’s known wishes. Health care treatment choices are to be made by a proxy who, if the person`s directives are not known or are inapplicable, must make treatment decisions based upon the dying person’s known needs, values and wishes.
92. …decisions should take into account the person’s past and present expressed wishes…[6]

Although the organization is meant to hold to a Roman Catholic vision, the guide ensures that this vision is not to impinge on the precedence that is given to a person’s uniqueness as expressed through their particular needs, specific values and individual spirituality which will all influence a person’s wishes with regard to their care. Therefore, those who deny Ms. T her spiritual heritage by careening her off to Mass are not only acting out of accordance with fundamental ethical principles, they are also acting out of accordance with the institution itself.

Stakeholders

The stakeholders in this scenario are the patient, those connected to her such as her brother, friend and clergy, her caregivers, and the hospital. All have the patient’s best interests at heart, but what becomes tricky is how ‘best interests’ is defined by the Catholic healthcare providers who have a hand in bringing her to Mass. They may, with their Roman Catholic vision of the world, see the act of reconnecting her with her familial religion as saving her from certain doom. However, the Health Care Consent Act clearly states that, with regard to a proxy deciding for the incapable person,

“[i]n deciding what the recipient’s best interests are, the person shall take into consideration the values and beliefs that the person knows that the recipient held when capable and believes he or she would still act on if capable…[7]

For 20 years Ms. T was practicing Tibetan Buddhism and there is no reason to assume that she would suddenly throw this long-standing practice out the window. The missionary agenda of the Catholic members of the team may be relying on the idea that “[c]apacity can change over time…[where] a person may be temporarily incapable because of delirium but subsequently recover his or her capacity.”[8] They could very well try to point to Ms. T’s moments of lucidity as the occasions during which they re-engaged her, with her consent, in Catholicism. This is risky given both the very strong ground her documented history and the SDM advocacy (in relation to her religious practice) stand on, and the unreliability of her changing mental status (which is sometimes momentary). The Catholic missionary members of the team could also be relying on the fact that “Powers of Attorney for Personal Care and other forms of advance directives and living wills ‘speak’ to the substitute decision maker, NOT to the health practitioner.”[9] Again, this is not going to hold up as a way to ignore the patient’s history of practicing, and previous wishes to have continued involvement with, Tibetan Buddhism, since the health practitioners must speak to the substitute decision makers when the patient is incapable, and both SDMs advocate for the patient’s unique religious wishes. Additionally, even though both clergy members are not substitute decision makers, and despite one clergy having a dual role that includes being on the healthcare team as well, both are vested in helping fulfil Ms. T’s Buddhist spiritual needs.

Options and Assessments, Decision, Implementation

Tyler, the monastic nursing aide, is compelled by many forces to act: bioethical principles such as autonomy, beneficence, non-maleficence, integrity, dignity, diversity, transparency, and the avoidance of conflict of interest all are very much in line with both the Catholic ethics of the institution and the vows of non-harm of a Buddhist monastic. The question is, what is the best action to take?

Tyler can speak out directly to the nursing staff during report, at the time when the actions of the priest are revealed for the first time to someone in his unique position of being in two overlapping fields of the patient’s care: spirituality and healthcare. He can also go to the charge nurse, or to the manager, in private. He could choose to approach the unit’s bioethicist for advice. Alternatively, he could go to the nursing co-ordinator for the hospital, or to the head of spiritual care.

There are potential repercussions of approaches to broaching the problem that are kept within the unit and those taken outside the unit. Since this activity of bringing the incapable Buddhist off the unit to Catholic Mass happened over the course of some time, without interruption, it is likely that there are many within the unit that participated or ignored it, tacitly assenting by way of silence. If brought up directly to the unit staff, the nurses could find ways to shut down a process of inquiry to protect each other and the manager, also a nurse, could be a very strong advocate for her nursing staff and defend them by explaining the situation away as a simple misunderstanding. Alternately, going to anyone outside of the unit, although reasonable, could very well be seen from within the unit as jumping rank and could affect Tyler’s future relations with nursing staff. Regardless, this seems to be the best option given the signs of collusion within the ranks of the palliative care unit. Care must be taken not to jump too high too fast among those approached outside of the unit, because it could be that the higher the position held by staff outside the unit, the more dramatic the response to the problem. An extreme response might not be required for the desired effect of protecting Ms. T from being subjected to religious activities that are not part of her chosen tradition. Judging by the actions taken to put a stop to this by one’s allies outside the unit itself, and the effectiveness of the results obtained, will be a good indicator of whether Tyler has brought the issue high enough in hospital hierarchy or if more is required.

Butcher vs. IDEA: Ethical Frameworks Compared and Contrasted

Both frameworks have their place and have much to offer when used for addressing ethical problems, but, in general, Dr. Butcher’s is best for direct and immediate application whereas the IDEA framework is more suited to a problem that might be more complicated and that which requires being approached over a lengthier period of time.

Dr. Butcher's ethical framework provides a clear methodology for approaching difficult issues, unburdened by too much information and many sub-processes within each step. Easily and efficiently applied to ethical dilemmas, it is, however, thin when taken only on its own. It is not fleshed out with charts or additional information, such as a glossary of important terminology. It leaves much to the imagination, which can be helpful in leaving room for a creative approach to ethical dilemmas, but it can also leave participants (who are already in a difficult spot) grasping for more.

Although the IDEA framework has a simple overall scheme, with four steps, it is lengthy and includes not only multiple processes within each step but also the requirement to meet the five conditions of empowerment publicity, relevance, revisions/appeals and compliance/enforcement. This makes it a very rigorous approach, but perhaps more difficult to apply with expediency. The inclusion of appendices, such as an outline of various ethical principles and such distinctions as those between ‘ethical violations’ and ‘ethical dilemmas,’ give the user more material and guidance to assist with addressing a situation if they have an abundance of time to do so.

References

Butcher, Dr. Robert (2009); Framework for Ethical Decision-Making; Foundations: Consultants on Ethics & Values Inc.

Catholic Health Association of Canada (2000); Catholic Health Ethics Guide.

Etchells, E. et al (1996) Bioethics at the Bedside, CMAJ.

Health Care Consent Act (Canada), 1996. (As of August 31, 2007)

The IDEA: Ethical Decision-Making Framework builds upon the Toronto Central Community Care Access Centre Community Ethics Toolkit (2008), which was based on the work of Jonsen, Seigler, & Winslade (2002); the work of the Core Curriculum Working Group at the University of Toronto Joint Centre for Bioethics; and incorporates aspects of the accountability for reasonableness framework developed by Daniels and Sabin (2002) and adapted by Gibson, Martin, & Singer (2005).

Wahl, J. (2003) 25 Common Misconceptions about the Substitute Decisions Act and Health Care Consent Act; Advocacy Centre for the Elderly.

[1] Butcher, Dr. Robert (2009); Framework for Ethical Decision-Making; Foundations: Consultants on Ethics & Values Inc.
[2] The IDEA: Ethical Decision-Making Framework builds upon the Toronto Central Community Care Access Centre Community Ethics Toolkit (2008), which was based on the work of Jonsen, Seigler, & Winslade (2002); the work of the Core Curriculum Working Group at the University of Toronto Joint Centre for Bioethics; and incorporates aspects of the accountability for reasonableness framework developed by Daniels and Sabin (2002) and adapted by Gibson, Martin, & Singer (2005).
[3] Catholic Health Association of Canada (2000); Catholic Health Ethics Guide; p.20.
[4] Ibid.; p.21.
[5] Ibid.; p.21.
[6] Ibid; pp.56-57.
[7] Health Care Consent Act, 1996: c.2, Sched. A, s. 59 (1)
[8] Etchells et al 1996: p.18.
[9] Wahl 2003, p.11.

Eight short pieces on various topics related to Religion and Magic in Asia

2010-12-07T13:34:00.000-08:00

Sean Hillman, 2010
M.A. (c) Religion (Buddhist Studies)/Bioethics
B.A. East Asian Studies
Department and Centre for the Study of Religion
Joint Centre for Bioethics
University of Toronto, CANADA

1) Separating religion and magic in Buddhism and Jainism: texts vs. practice
(re: theorizing religion and magic: problems and questions in the study of early magic)
2) Causality, Representation and Personhood in Greece and Asia
(re: theorizing religion and magic: case study)
3) Health in astrology, and early Hindu remnants in funerary rites
and Buddhist tantra
(re: alchemy, possession, and empowerment)
4) Karma and non-Hindu Sources
(re: alchemy, possession, and empowerment II)
5) Chinese inherited burden and Indian/Tibetan Karma
(re: protection and healing)
6) View vs. Practice
(re: protection and healing II)
7) Broaching Secrets and Digging Up the Past
(re: words, spells, and secrecy)
8) Magic and Translation
(re: sorcery and destruction)

Separating religion and magic in Buddhism and Jainism: texts vs. practice
(re: theorizing religion and magic: problems and questions in the study of early magic)

The separation between religion and magic came up frequently in our readings, and still I feel there is much to say about it. I often thought of how this appears in the Indian religious traditions. In the Buddhist Vinaya, there is an admonition for fully ordained monastics to refrain from practicing (and sharing the observations gleaned from) astrology and other ‘worldy arts,’ including medicine. This would be particularly in relation to laypeople, the logic being that such practices could be a means to gain favour or wealth from patrons, develop name and fame and, perhaps most dangerously, possibly be making claims of having attained some degree of prescience. The very existence of such a vow prohibiting astrology in monastic practice points to a cultural prevalence of such ‘wordly arts’ at the time of the vows’ implementation, or at the very least, when the Vinaya texts were formally documented. It is difficult to say whether such a vow came into being at the behest of the Buddha, who might see such practices as leading a practitioner away from the training, or if it was added by later redactors who saw the practice of astrology as a potential threat to the cohesion of the order with the potential for individual mendicants to accumulate wealth for themselves. One might consider this a non-issue when non-possession is assumed to be a key component of the Buddhist monastic order, but Gregory Schopen’s extensive exploration of the rules governing the distribution of monastic’s inheritance betrays this.

The eschewing of astrology is not reserved for the ethics texts, as there are similar admonitions to be found in other genres, such as mind training. Dharmarakshita’s “Wheel of Sharp Weapons” a 10^th century text from the Sumatran teacher of the Indian Pandit Atisha, warns against it as contradicting the refuge commitment of sole reliance on the Three Jewels. Vinaya is a crucial part of every monastic college syllabus, and the mind training group of texts are very popular among Tibetan Buddhists. Does the warning against the practice of astrology show up on the ground nowadays? In contemporary Tibetan Buddhist contexts, what has been called ‘worldly arts’ are practiced and even encouraged. The existence of the Men-Tsee-Khang ‘Tibetan Medical & Astrological Institute’ attests to this, and many monastics graduate from this institution and even are on its faculty. Among the demographic of traditional Tibetan doctors, those who are not monastic have most often trained under a monastic doctor with a relationship that very much resembles that of tantric guru and disciple. This even within the lineage of Je Tsong Khapa who himself, out of his reverence for and dependence upon the code of monastic discipline (and wanting to encourage others to tighten up their pratimoksha or ‘personal liberation’ ethic), gave up the practice of medicine in favour of stricter Vinaya adherence. Additionally, most Lamas will perform some form of divination to both predict an outcome and prescribe purificatory and other religious activities based on a result, such as in the case of a thrown die revealing Tibetan letters in the Mo divination system. So we see a discrepancy between textual advice, and hagiographic advice by example, and modern religious practice. Discussing the reasoning behind modern engagement in astrology and medicine must be saved for another occasion, but I will set this Buddhist phenomenon briefly beside that of the Jains.

The Jain codes of discipline for both ascetics and lay people can be said to be far stricter than the Buddhist codes. The monastics practice of non-possession goes much further, with Digambara munis living ‘sky-clad’ and only carrying a peacock fan to clear a seating area of life, and a small water-pot for bathing. As such, astrological or other divininatory practices in service of laypeople are frowned upon as they could potentially lead to a transaction of exchange, and to some claiming clairvoyance in an age where the tradition says kivalijnan or the omniscience of a Jain ascetic and other such higher states of mind are impossible to attain. Regardless of this strict discipline, which Jain laypeople typically hold in the highest of esteem, astrology shows up in modern religious practice among laypeople but not among the monastics, as far as I have seen. The date for a puja required to seal an engagement or marriage is determined by astrological observations. Many temple shrines hold tantric-type amulets with power-mantras engraved geometrically (which they also refer to as yantras). The furthest I saw Jain laypeople go from the Jain ascetic ideal was at the Padampura Digambara temple near Jaipur in Rajasthan where 42 day-long exorcism rituals take place. There is a lot to say about these communal events, but I will make an observation that might fall under Noegel/Walker/Wheeler’s criticism of the subsuming of magic under undifferentiated/ambiguous categories such as ‘religious experience’ or ‘ritual’. It seemed to me, while attempting to participate but with a group of western scholars quite obviously an outsider if not so obviously an ethnographic observer, that the females who were possessed were inducing an ecstatic trance by choreographed and shared verbal formula (or perhaps a speech-style) and physical gestures. For example, they cried out to be released, banged on tables, spun their hair around like a wind-mill and rolled on the floor. It hardly seemed to be a case of being controlled by an other autonomous power. They were all doing the same thing! The possessed also seemed to be given space and respect, as if, as with the shaman in the Hmong culture, they were treated as special for their ability to be influenced by a non-corporeal being. Their ‘illness’ showed a unique sensitivity to the metaphysical. Given the seeming anomaly that in a religious tradition that stems from the extreme ascetic example of the naked and possessionless Mahavira there is a disproportionate wealth among the minority Jain population in India, it is not such a stretch that astrology, protective amulets and exorcism are seen in everyday life among them.

I was asked by a fellow grad student: "What of figures like Bhaisajyaguru, who vowed to help heal physical and mental afflictions upon attaining enlightenment? does this Buddha contradict the rules of the Vinaya?" and "I might be misreading your intention, but why does the uniformity of the actions of the Jain possessed women belie the authenticity of their possession? the reactions to possession may be culturally-constructed, learned patterns, but I think we should be careful about casting aspersions on the reality of the phenomena. maybe the spirits are just unimaginative."

I am thankful for the questions. As for the first question, I would just say that the Vinaya is described in various commentaries as specifically aimed at the achievement of perfect concentration, and also a means of acting ‘as if’ one were an Arya being (who has accomplished certain non-regressive realizations such as the direct perception of emptiness). A Buddha is defined in the tenets texts as being beyond both perfect concentration and Arya-hood in that every perception is not only direct but also uncontaminated. Being beyond both these levels of development it would logically follow that an enlightened being would also be beyond the training for both…Vinaya is no longer relevant for them. Another thing is that with incorporating other systems of ethics, such as the bodhisattva code, there is a trumping of some of the Vinaya vows by the bodhisattva vows…and practicing medicine/healing with compassion and for the benefit of the recipient would be considered to be a higher training than the commitment to abstain from practicing medicine. The Vinaya would be for personal liberation and the bodhisattva code would be for other liberation. So, in this way there is no contradiction, or a case where a Buddha is breaking Vinaya. I have a book that I am just about to lend Bhante-ji which is a commentary of a root text ‘Ascertaining the Three Vows’ by Ngari Panchen Pema Wangyi Gyalpo (1487-1542) where the harmony between the three levels of vows (pratimoksha, bodhisattva, tantra) is explained. The main thrust is to show that the three ethical systems can operate together to lead to enlightenment even though they have a slight variation in their specific purposes.

As for the second question, I wholeheartedly agree. I did not set out at all to suggest that there is no such phenomenon as possession, and I am sorry if it seemed that way. I was just speaking off-the-cuff about something that I haven’t written about much. I am glad you jumped on it. Belief aside, there would be no way to confirm or deny possession as an observer except by way of some sort of clairvoyance or being possessed oneself. When I observed uniform behaviors among the Jain women it was, as you so eloquently said, ‘culturally-constructed, learned patterns’ used as ‘reactions to possession’ and not possession itself…which is what we ethnographers thought we would be witnessing at this particular temple. Several in our group were looking specifically at cross-cultural possession and demonology, and we thought we would see possession itself and I am not sure if we did. I can say that my expectation for someone possessed would be erratic behavior that could include bodily harm…but that also could indicate something else, like schizophrenia. Maybe I have already seen possession among some of my patients in the emergency room, a place where we automatically assume there is some medical explanation for some problem rather than some metaphysical crisis, but really…I wouldn’t know what possession looks like.

Readings
“The Meanings of Magic,” by Michael D. Bailey, in Magic, Ritual and Witchcraft 1:1 (2006)
“Introduction,” Magic and Magicians in the Greco-Roman World, by Matthew Dickie (Routledge 2001)
Table of contents from Magic and Ritual in the Ancient World , eds. Mirecki and Meyer (Brill 2002)
Table of contents and “Introduction” from Magic, Witchcraft and Ghosts in the Greek and Roman Worlds, ed. Ogden (Oxford 2009)
“Introduction,” Prayer, Magic, and the Stars, in the Ancient and Late Antique World, eds. Noegel, Walker and Wheeler (Penn State 2003)
“Here, There, and Anywhere” by Jonathan Z. Smith, in Prayer, Magic, and the Stars, in the Ancient and Late Antique World
“Preface” & “Introduction,” Naming the Witch: Magic, Ideology & Stereotype in the Ancient World, by Kimberly B. Stratton

Causality, Representation and Personhood in Greece and Asia
(re: theorizing religion and magic: case study)

A few themes truly intrigue me in Collins’s “Magic in the Ancient Greek World,” particularly those of causality, representation and personhood.

There are some striking parallels between causality in Greek magic and some presentations of Buddhist karmic theory. Greek and Buddhist philosophers alike have spent a great deal of time debating the workings of causality, and both have arrived at lines of reasoning that can seem counterintuitive to those of us outside of the worldview from which they arise. The javelin case, explored from various angles by Plutarch and Pericles, is an excellent example to which we can attempt to apply Buddhist logic.

The thrower, the javelin, the coach and the impaled victim all were investigated by the Greek philosophers with regard to their accountability for the event, the thrower being relieved of responsibility if there was divine influence to ensure the victim would suffer to make up for past impiety. Similarly, in a Buddhist karmic analysis, the victim most certainly would bear personal responsibility with former negative actions leading to the current traumatic death. To the Greek philosophers, the coach could both be considered a proximal cause, and the thrower and javelin as direct causes. The Buddhist philosopher would see the thrower and the javelin as the instrumental causes (synonymous with direct), and the coach as an indirect cause or co-operative condition. Although Collins bundles ‘causal conditions’ together, where in Buddhist texts causes and conditions are treated separately, there still is great subtlety in the manner in which causality is approached both systems.

The discussion of the outward behaviours in the practice of Greek magic showing intentionality can be seen in Asian religious practices. In front of a statue of a Jain Tirthankara, the waving of a whisk and the fanning of a mirror in which one can see the reflection of the statue, both demonstrate a feeling of reverence on the part of the Jain devotee by actions that are the performing of service for the Lord. Hindus, Taoists, Jains, Buddhists (and quite possibly every other Asian religious group), make extensive physical offerings in relation to the various senses of holy beings and prostrate, whether belonging to iconic or aniconic sects. The emotional force driving such actions can be gratitude, humility or remorse. Here, Collins’s distinction between symbolic and literal actions is also quite relevant. Such actions, I would say, are quite literal in relation to the object of reverence. In Asian religious practice as well, having literal ritual action does not exclude the existence of symbolic ritual actions, as Collins points out with regard to Greek magic. Making mandala offering may be ‘encapsulating in miniature its intended consequences’ but is most certainly a symbolic offering by way of a hand mudra, variegated offering plate or sand painting of the universe.

I wonder upon what the statement that Ancient Greeks would think of the images of gods as actually eating food offerings is based. I question the statetment’s validity and source. We do sometimes find language that points to the objects of reverence somehow partaking of the essence of offerings in Indian and Tibetan puja ceremonies, which would most certainly be an interaction if not a ‘real physical interaction’. Perhaps this is a means to feel some sense of fulfillment that the practitioner can relate to rather than emphasizing the transcendent quality of extraordinary beings often described as beyond pleasure or pain. Despite what is possibly a process of making the extraordinary just a bit more ordinary, I have not come across anything textually or ethnographically that would indicate Asian religious practitioners thinking that those represented by images actually consume offerings.

I find it interesting too that with some outward displays of Greek magic Collins states that the intention of the performer towards the recipient is clearly harmful, although how the harm will come about is not clear. With my suggestion of possible intentions of the Asian devotee during certain ritual performances, I will not eliminate the potential for more worldly or even harmful emotions motivating the same outward performance. Could this not also be the case with an outward magical display in a Greek context? A figurine by a grave might contextually and typically in Ancient Greece indicate a practitioner of magic’s recruitment, if you will, of the recipient’s deceased relative in order to harm them. Collins seems to say that it can only ever be from harmful intent, and I wonder why it is presented as always being so when, in fact, many outward operations can indicate multifarious motivations and purposes.

There are again parallels between the Greek treatment of statues as having human attributes and some Buddhist approaches to statues. A refuge commitment might require treating all images of a Buddha as if they were actually the Buddha, and the consecrating of a statue is felt to bring the statue to life. Something that I found even more striking is the mention of the ambiguous status of matter itself in Greece, exemplified by Thales of Miletus who held that stones with magnetic properties contained souls. Around the same time in India, 6^th Century BCE, Mahavira was preaching that the elements themselves were actually living beings. Interestingly, the muhapatti face-mask worn by Shvetambara Jain monastics are not just meant for preventing the accidental killing of insects by inhaling them, but also to prevent the demise of air beings from the change in temperature caused by breathing. I am often thrilled to find such similarities occurring at similar times and different locations on the planet.

A final thought: Collins’s discussion of contagious magic implying an “extended notion of personhood”, a distributed or fractal person, caused me to think of Buddhist practices with the remains of the deceased. “Acting on distributed parts will still affect the whole” and “part of the person standing for the whole person” are very similar to the principles in action when a Buddhist practitioner uses remains, such as the ash of a cremated relative, to forge a clay tsa tsa icon in order to help the deceased accumulate merit and strengthen their connection with the deity represented.

Readings
Magic in the Ancient Greek World, by Derek Collins (Blackwell 2008)

Health in astrology, and early Hindu remnants in funerary rites
and Buddhist tantra
(re: alchemy, possession, and empowerment)

I am struck at how non-fantastical the presentation makes healing, alchemy and yogic practice when placed in the micro, meso and macro framework. The magical or clairvoyant tone of astrological prognostication, for example, is removed when seen as a model for diagnosis and treatment decision-making according to the interaction between the inner and outer climates of the human body and planetary environment respectively. The medical underpinnings for astrological practices are endlessly fascinating and easy to connect to. Seasonal shifts causing humor imbalances and health disturbance is an ongoing visceral experience for me, as you have probably noticed in class with my chronic and uncontrollable sinus allergy attacks, and doesn’t leave much to the imagination. Such a clear causal model of the mirroring and interaction of the inner and outer worlds, if free from any faith-based or mystic concepts such as rebirth or the multiple realms of being, can appeal to and potentially influence either the Hindu who embraces such things or the non-Hindu who doesn’t, or in general the religious or secular. This search for elements in religious systems that can be transferable outside of their insular context, for ideas and methods which are enduring, novel and potentially useful to anyone regardless of their frame of reference, is a major part of my research.

While reading this week’s most amazing book selection, I cannot help but constantly refer back to what I know of Buddhist tantra to look for conceptual and linguistic threads of continuity that remain from early textual sources such as the Brahmanas and Upanishads. Interestingly, one Tibetan term for tantra (rGyud) also refers to the process of connecting or the thread of continuity, the consciousness being the connecting thread between lives like the string of a rosary. This is unlike White’s translation of tantra as ‘to warp reality.’ The elemental yogic ‘implosion’ of the grosser elements into the more subtle in the Upanishads remains intact in the elemental dissolution practices in Buddhist tantra that are implemented during yogic exercices that replicate the death process, or during the increasingly subtle shifts of consciousness during the phases of sleep and during the death process itself. The womb (garbha) as a metaphor for a time and place of perfect health where the bodily elements are in harmony is also a very strong image used in Buddhist texts also with the Buddha-nature (Tathagatagarbha or Womb of Suchness/Thus come thus gone), as the aspect of consciousness that is primordially and indestructibly perfectly healthy.

Rita Langer in her “Buddhist Rituals Death And Rebirth: Contemporary Sri Lankan Practice,” an ethnography that, in part, searches for pre-Buddhist textual examples of practices and concept lingering in contemporary Sri Lankan funerary rites, tries to show the sacrificial aspect of Vedic cremation ceremonies remaining in Buddhism by way of the Parinirvana Sutra. An ornament is offered to the Buddha’s body at his funeral and she likens it to the offering of an animal skin in Vedic practice. I found it a stretch, but she also attempts to make the fascinating connection in Buddhist funerary practice with Hindu ideas of purity as found in practices of sifting bone from ash in remains. When considering the possible continuity of earlier Hindu concepts themselves remaining in contemporary Hindu funeral rites, the quotation from Sankara’s commentary of the Chandogya Upanishad took me back to my witnessing of many cremations at the burning ghats on the River Ganges this summer. Sankara states that the ‘liquid elements employed in the funerary rites combine with other elements, and reach the heavenly regions,’ with the liquid being an aspect of the all-important rasa vitality source. At the burning ghats I painstakingly documented the substances and processes of the rites at the funeral pyres, and other than the bathing of the body in the river before being placed on the wood, all of the substances are solids, such as the wood, cotton cloth, incense and multifarious powders. The rite is, however, always concluded with the throwing of a clay pot full of Ganga Amrita from the river. The first-born son faces away from the pyre and throws it over the right shoulder onto the fire, and everyone walks away without looking back. This is considered the moment when the family and the deceased break their bond. Even though this is the very end of the rite, this could be a remnant of the early importance placed on the vital liquid.

Readings
White, The Alchemical Body (The University of Chicago Press 1996)

Karma and non-Hindu Sources
(re: alchemy, possession, and empowerment II)

I spent a great deal of time while reading the seemingly exhaustive listing of classes of supernatural female beings in White’s “Kiss of the Yoginī” waiting for the punchline, in a sense. I wasn’t fully aware of this anticipation until I came across the example of Harītī in the Yakṣiṇī sub-section where White states that “[i]n her Buddhist legend, the demoness called Harītī (“Kidnapper”) is converted by the Buddha and elevated into a protectress of children” (2003: 63) and how “Buddhist mythology tells us that Harītī’s wrathful behaviour stems from wrongs committed against her in a previous life.” (2003: 64).

This will definitely betray my having less exposure to Hindu texts, but somehow this triggered my questioning of a lack of reference to karmic causality with regard to harm from female supernatural beings in the form of kidnapping, disease, sapping of vital fluids and so on in the Hindu sources. There was mention of humans being more or less susceptible to supernatural harm or disease caused by supernatural beings, but it often seems random such as susceptibility being dependent on one’s stage of life. The harm seems more often to come from a desire on the part of the supernatural perpetrator, such as those that crave marrow and flesh or those that are madly driven by the maternal instinct when childless, rather than some sort of causal retribution returning to the victim from past actions. This struck me as an odd missing element, the punchline, since Hindu thought does include karmic theory.

To make some technical points regarding White’s use of non-Hindu sources, it seems to me that now and again when he throws something in from another tradition to shore up a point it is not entirely accurate. For example, in “The Alchemical Body” White proposes that “…the Vidyādharas, the Wizards, may be considered to be not only the denizens of such [sacred] mountains, but also the mountains themselves…suggesting…that behind the medieval Indian cults of divine Siddhas and Vidyādharas as denizens of mountains there lay a more archaic cult of these mountains themselves as a group of demigods.” (1996: 329) Soon after, White mentions “[t]he Girnar peak which Jains identify as Nemīnāth” (1996: 332) which is a statement for which I have found no evidence.

Jains certainly identify sites with both great practitioners and entirely liberated souls such as Nemīnāth. As a Tirthankara, Nemīnāth, being the twenty-second out of twenty-four Jinas in this downward swing (avasarpini) of the Jain cosmological cycle (so, two before Shakyamuni Buddha’s contemporary Mahavira), is by definition located in the Siddha Loka and thus entirely removed in every way from any other realm. White’s statement is out of accordance with the Jain texts and the predominant contemporary Jain view regarding the status of Jinas, but it would be hard to argue against a statement that some Jains identify certain places AS the Jina themselves since some practitioners might not have exposure to either texts or teachers and thus not tow the ‘party line.’ Most Jains that I have met, however, are quite engaged with temple life, teachers and ascetics if not the texts, and seem to usually know a great deal about the founders in particular. So, my point, again, is that White occasionally stretches his use of sources from non-Hindu traditions to fit his ideas.

Another example of this was the quick mention in “Kiss of the Yoginī” of the Tibetan word for ḍākinī, Kha Dro Ma (mkha’ ‘gro ma), as having colloquial usage to indicate ‘bird’ to help support the statement that “the terms ḍākinī and yoginī are nearly synonymous in Tantric traditions, with Buddhist sources favoring the former and Hindu the latter. (2003: 62) I stand to be corrected, but despite the fact that I have probably used this term in the past when I have forgotten the words ordinarily used for bird, such as chi’u (the more literal ‘sky-goer’ is much easier to remember!), I am not familiar with a common colloquial use of Kha Dro Ma colloquially to refer to birds. In this case, the example was unnecessary because there are so many other means to show the predominance of the term ḍākinī in Buddhist texts.

Readings
White, Kiss of the Yogini (The University of Chicago Press 2003)

Chinese inherited burden and Indian/Tibetan Karma
(re: protection and healing)

I can’t keep away from karma. By this I am not making a pun by referring to my past actions following me like a shadow, but rather that it is endlessly fascinating to me. The topic truly was my entrance into Buddhist studies, and it remains crucial in my research in the attempts to find what drives people to make healthcare decisions in the way that they do.

In an attempt to make sense of their experience and to find order amongst seemingly random chaos, the sick and their loved-ones are compelled to ask ‘why me?’ The more difficult it is to find an apparent physical cause for illness, and the more out of accordance with what is considered to be ‘natural’ (such as a dying child, very rare diseases, and those that have no relationship with social determinants of health or lifestyle choices), the more intensely the question is asked and, I would say, the more anxiety in the process of seeking answers.

Strickman`s explanation of received/inherited burden and karma, and his application of these approaches to healing, provides a lot of clarification around the Chinese cultural emphasis on ancestors and the departed, but leaves many more questions as well. For me, broaching this area has definitely opened up a well-spring. His statements regarding filial piety preventing the admission, and processing, of negativity towards the father is very powerful, and his idea that perhaps there could be a Sino-psychology that addresses this is not merely a quip but a very important suggestion with wide-spread, long-lasting and deep implications. What Strickman failed to mention is the negativity that could naturally come from having the idea that what one experiences now is dependent on the actions of others in the past. The spiritual-legal brokering of the Taoist priest, of course, is one means of dealing with both the emotional and physical sufferings of illness. The patient may have confidence in the skill of the priest, and even see results from his activities, and restore some sense of control over what is happening in their body. But is that enough? Even after averting one crisis, there remains endless concern over what else one’s ancestors might have done that could strike one now.

Strickman draws two parallels between Chinese inherited burden and Indian karma, in that both relieve the person of responsibility as the cause of something is either an ancestor or one’s previous incarnation, and in serving to explain why ‘good things happen to bad people’ and vice versa. I don’t agree that the Indian presentation of karma exonerates an individual, since it is not the differences between lives that is emphasized in such an ethical presentation (different body, different circumstances etc.) but rather the continuity of consciousness…some aspect (one could say the most important aspect) is the same and this transmigrating mind is the basis for the connection between cause and effect. Pabonka Rinpoche quotes from The Root of Wisdom in his oral teaching entitled Liberation in the Palm of Your Hand: “If the past ‘I’ were different, it would also become non-existent. Further: it would remain and, without dying, be reborn. Then, it would follow that, as one is cut off from other lives, karma would disappear of its own; others would individually experience the karma committed by another; and so on.”(p.693)

Two other parallels that I see between inherited burden and karma are the weightiness of the result being dependant on the social position of the perpetrator of the action, and merit transfer. Regarding the first idea, the Tibetan Pandit Patrul Rinpoche in his Words of my Perfect Teacher Lam Rim text states that “some people imagine that only the person who physically carries out the killing is creating a negative karmic effect, and that the person who just gave the orders is not – or, if he is, then only a little. But you should know that the same karmic result comes to everyone involved.” (p.104) Here, Patrul Rinpoche is talking about a number of people involved in the killing of one individual. What it doesn’t say here, but something which appears in many karma expositions, is that the one who orders the killing of many (such as someone of high rank in the military) receives the karmic result of every single life taken even though not performed by their own hands.

Regarding the latter, merit transfer, in the inherited burden system of thought merit-based benefits such as current happiness are traced back 7 generations, and current misery goes back to the most recent generation. In many Buddhist cultures I have more often seen practices based on the idea of retroactive benefits by present practitioners doing positive and religious actions to help their deceased loved-ones. I have never come across the idea of harms going in either direction between the living and dead. In many texts it is stated that Shakyamuni Buddha, and other enlightened beings such as the Bodhisattva Samantabadra, have dedicated their own merit for future praticitoners…such that they will have resources if they practice the Dharma purely and so on. In contemporary Tibetan Buddhist thought, I have caught wind of the idea that a person becoming ordained will retroactively benefit 7 past generations of their family.

Another very important observation Strickman makes is the Taoist shift from the 4^th century to the 12^th century from the view of disease as an inherited burden to that of a proximity-based contagion. It is so crucial in uncovering a Chinese view of health and disease and I intend on devoting more time to its exploration.

Readings
Chinese Magical Medicine, by Michel Strickmann (Stanford)
“The Medicalization of Possession in Ayurveda and Tantra,” in The Self Possessed: Deity and Spirit Possession in South Asian Literature and Civilization, by Frederick M. Smith

View vs. Practice
(re: protection and healing II)

I am particularly concerned with how Cabezon, Mengele and Samuel each dealt with the seeming inconsistencies between views and practice, such as that between normative Buddhist doctrine and Tibetan Buddhist ritual practice or religious views of disease and medical treatment.

In this regard Cabezon asks: “…is reliance on mundane protector deities consistent with the claim that the Buddha is the highest source of refuge – the only protector that one really needs? How is it possible, on the one hand, that everything experienced in life is the result of one’s own previous actions (karma), while, on the other, the good and evil can be the result of spirits freely intervening in human affairs? Is beseeching a deity for blessings or requesting a spirit to cure one’s illness consistent with a belief in karma? How can rituals that are enacted by grieving relatives help a deceased person? Such theological questions point to fundamental problems within the Tibetan and Indian worldviews. These issues are not, of course, unknown either to the elite texts or to less literate traditions, both of which attempt to resolve them in a variety of ways. Such idealogical problems, however, seem to have little effect on Tibetans’ attitudes or daily behaviours vis-à-vis the nonhuman world, or on their belief in the efficacy of ritual.” (Cabezon 2010, p.10; italics added)

I found this section quite disturbing. It seems as though the reader is expected to join the author in answering in the negative to each question, each presented quite rhetorically…as if the answer is obvious. But these ‘problems’ are etic ones, not emic ones, as shown by the concluding statement that the Tibetan remain unaffected by these apparent dilemmas. The problem is not within the Tibetan and Indian worldviews, but a etic problem of attempting to understand an emic view and superimposing a bias from which the etic investigator is supposed to be free. This objective judgment seems to stand in opposition to the more sensitive (maybe even empathetic) approach in the rest of the paper as seen later, for example, when Cabezon says that it is “not that ritual theories…are irrelevant to the Tibetan case, but that they must be used with care, and with an eye to Tibetans’ own theories of what ritual is and how it functions.” (Cabezon 2010; p.11)

Again, in Mengele’s paper we see the struggle of the scholar in trying to explain apparent inconsistencies found in the views of a religious culture, and in this case it is again the concept of karma that features prominently. Even after approaching contemporary practitioners with some of the questions at hand, Mengele is ‘unconvinced’ of there being a satisfactory resolution between the concepts of karma, merit, obstacles and the influence of ritual on karma and one of the paper’s conclusions is that this points to an attempt to forcefully fit pre-existing rituals into the later-imported Buddhist framework. Granted, one of the informants felt that some types of death-deceiving rituals come from Bon and the author could find no Indian equivalent, but I am left unconvinced that the difficulty in understanding the relationship between karma, merit, obstacles and the influence of ritual on karma from an emic perspective proves the grafting of Buddhist principles onto pre-Buddhist rites.

Noteworthy in Mengele’s paper also, I particularly enjoyed Samuel’s integration of textual and ethnographic data. I also thought that his approach to the two sides of treating patients, perhaps we could call them religious and medico-physiological, was the most balanced way of presenting differences between views and practice as it did not set out to put these two sides at odds. This is typified by the case of the doctor who “was willing to go along with the spirit-causation assumptions of his patients” (Samuels 2007; p.218) despite his personal feeling that the disease was one of a ‘white-channel’ nature or related to the nervous system, and treated the patient with a drug that would address both spirit-related and non-spirit-related causes. I found Samuel’s suggestion that the views of spirit harm arise from the community experience and in turn affect their responses to the environment quite powerful, and appreciated his mention of cost sometimes being a barrier to Tibetans accessing both traditional disease treatments, such as exorcisms, as well as those of modern pharmacology.

Readings
“Introduction,” by Jose Cabezon, and “Chilu (‘Chi bslu): Rituals for ‘Deceiving Death’,” by Irmgard Mengele, in Tibetan Ritual, ed. Jose Cabezon (Oxford 2010)
“Spirit Causation and Illness in Tibetan medicine,” by Geoffrey Samuel, in Soundings in Tibetan Medicine, ed. Mona Schrempf (Brill 2007).
“‘Medicine and the Changes are One’: An Essay on Divination Healing with Commentary,” by Judith Farquhar, in ChineseScience 13 (1996): 107-134.
Selections from Oracles and Demons of Tibet, by Rene de Nebesky-Wojkowitz

Broaching Secrets and Digging Up the Past
(re: words, spells, and secrecy)

I question the exposure of texts, teachings and religious activities that were originally intended to be shown to only certain people under certain circumstances, just as I question the unearthing of tombs that were intended at the time of the rites of burial to remain sealed. I am not proposing that such activities are at all times and in all circumstances inappropriate, but merely that it could be that in our quest for knowledge and with the arrogance of being “modern society” we sometimes might not be approaching such areas of reverence and protection with enough sensitivity and due consideration. Even though “[t]he passage of time has removed from our collective memory and from the records of history and archaeology the overwhelming majority of ‘facts’ that we would be eager to know,” (Jong 2006, p.45) is this eagerness enough for us to broach areas of our own interest for which we might find evidence that it was not for initially produced for public consumption? Also, is the passage of time enough to trump earlier injunctions for secrecy? To briefly explore the former, I will look at how some justify the usage of Tantric Buddhist texts and rituals outside of their closed religious context, and the use of Vinaya texts within and without the Buddhist tradition. For the latter, I want to consider the processes around intellectual property in the form of copyright and the confidentiality medical records

When His Holiness the Dalai Lama was asked to explain why troupes of monks touring the West were performing secret tantric rituals to secular audiences, his answer was simply that since the rituals were being performed in a language unknown to the audience, and the meanings behind the chanting, hand-gestures, implements and so on remain hidden, it satisfies the need for secrecy while also planting seeds on the mindstreams of the observers that will ripen in future lifetimes. It also is a means of garnering support for the endangered Tibetan culture. From this emic perspective, the connection to the tantric practice that the audience members gain in their current lifetime from merely observing and hearing the ritual as an outsider will necessarily bring about benefit because they will be predisposed to engage in the practice in a future lifetime. This is seen as a very strong reason to allow a secret practice to be shown publicly.

In the scholarly usage of Buddhist Tantric texts, both with translation and analysis of their contents, some go beyond the idea that all knowledge is fair game for study because it serves to add to the corpus of information about humanity and gives us a better understanding of a particular group by adding more dimensions. Some select excerpts from Tantric texts, such as cosmological selections in the Kalachakra Tantra and those pertaining to death dissolutions in the Guhyasamaja Tantra, are extracted out of the context of the full text in order to look specifically at a certain topic. We could say that this does the text an injustice because to understand the selection one needs context, but it could be a way of preserving the secrecy of the text as a whole by looking only at sections that deal with common human dilemmas (understanding the cosmos and the workings of death) where the insights found in the text can be helpful to many, both for insiders and outsiders of the tradition. There are similar moves with the usage of Kabbalistic texts, many of which were traditionally restricted to married males, and those over 40 or so who have a lifetime of Torah study under their belt. For many, it is worth breaching secrecy for the depth of meaning added to the experience of being a Jew that comes from mystic texts like the Zohar, which offers profound explanations of the nature of divinity, cosmology, religious practices and the Torah.

Jong’s statement that “…in the development of Platonism as a religious tradition, the injunction against silence is often encountered for the stated reason that people may laugh at the knowledge that is passed on” (Jong 2006, p.48) made me think of the use of the Vinaya. I am not sure if I have ever seen mention of the restriction of the Buddhist discipline vows in an academic work, but in the practice of Buddhist monastic communities in the Tibetan tradition the vows are not studied or even known by those who are not imminently taking such vows. The logic is that because some of the vows require great context, without which they would be potentially mocked, they need to be transmitted with great care or else the person who mocks the vows will develop and obstruction to receiving such vows in future lives.

One problem that I have seen regarding Vinaya in the 10-20 year course of study known as the ‘Geshe degree’, is that it is reserved to the very end. It seems to me that due to this, many monks don’t know the vows very well and this could be one of the causes that Tibetan monks are often seen as quite lax in their practice of Vinaya. Monks from traditions that strictly follow the rule of not eating at an inappropriate time are critical of the habit amongst Tibetan monks of eating at any time. In Thailand we see the opposite in terms of knowledge of the contents of the Vinaya. Since most young males are sent to the monastery and hold novice monk vows for a spell (like being at religious camp), almost every male knows at least all of the novice vows and even many of the full ordination vows. For many monks of various Buddhist traditions, the Thai monks serve as a barometer of good discipline nowadays. Could it be that their behaviour as an order benefits by the influence of the general population who know what is and is not considered to be proper conduct in the Vinaya?

Briefly, regarding copyright and the confidentiality of medical records, the passage of a certain amount of time after a book is published in the former, and the death of a patient in the latter, both similarly negate former restrictions on the usage of material. About this I will only say that if copyright is the protection of intellectual property and is meant to ensure proper compensation, if the author or their estate no longer exists than it seems reasonable to lift restrictions on the usage of a book, while still crediting the author in some way. In the case of a patient who is deceased, I would say that we might look more closely at our practice of more freely revealing sensitive information belonging to the deceased to stay in line with other practices of respect that we have for the deceased such as preserving the dignity of a cadaver and respect for graves and headstones. Just because a person has died does not mean that we are free to use their body, belongings or information in whatever way we see fit. By extension, the remains, belongings and information left behind by former societies must not be treated with abandon. Both medical information of the deceased and all that is left behind by earlier societies can teach us a lot, but we need to approach with care. There is a lot more to be said about this.

Readings
"Secrets and secrecy in the study of religion: Comparative views from the Ancient World,” by Albert de Jong, and “The problem of secrecy in Indian Tantric Buddhism,” by Ronald Davidson, in The Culture of Secrecy in Japanese Religion, eds. Scheid and Teeuwen (Routledge 2006)
“Introduction” to Binding Words: Textual Amulets in the Middle Ages, by Don C. Skemer (Penn State 2006)
“The ‘Magical’ Language of Mantra” by Patton E. Burchett, in Journal of the American Academy of Religion 76:4 (2008)
“Eating Letters in the Tibetan Treasure Tradition,” by Frances Garrett, forthcoming in Journal of the International Association of Buddhist Studies
“Signs of Power: Talismanic Writing in Chinese Buddhism,” by James Robson, in History of Religions 48:2 (2008)

Magic and Translation
(re: sorcery and destruction)

There is great inconsistency in the usage of the term ‘magic.’ Different scholars and translators will approach the term differently, or choose to be free with its usage or not. Even one scholar can show such inconsistency in the use of ‘magic’ within their own body of work.

In his “Illustrations of Human Effigies in Tibetan Ritual Texts,” Cuevas has this to say: “Concentrating on the gtor-ma as a weapon and taking aim, the ritualist should hurl the gtor-zor in the direction of the enemy and imagine that its totem deity’s strength and magical powers are annihilated.” (Cuevas p.4-5) The focus of the term ‘magic’ here is on the supramundane abilities on the deity.

In “The ‘Calf’s Nipple’ (Be’u bum) of Ju Mipham, A Handbook of Ritual Magic” Cuevas says: “Perfect examples of imitative or mimetic magic in Tibetan practice are the forming of the liṅga – molded effigies in the likeness of an enemy or designs drawn on paper into which the practitioner directs the divine or demonic powers that he controls.” (Cuevas p.169) Here, in a discussion explicitly concerning magic, Cuevas doesn’t talk about the powers of divinities or demons by invoking the term ‘magical powers’ but just simply calls them ‘powers.’ The term ‘magic’ is now reserved for the type of ritual operation and no longer refers to the power of non-humans as magical but rather as “divine or demonic.” If we connect these two pieces from two different papers, we can see that Cuevas holds both certain ritual operations as well as the powers of non-humans of the upper or lowers realms as magic. Why does he conveniently reserve the term for one or the other but not together? It seems to me to be a term that he bandies about quite freely.

In another example, Cuevas translates the term las sbyor ལས་སྦྱོར as ‘magic’, or an action of correlation and states that “with this [term] we see that magic exists in Tibet as a definitive category, designated by the term le-jor.” (Cuevas p.170) Not everyone would translate las sbyor as ‘magic.’ Jim Valby gives “destructive action,” and both Ives Waldo and Rangjung Yeshe give ‘application of the activities’ for las sbyor. Cuevas then goes on to give karma yoga (practical application), karma bandha (bonds of action) and karma nibandha (consequence of action) as Sanskrit equivalents for the term, but I don’t see this as strengthening his case since karma, actions and results or cause and effect, seem very unmagical indeed.

Gentry seems to implant the term ‘magic’ in two of the 25 means of averting armies. First, in ཆུ་ལ་རྫས་ཀྱིས་ངར་བླུད་དེ་ཟློག་པ chu la rdzas kyis ngar blud de zlog pa which is translated as “repelling and army, compelling it with magical substances in water,”and in རྫས་ཀྱིས་ངར་བླུད་དེ་ཟློག་པ rdzas kyis ngar blud de zlog pa, translated as “repelling an army with magical substances.” (Gentry p.137) I could find no other translation of any of these terms as ‘magic,’ but rather found rdzas as ‘thing’ and ngar blud as ‘valor’ or ‘strength’. Where is ‘magic’?

Shen-Yu translates ‘phrul འཕྲུལ་ as magic (Shen-Yu, p.116) when used in ‘phrul gyi rgyal po (King of Magic) and ’phrul yig (Magical Words), but again there is discrepancy with other translators. Rangjung Yeshe may give some magical connotations to the term (conjuring, flirtation, jugglers, magical deception, magic, miracle, trick, mischief, transformation, miraculous, – manifestation, – power, emanation. {sgyu ‘phrul}; ingenious; magic) but Ives Waldo does not even mention magic in relation to ‘phrul (1) jugglery, trick; 2) *[al illusion], conjuring; 3) miracle, emanation; 4) mischief; 5) technology, mechanics; 6) transformation, manifestation, power; 7) flirtation; 8) confusion.)

There are other terms that show the usage and non-usage of ‘magic’ by translators. Shen-Yu’s paper discusses gto གཏོ་, which is treated very differently by Jim Valby (bon po rite of ransom, magic ceremony for the purpose of averting misfortune, rituals, beneficial rite, general name designating various types of rites in which the officiant relies on the power of his protective deity after having satisfied the deity with offerings, to eliminate disturbances and subjugate negative forces, rites) who uses ‘magic’ freely, Rangjung Yeshe (exorcise ritual. {gtog pa} to pluck off, gather, crop, tear out; ransom offerings) refers to exorcism but avoids the term ‘magic’, and Ives Waldo (pluck off, gather, crop, tear out, rim gro’i ritual) avoids referring to both exorcism and magic by giving definitions of the term both independent of ritual and as a category of ritual.

So too do we find variation with the term gzungs གཟུངས which Cuevas calls “spells in rites of magic” (Cuevas p. 170) Rangjung Yeshe does refer to such as potentially magical, (Sacred Incantation, Skt. dharani. A particular type of mantra, usually quite long. retention, mantra, mystic formulas, memory, memorization, dharani ‘that which holds’. dharani [mantra], recall, a hold, power, strength, memory, retentive mantras. a magic spell), but Jim Valby does not and prefers the vagueness of their possibly being ‘mystic.’ (dharani, health, spiritual sustenance, that which seizes or holds, spell, mystic charm, recollections, recollection, long sacred verbal formula, instrument, restraining instrument).

In terms of how Cuevas sets other categories of practice of knowledge against magic, even though he is attempting to show the liṅga as a point of overlap between them, by their appearance in both medical and ritual texts, he still cannot help but set medicine and magic in opposition to each other (italics added):

“In Tibet the diagnosis and treatment of disease and mental illness, the distinguishing and administering of the healing properties of plants and herbs, the calculation of the stars and planets, the control and manipulation of the energies of mind and body and so on, are all traditional ‘medical’ or healing techniques that are essentially the same as those for many of the conventional practices of Tibetan Buddhist (and Bon) ritual. Indeed, standard Tibetan medical works frequently contain instructions for all such practices while also including alongside them instructions for the rites of exorcism, divination, the use of talismans, and other ‘magical’ operations for healing or protection, enrichment, control, or even for harm, and many of these rites requiring the use of mimetic substitutions. It should come as no surprise, then, and is by no means accidental that Tibetan liṅga belong also to the medical tradition and are thus illustrated in both medical and ritual books using the form and posture of anatomical figures.” (Cuevas p.13)

As we have been discovering, the term ‘magic’ is often used as a convenient attempt to set certain types of operations or aspects of experience that are difficult to categorize against those that are more easily determined. It also seems to be sometimes, quite randomly, thrown around to lend an air of the exotic.

I find it a not helpful term.

(Translations from the Tibetan & Himalayan Library)

Readings
“Illustrations of Human Effigies in Tibetan Ritual Texts,” by Bryan Cuevas
"Representations of Efficacy: The Ritual Expulsion of Mongol Armies,” by James Gentry, and “The ‘Calf’s Nipple’ (Be’u bum) of Ju Mipham, A Handbook of Ritual Magic” by Bryan Cuevas, in Tibetan Ritual
“Tibetan Magic for Daily Life: Mi pham’s Texts on gTo-rituals” by Shen-yu Lu, in Cahiers d’Extreme-Asie 15 (2005)
Selections from Oracles and Demons of Tibet, by Rene de Nebesky-Wojkowitz
“In Pursuit of the Sorcerers,” by Christine Mollier, in her Buddhism and Taoism Face to Face (U. Hawaii 2008)

Jain Voluntary Death and Secular End-of-life Care

2010-08-31T01:48:00.000-07:00

Jain Voluntary Death and Secular End-of-life Care

Sean Hillman, 2010
M.A. (c) Religion (Buddhist Studies)/Bioethics
B.A. East Asian Studies
Department and Centre for the Study of Religion
Joint Centre for Bioethics
University of Toronto, CANADA

sean.hillman@utoronto.ca

Research funded by the International Summer School for Jain Studies (New Delhi, INDIA)

and conducted June/July 2010 in Delhi, Jaipur Varanasi; INDIA.

Soon to be published in an Indian quarterly Jainology journal "Sramana," produced by the Parshvanath Vidyapeeth Centre for Jain Studies and Research in Varanasi, as well as in a second publication in Canada TBA.

Purpose of study

Jain voluntary death has been practiced in India for millennia. The three-fold process of Sallekhana-santhārā-samādhimaraņa has allowed countless Jain practitioners to enter death consciously and most effectively, departing smoothly and on their own terms. As the interaction between cultures is possibly at a new height, given population diversity and information exchange, the existence of such a venerable and novel death methodology can lead to our asking: (1) Are there aspects of Jain voluntary death that can be incorporated into secular end-of-life care? and, (2) Can Jains receive the end-of-life care they need in a secular healthcare setting? Both questions could be pursued for the betterment of multi-cultural end-of-life care delivery by introducing potentially transferable and distinctly Jain ideas/practice to secular healthcare practitioners and their clients.
This paper will show that despite some tension between Jain ethics and contemporary bioethics, the answer to both questions is in the affirmative. Given that every human must not only die but also must stop eating, drinking and moving at some point before death, I am convinced that the Jain systematic methodology for this time holds the potential for immense continued benefit to many more people in the future, both Jain and non-Jain and regardless of context. Among those who are non-Jain, some will embrace transmigration or some other post-death continuity of existence as part of their world-view and some will not. Holding to such religious concepts is not required for the essential elements of Jain voluntary death to be useful to non-Jains. Additionally, for Jains in diaspora or in India who find themselves in a secular healthcare environment, modern bioethics are amenable to aspects of Jain voluntary death based on respect for autonomy and the unique values and beliefs of the client. A secular end-of-life setting is not reserved to a palliative or hospice environment but can include emergency, critical care, acute and chronic care settings where many people also die on a regular basis. In any environment, the Jain emphasis on: (1) voluntary and autonomous decision-making to withdraw treatment, including (but not limited to) nutrition, hydration and ambulation; and (2) qualified assistance and separation from objects of attachment and aversion, have great potential to assist the dying.

Death in Jain thought

Death is described in the Painnayam as the "...last moment of earthly life...when the atoms disintegrate..."[1]. Even more dramatic, sometimes "[t]he Jains define death as the blowing up (samudghāta) of the atoms of life..." [2] Since death is described as a time of destruction, explosive even, it provides a strong impetus for the development of means in Jain practice to prepare physically and psychically to meet this difficult experience in the best way possible. The trauma of death is the main reason not only for the existence Jain voluntary death practices, but also for the great importance placed on them by the Jain community, to the point of reverence. It is a practice so highly considered, in fact, that the distinction between layperson and monastic dissolves in the asceticism of such a death. Jain voluntary death has three aspects: (1) Sallekhana; “emaciation of body and of passions through external and internal penances”,[3] (2) Santhārā; the death-bed or, by extension, the environment in which the practitioner dies, and (3) Samādhimaraņa; end practices for achieving death in equanimity.
Jain voluntary death practices are also of crucial importance because the quality of death is the cause of the quality of the experience after death, which can be another birth or even potentially liberation. Since death is the cause what comes afterwards, death is sub-divided into various qualitative levels based on commensurate levels of the state of mind of the dying person. The quality of the death is measured by the spiritual realizations attained from the progressive mastering of restrained conduct. The list is sometimes compressed into two types, or three, and both the Bhagavatī Ārādhanā and Uttarādhyayana-Nīryakti enumerate and describe seventeen types of death.[4] Jnānamatī gives a middling-length list which shows "death ha[ving] five varieties:

(1) Extreme Prudent's Death (Pandita-pandita Maraņa)
(2) Prudent's Death (Pandita Maraņa)
(3) Fool-Prudent's Death (Bāla-pandita Maraņa)
(4) Fool's Death (Bāla Maraņa)
(5) Extreme Fool's Death (Bāla bāla Maraņa)"[5]

Often the highest type of death is a reserved designation for the death of a liberated being, or a death which results in liberation from saṃsāra, the cycle of existence. The worst type of death is described by Jnānamatī as "[t]he death of a wrong-faithed living beings and death by suicide and accident etc."[6] It would problematic in modern bioethics, where even the word ‘accident’ has been replaced by terminology such as ‘collision’, to associate events causing sudden death with foolishness. This would be unfair to a pedestrian struck by no fault of their own. Additionally, ‘wrong-faith’ needs to be qualified because such logic would not survive outside of a Jain context if it meant ‘non-Jain.’ Betraying the above description of the worst type of death are other indications in Jain thought which show that, in fact, the last moments of life continue to hold the redemptive opportunity to improve one’s death by way of supplementary purification practices, such as confession. A sudden, traumatic death would, indeed, make dying more problematic. However, even if there is little time to prepare and only mere moments of consciousness remaining, Jain death practice allows for the continued potential to transform the mind.

Fasting (anaśana) and bodily turmoil (kāyakleśa) austerities (tapa) in Jain Voluntary Death

Austerities, particularly fasting and immobilization, are a crucial part of understanding Jain voluntary death practice. Generally, we can categorize fasts into three types: (1) instrumental; (2) protest; and (3) purificatory/liberative. The first would be those aimed at achieving a specific worldly end, the second would be those associated with social activism, and the last would be concerned with karma.
Instrumental fasting and that used for protest are rejected in Jain thought and practice. "[F]orms of instrumental fasting (vrata) are invariably criticized by the Jains..",[7] and it is also felt that “[f]asting unto death for specific purposes has an element of coercion which is against the spirit of non-violence."[8] They are distinguished as inappropriate types of fasting because they keep one “…caught in the wheel of Samsāra…",[9] rather than being a cause of liberation from the cycle of existence.
Immobility austerity types also are generally sub-divided into three: (1) taking certain postures to the exclusion of others; (2) restriction motion to a certain limited area; and (2) refraining from all bodily motion altogether.
All Jain austerities are aimed only towards purification and liberation, and are mainly concerned with karma. On a lower level, austerities make for the accumulation of merit (puņya) which brings about good results. Some good results, such as material gain, can be counterproductive on the path to liberation by being a distraction to the goal. They can, however, be useful. Consider the good result of having resources and using them to support religious organizations. A commentary to Āchārya Amitagati's Yogasā Ra-prābhrta states that such actions “may bring some good (śuba) but not spiritual purity (śuddhi).”[10] Merit is helpful, but ultimately still obstructs liberation. On a higher level, austerities are for the purpose of stopping the influx of all karma (samvara), positive and negative, and for destroying karma already bonded (nirjarā).
Most literature concerning Jain voluntary death practices focus mainly on fasting, but it is important to keep in mind that the austerity of limiting mobility also features prominently. Since both fasting and mobility-restricting austerities could fall under the category of kāyakleśa, which “literally means to give turmoil to the body,”[11] and kāyakleśa is one of “the twelve types of elimination of karma (nirjarā)”,[12] both austerity-types destroy karma. Not only this, but they also both prevent the influx of new karma. This is so because both are of the fifth “of the five types of samvara…[that of] Ayoga – stopping all the mental vocal, mental and bodily activities.”[13]
This overlap in the functions of fasting and immobility austerities carries over to their practice as well. The distinctions between the main fast types in Jain death practice are not based on the fasting itself, but rather with regard to mobility and assistance to oneself (by oneself or others). The three fast-types are: (1) bhatta-paccakkhāņa, in which one renounces food and drink, and can receive help from oneself or others; (2) itvara or ingiņi-maraņa, in which one renounces food and drink and limits physical movement, and can receive help from oneself; (3) pāovagamaņa, in which one renounces food and drink and all motion, and receives no help from anyone (self or others).

Stoppage of oral intake & ambulation in secular end-of-life care

There are three main causes which lead people to stop oral intake and ambulation in a health care setting: (1) The requirement to stop such activities temporarily to prevent further deterioration of health and to allow for diagnostics and treatments; (2) debilitation; and (3) choice. For our purposes, it is this last cause that is most significant.
The Health Ethics Guide of the Catholic Health Association of Canada governs the principles of care in many hospitals which serve diverse patient populations. I have consciously chosen to use this document when looking at health ethics in hospital because it comes from a religious organisation that is often seen as having extreme views about euthanasia and assisted-suicide, among other controversial issues. Since much of the controversy around Jain voluntary death stems from opponents accusing Jains of engaging in suicide, and much of the literature is in defence of Jain voluntary death as not suicide, it seems that if the Jain voluntary death model can survive Catholic ethics then it can survive anywhere. The context that Catholic and Jain ethics share is the necessary interaction with secular healthcare within diverse populations. First we will look at how Catholic health ethics deal with decision-making and the individual, and then we will look at how Catholic and Jain ethics interact in end-of-life practices.
Regarding ‘The Primary Role of the Person Receiving Care’ in Section II ‘Dignity of the Human Person’, the Catholic Health Ethics Guide states that:

Article 25. The competent person receiving care is the primary decision-maker with respect to proposed treatment and care options.
Article 27. The competent person has the right to refuse, or withdraw consent to, any care or treatment, including life-sustaining treatment.[14]

Further, regarding ‘Criteria for Decision-making’ in Section V on the ‘Care of the Dying Person’:

Article 92. Decisions about end-of-life care…should take into account the person’s past and present expressed wishes; …as well as the person’s culture, religion, personal goals, relationships, values and beliefs.[15]

Lastly, in the same section on ‘Care of the Dying Person’ regarding ‘Refusing or Stopping Treatment’, the guide states:

Article 96. Morally, a person can refuse life-sustaining treatment when it is determined that the procedure would impose strain or suffering out of proportion with the benefits to be gained from the procedure.
Article 97. Even when life-sustaining treatment has been undertaken, this treatment may be interrupted when the burdens outweigh the benefits. The competent person receiving care makes this decision. When such a decision is being made for a non-competent person, his or her known needs, values and wishes are to be followed.[16]

Here it is demonstrated that, according to the principles of Catholic health ethics, decisions are guided both by the autonomy and uniqueness of each individual. Although arising from the ideology of a Christian religious group, there is nothing here that is faith-based or particularly Catholic and not transferable to a secular context.
Next, to properly set the stage for attempting an interaction between Jain and secular death practices, we will determine how the choice to engage in Jain voluntary death practice and the choice to withdraw treatment in secular end-of-life practice are arrived at.

The Choice to stop oral intake and motion in Jain and secular death practices

Jain voluntary death practice: A personal choice from the inability to perform religious duties

It is a crucial point that in Jain voluntary death practice the taking of death vows is not suggested or encouraged by others but chosen by oneself. This non-coercive decision is followed by a request to a qualified teacher to engage in the practice, and a subsequent permission or denial. It is a process initiated by the individual, but chosen interdependently with a preceptor.
What leads a person to want to engage in Jain voluntary death practice? Most sources repeat the same main justifiable reasons for starting a fast unto death as we find in "Ācārya Samantabhadra[‘s]…authoritative work entitled Ratanakaraņda-śrāvakāchāra..."When overtaken by a calamity, by famine, by old age, or by an incurable disease, to get rid of the body for 'dharma' is called 'Sallekhana.' One should by degrees…quit the body".[17] We could include any number of situations under ‘calamity,’ such as environmental disasters, mortal injury and so on. The crux of the matter is that these instances have in common the potential to leave a person unable to perform their religious duties, also often mentioned in Jain texts as the cause for choosing Jain voluntary death. The Ācārānga Sūtra says this:

“If this thought occurs to a monk:
'I am sick and not able, at this time, to regularly mortify the flesh,'
that monk should regularly reduce his food;
regularly reducing his food, and diminishing his sins,
he should take proper care of his body,
being immovable like a beam; exerting himself he dissolves his body.”[18]

Entrance into Jain voluntary death practices is considered, therefore, when religious duties are no longer able to be performed and when death approaches. This is to prevent the influx of negative karma from breaking commitments, which occurs naturally even if unintentional: "If...a person allows his vows to fall into disuse due to the onset of infirmity or senility, he will pass his final hours in asamyama, nonrestraint; such an unfortunate circumstance, it is believed, will adversely affect his next birth."[19] The importance of preparing for death is shown in the Samaṇ Sutta, which recommends that “when death is inevitable in any case, it is better to die possessed of a calm disposition.”[20]

Secular healthcare and withdrawing life-sustaining treatment:
Imminency of death and quality of life

In medicine, educated-guessing of how much time a person has to live is a frequent occurrence. It is part science and part prognostication and thus, only as good as the accuracy of the diagnostic means and experience of the physician. Such predicting can be misused, of course, if a physician makes a statement based on insufficient diagnostic evidence or with a confidence exceeding their ability. It can be devastating to a patient and their family if someone is told that they have less or more time than they actually do. A patient is at risk of giving up hope, or having too much hope for longevity and delaying preparations for the end of life. On the other hand, it can also be a useful tool if done well and used sensitively and appropriately, with the humility that comes with the use of an imperfect tool. Even with a reasonable margin of error, it is very helpful to decision-making to have some indication of length of life remaining. For instance, some palliative care units disallow certain life-sustaining treatments, such as intravenous hydration and blood-transfusion, because the focus in such a place is comfort and not curing. As such, they have parameters on whom to admit, given both their focus and scarcity of beds. One of the pre-requisites for admission has to do with remaining length of life, which can be three weeks to a month in some places but varies with demand. So, having some idea of how long a person will live can contribute to their entrance into palliative care and all that comes with that shift, including stoppage of certain treatments such as artificial hydration and nutrition.
The usefulness of medical treatment is often based on assessing if it will at all improve a person's quality of life. If it does not, or if it is burdensome, it is considered futile. Quality of life is not determined by a person having all of their physical faculties intact or being able to take care of themselves. To be sure, many disabled people lead very rich and meaningful lives. Quality of life, which is of crucial importance in healthcare in deciding on treatments or their withdrawal, is measured by conscious awareness and, based on that, the level of one’s meaningful participation. It is determined primarily by mental status and not by physical ability.

Does the Jain voluntary death decision-making model fit secular end-of-life?

According to a secular health ethics model, determining quality of life by measuring a person’s ability to perform duties would be unacceptable. Let us for a moment put aside Jain religious duties, such as the required performance of austerities (which require physical ability), and merely look at secular duties such as the duty a father has to support his family. It is a commitment taken for life, which continues even after a divorce. If this father falls ill, reasonable people would not begrudge his inability to work. Actually, the tides might turn and the children might then have to care for their father. Also, social systems can build in accommodations that protect both the children and father, such as disability, unemployment and health insurances. This does not mean that the sick or disabled person themselves has an easy task finding fulfilment after losing certain functionalities and means of participation. Many of the disabled clients I have cared for over the years struggle with depression and suicidal feelings, especially during the time when their injury is new. The saving grace in the Jain voluntary death practice is the inclusion of means to ensure that the choice to die voluntarily is not based on despondency. The Jain system even eschews less negative motivations, such as wanting gain in the future, since such feelings are tipping the scale away from equanimity and renunciation.
The disconnect between the Jain and secular approaches here, it seems, from the view that after a certain threshold the negative consequences from the inability to fulfil commitments made does not outweigh positive consequences from any good activities. Even if a person can still participate, such as an ascetic being confined to a chair but still being able to give discourses and which surely causes the influx of positive karma, the inability to perform other ascetic duties is still causing the influx of negative karma. Jain karmic theory, here, does not leave much room for intention. Even for the Jain who sincerely wishes they could continue fulfilling their religious commitments, and feels remorse for not being able to, negative karma relentlessly bonds. In all the traditions that embrace karma and rebirth, it is usually said in one way or another that ‘a short life of high quality is better than a long life of low quality.’ Quality here could be measured by non-harm and the fulfillment of religious duties, both religious ideals. From the secular perspective of health care ethics, quality of life can ever be defined this way. I would even go as far as to say that it would be dangerous to determine life being worthwhile in health care based on non-harm and the fulfilment of religious duties that rely on physical ability rather than mental capacity and meaningful participation in society. In this way, in principle, health ethics aim towards equal treatment in considering people equally worthwhile and deserving of all means of help for cure or comfort even if clients are harmful or lack physical ability.
There are occasions in the Jain tradition, however, where exceptions are made for a monastic unable to fulfil certain religious obligations due to ill-health. "[I]f an ascetic can no longer walk, he (or she) is temporar[ily] or [in]definitely exempted from the practice of wandering."[21] In Jaipur, I saw a sort of bike used for monastics when they are unable to walk. A same-gendered monastic pushes the three-wheeled bike from the back, using handle-bars with brakes, and the monastic being pushed sits inside. This allows the monastic to fulfil the commitment to wander and not stay in one place beyond a certain length of time. This sort of creative flexibility shows an active concern for debilitated monastics, which can only be beneficial for those who require help, those who help and for the order itself in keeping the spirit of the vows in changing times.
It seems, therefore, that the Jain push towards choosing to engage in death practices when one can no longer fulfil religious commitments, such as self-study for the layperson or wandering for the ascetic, does not lend itself well to a secular end-of-life context. However, the Jain emphasis on choosing to engage in death practices to most effectively prepare for death when it is imminent can easily be accommodated in a secular end-of-life setting.

Can Jain voluntary death be practiced in secular healthcare?

We have already determined the importance placed on the autonomy and uniqueness of the individual in health ethics. Both would allow for the individual to choose to withdraw oral intake and ambulation. Next, let us go even further and look at an explicit reference to withdrawal of treatment that leads to death in the Catholic Health Ethics Guide. Under the ‘Suicide and Euthanasia’ section of the ‘Care of the Dying Person’ chapter we find this:

Article 105. Refusal to begin or to continue to use a medical procedure where the burdens, harm or risks of harm are out of proportion to any anticipated benefit is not the equivalent of suicide or euthanasia.[22]

All together, autonomy, the unique background and perspective of the individual, and the Health Ethics Guide not equating withdrawal of treatment with suicide, make a secular end-of-life setting very amenable for Jain voluntary death. There remains some tension, however.
In end-of-life care, people are offered food and drink by mouth, but are not pressured to eat or drink. They are also not required to move. A palliative client can walk, sit in a chair or go for a stroll in a wheelchair if they wish, but they may also stay in bed. Here, based on the acceptance and understanding of the imminent approach of death in a palliative care environment, choosing to engage in Jain voluntary death practices such as taking any of the three types of fast-vows, such as to not take anything by mouth (bhatta-paccakkhāņa) and also to not move beyond a certain area (ingiņi-maraņa), or to not move at all (pāovagamaņa), would fit easily. The third aspect of the vows regarding receiving help from others might require negotiation. With bhatta-paccakkhāņa one can receive the full assistance of others, thus requiring no alteration of the delivery of personal care on the part of palliative caregivers. With pāovagamaņa, however, one can receive no help from others. Standard nursing care for a patient who cannot move themselves requires them to have their position changed in bed at least every two hours. Also, incontinent urine and feces must be cleaned immediately upon detection. I have often been witness to cases where, after crossing a certain threshold in the dying process (which is often a dramatic change in respiration called 'cheyne-stoking' which resembles a fish gasping when out of water), the family and staff decide to not turn the person anymore. In fact, turning the patient may be enough of a disturbance to the body-systems to hasten death. Colloquially we refer to this as 'the last turn.' Because death is so near at this point, the development of bed-sores from an unchanging position is no longer relevant. It could happen that the decision is made to stop turning someone and they linger. Perhaps for days on end. This might be tricky because of the caregiver's habit and injunction to turn patients. Here, the Jain tradition can offer a very good approach. It is recommended to not take final vows until it is sure there will be no improvement in one's illness or deterioration, because in the Jain tradition vows once taken cannot be recinded. This is not the case during the stage of preparation for sallekhana, before taking formal voluntary death vows. One finds this in the Ācārānga Sūtra:

“Subduing the passions and living on little food
he should endure (hardships). If a mendicant falls sick,
let him again take food.”[23]

But with vows there is no turning back.

"Occasionally, it may happen that a supposedly "fatal" illness undergoes remission or complete cure during the course of progressive fasting. In such cases the vows which have been taken cannot be rescinded; the aspirant must continue to take no more food per day than his current allotment far as long as he lives. This possibility explains the usual practice of refraining from a vow of total fasting until such time as death is clearly at hand."[24]

So, great care must be taken with the timeliness of vow-taking. The vow to not receive help can come at the time when definitely there will be no more mobility or improvement. Another problem arises here because at this point, generally, people become unconscious and an unconscious person cannot take a vow. This issue become very subtle and requires more investigation. It requires delving into advance directives and proxy decision-making and how they might relate to vows, which brevity prevents. Would a Jain death vow be valid if in advance, with clear mind, competancy and consultation with a preceptor, a practitioner wanted a vow to be installed at a certain point even if they are not conscious or competent? It is a fascinating question. There is also the problem of bowel and bladder elimination. This is less of a problem close to death because with the stoppage of oral intake, there is a reduction in elimination. Another way around this problem is to insert a urinary catheter and rectal tube which collect elimination. This way, elimination can continue without requiring bodily movement and the vow to not receive help anymore can be maintained.
As with the initial choice to engage in death practices, when death is imminent the fulfilment of the various Jain voluntary death vows can also be accommodated in a secular end-of-life setting.

Qualifications of those caring for the dying in Jain voluntary death

The unique relations of a householder are quite complex. Attachment to loved ones and wealth can interfere with death in equanimity. To be qualified, "[b]efore [voluntary death] can be resorted to, all worldly ties are to be severed: the individual will already be out of this world..."[25] This, of course, is very difficult. Even when someone considers themselves prepared for voluntary death practice and confirms it with the assessment of a highly qualified preceptor, one cannot predict what will happen as death approaches. The process of dying, when the elemental particles are coming to destruction or blowing up, “may give rise to emotional excitement and morbid thoughts, which are harmful to the undisturbed spiritual end."[26] In service of equanimity, there are practical ways to improve the chances of the practitioner being ”free from the memories of the friendly attachment…"[27] In terms of attachment to wealth, one part of the process of voluntary death is in the "...intermediate phase…of renunciation... [when h]e gives all his belongings away...."[28] In terms of attachment to loved-ones, the practitioner is not surrounded by family, but rather, monastic assistants.

"...the saints who ordain or cause the saints to undertake this vow in a prescribed way, are called 'Expiation/holy death preceptors' (niryāpakas).

The Head-Saints have advocated the presence of 48 saints when a saint undertakes the vow of holy death. They let him undertake the vow of holy death in a proper place and, then, perform various duties as described below:

(1) Four saints serve the mortifier saint to raise him, to get him seated and so on so that there may be no difficulty in observance of restraint.
(2) Four saints cause him to listen to religious scriptures.
(3) Four saints cause him to take foods as prescribed by Ācārānga (Book on Monastic Conduct).
(4) Four saints arrange for the potable drinks for him.
(5) Four saints try to protect him.
(6) Four saints remove the filthy excretions of the body of the saint.
(7) Four saints remain at the door of the place where the saint is undertaking his holy death vow.
(8) Four saints arrange and address the visitors to the saint.
(9) Four saints take care of the saint in the night while awake.
(10) Four saints judge the situation of the country and public.
(11) Four saints tell the religious stories to the outside visitors.
(12) Four saints refute the alien doctrines through debates.

Thus, these forty eight holy death preceptor saints try to get the saint cross the ocean of weary world through their care in maintaining the meditation and equanimity of the mortifier saint. If one does not get the required number of holy death preceptor saints, one can arrange the above activities with the number of saints available at the time. However, it is necessary that at least two saints be there."[29]

We know that such death assistants must be monastics, and thus necessarily follows the “ twenty eight basic and primary properties (mūla-guņa) of a Jaina ascetic [which is] comprise[d of] the five great vows (mahā-vrata), the five ‘cares’ (samiti) [which aim to not harm beings], the six essential duties (āvaśyaka) [which consist of inner and outer practices], the five-fold abjuration (of indulgence in the pursuits of the five senses)…”[30] and seven more bodily austerities. The “mahāvratas (five great vows) [are] - ahimsā, satya (truthfulness), asteya (taking nothing belonging to others, for own use, without permission of the owner), brahmacarya (chastity), and aparigraha (possessionlessness).”[31] This would ensure great discipline. A monastic, also, “must be totally obedient to his upādhyāya (preceptor) and to his Ācārya (the head of his order)…” [32] and thus has a two-fold accountability. Generally, then, Jain voluntary death assistants are both highly disciplined and highly accountable.
It is significant that those who assist a practitioner who is engaging in Jain voluntary death practice is expected to be so highly qualified. Not only is this time the most crucial for the practitioner, one they have been preparing for their entire life and which will determine the quality of their rebirth, but there are also very subtle negotiations that need to occur between the practitioner and the community. Jain voluntary death practice is done by monastics and householders, and in both cases it must be supervised by a qualified teacher. In both cases, also, apologies are made. For the monk, the Brhat Kathākosa mentions “ksamāpaņā: apology to the congregation”,[33] and for the householder, many sources suggest that "[h]aving called relatives and friends, one should seek their forgiveness for any transgressions in conduct..."[34] This can be seen as the occasion for saying farewell. In both monastic and lay communities, there will be potential grief at the departure of a close one, but considering "Samlekhana as the highest end...[there is] no cause for tears."[35] Grieving around the practitioner can cause mental agitation, and thus hinder the dying process, and so separation from all but the death assistants after the farewell is recommended. Likewise, in what is a great parallel between Jain voluntary death and initiation (diksha, or entrance into the monastic order), the practitioner “gives all his belongings away...."[36] and they are “practically a monk."[37] As such, separation from both loved-ones and wealth is undertaken in preparation for death in Jain practice.

Qualifications of those caring for the dying in secular end-of-life care

In a healthcare institution, the qualifications and accountability of the various members of the multidisciplinary end-of-life care team are well-known. We can draw many parallels between such a team and the Jain death assistants. But what are the qualifications of the others who remain at the bedside in end-of-life care, those whom we do not see in the Jain voluntary death model? Is the Jain voluntary death practice of separation from loved-ones and wealth applicable to secular end-of-life care? What can people do to appropriately resolve issues around their wealth and estate in end-of-life care? To answer these questions we can look to both the Health Care Consent Act, and to actual practice in hospital.
In determining the qualifications of those who are permitted to be at the bedside of the dying person, the Health Care Consent Act favours spouses, partners and relatives in relation to decision-making. ‘Spouses’ are defined by marriage, or co-habitation, or having a child together[38] whereas ‘partners’ are defined as a “close personal relationship that is of primary importance in both persons’ lives”[39] which, happily, is accommodating to same-sex couples. These relationships are given prominence. Next, ‘relatives’ are defined by “blood, marriage or adoption.”[40] In hospital, such people are favoured as well. There is no mention of personal qualifications. Where in the Jain voluntary death practice those at the bedside are at least monastics holding to a code of discipline and accountability, in a secular hospital setting the qualifications of those at the bedside at death-time are dependent solely on interpersonal relations. These are useful indicators but because there is no behavioural or motivational expectations, they leave much room for difficulties around visitation of, and wealth distribution by (or inheritance from), the dying person. The Jain emphasis on relinquishing wealth in advance and separation from loved-ones during voluntary death, after proper farewell exercises such as confession and forgiveness are performed, helps the dying person achieve maximal calmness and equanimity. In secular health care, such as in Canada, the majority of families wait for estate distribution until after death.
Additionally, family typically want to be around the dying person until their last breath. Both can cause disturbances to the dying person, as visitation and concerns over wealth distribution can be from the best or worst of intentions. Visitation and inheritance can be linked, as in the case of a child who has not been in contact with a parent and breaks the estrangement in order to show support at the end of life in order specifically to win favour and influence wealth distribution. This happens more frequently than most would like to admit. I would even be bold enough to say that fighting over inheritances is one of the leading causes of the destruction of family harmony. It is difficult in practice to distribute wealth in advance and to screen visitors in hospital, especially around death because often everyone shows up. There are, however, precedents for both. It is possible to make wealth distribution known in advance, and for it to be dependent on conditions determined by the dying person. This would bring the person themselves much relief knowing that this has been adequately dealt with and will not cause fighting between family members nor inspire wrong actions in relation to the dying person to try and shift the weight of their distributive share. With visitation, in some environments, such as intensive, emergency and palliative care, ensuring that certain people who the patient does not want in their presence being prevented entry and access is common. If a person does not want family around the bed grieving after a certain point in the death process, so as to die undisturbed, they can make this request known and it will be followed. I would suggest that the separation from wealth and family in Jain voluntary death is one that can be very helpful in the pursuit of a peaceful death in secular health care, and entirely possible to achieve given the respect for patient autonomous wishes. Further, I would suggest that despite the compulsion and habit for people to consider presence with and grieving around the dying person as a necessary and beneficial part of the process of death, it may not be in the best interest of the dying person. Grieving is not only important, it is necessary. Death and loss are a trauma and the experience of grief is a part of healing this trauma. Despite this, grief does not have to be displayed around the dying person. The Jain voluntary death model strongly recommends against it, and I feel that the option to not have grief displayed at the bedside needs to be made available to individuals who may want to control their death environment in such a way, even though there may be great resistance to this novel approach.. Grief can be experienced in an anticipatory way, also during the death either in the same location as the death or not, and after the death has occurred. Who is around the dying person and when is entirely up to the individual. They may want family and grieving in their presence until the moment they are dead. However, they may not. In such a case, if a person does truly have the best interest of the dying loved-one at heart, it must be considered that their desire to grieve around the dying person against their wishes might be a self-centered act that actually will disturb the death-process by triggering feelings of attachment or aversion in the mind of the dying person and make it more difficult for them to leave smoothly.

Bibliography

Amiel, Pierre Paul; Jains Today in the World.
Parshvanath Vidyapeeth, Varanasi; 2008.

Caillat, Colette; Fasting Unto Death According to Ayaranga-Sutta and to Some Painnayas.
Mahāvīra and His Teachings (Upadhye, Dr. A.N., Editor); C.C. Shah Rishabhdas Ranka, 1977.

Caillat, Colette; Fasting Unto Death According to the Jaina Tradition.
Acta Orientalia 38, 1977

Catholic Health Association of Canada, Health Ethics Guide (Ottawa: CHAC, 2000)

Flugel, Peter; Jainism and Society. Bulletin of the School of Oriental and African Studies;
Cambridge University Press; 2006.

Government of Canada; Health Care Consent Act (Canada), 1996.
(As of August 31 2007)

Jacobi, Hermann (Translator); Jaina Sutras: Part I, The Ācārānga Sūtra, The Kalpa Sūtra
Oxford University Press, 1884

Jain, Dr. C.S. (translator); Ācārya Amitagati's Yogasāra-prābhrta (Gift of the Essence of Yoga). Bharatiya Jnanpath, New Delhi; 2003.

Jain, Dr. Jyoti Prasad; Religion and Culture of the Jains.
Bharatiya Jnanpith, New Delhi; 1975.

Jaini, Padmanabh S.; The Jain Path of Purification.
University of California Press; 1979.

Jnānamatī, Ganini; Jaina Bharati: The Essence of Jainism
Digambar Jain Institute of Cosmographic Research, Hastinapura; 1981.

Kalghatgi, Dr. T. G.; Jaina View of Life.
Lalchand Hirachand Doshi, 1969.

Sangave, Dr. Vilas Adinath; The Sacred Shravaņa-Belagola (A Socio-Religious Study)
Bharatiya Jnanpith, New Delhi, 1981.

Shastri, Devendra Muni; A Source Book in Jaina Philosophy.
Sri Tarak Guru Jain Granthalaya, Udaipur; 1983.

Upadhye, Dr. A.N; The Brhat Kathākosa of Āchārya Harisena
Bharatiya Vidva Bhavan, Bombay; 1943.

Varni, Sri Jinendra (Compiler), Jain, Prof. Sagarmal (Editor); Saman Suttam.
Bhagwan Mahavir Memorial Samiti, 1993.

Endnotes

[1] Caillat 1977: p.115.
[2] Ibid.: p.48, fn.15.
[3] Upadhye 1943: p.51.
[4] Ibid.: p.50
[5] Jnānamatī 1981: p. 240.
[6] Ibid.: p.240.
[7] Flugel 2006: f:30.
[8] Kalghatgi 1969: p.185.
[9] Ibid.: p.185.
[10] Jain 2003: p.178.
[11] Shastri 1983: p.209.
[12] Ibid: p.204.
[13] Ibid: p.196.
[14] CHAC, 2000: p.30.
[15] Ibid.: p.57.
[16] Ibid.: p.58.
[17] Sangave 1981:p.133.
[18] Jacobi 1884:p.71-72.
[19] Jaini 1979: p.227-228.
[20] Varni 1993: p.207.
[21] Amiel 2008: p.225.
[22] CHAC, 2000: p.59.
[23] Jacobi 1884:p.75.
[24] Jaini 1979: p.231.
[25] Caillat 1977: p.46.
[26] Kalghatgi 1969; p.190.
[27] Ibid.: p.190.
[28] Caillat 1977: pp.62-63.
[29] Jnānamatī 1981: pp. 242-243.
[30] Jain 1975: p.109.
[31] Ibid: p.109.
[32] Jaini 1979:p.246.
[33] Upadhye 1943: p.51.
[34] Kalghatgi 1969; p.190.
[35] Ibid.: p.189.
[36] Caillat 1977: p.62.
[37] Kalghatgi 1969; p.188.
[38] HCCA 1996: c.2, Sched. A, s. 59 (7).
[39] Ibid. 2002: c.18, Sched. A, s. 10.
[40] Ibid. 1996: c.2, Sched. A, s. 20 (10).

Delving into mystery of death - Hindustan Times (Lucknow Edition, INDIA) June 28, 2010

2010-06-29T00:31:00.000-07:00

Hindustan Times
Lucknow Edition
June 28, 2010

Delving into mystery of death
UNIQUE MISSION Foreign researchers are in Varanasi to study Jain literature and
explore the philosophical dimensions of death

Anuraag Singh

VARANASI: For ages, Varanasi has been described as the City of Moksha, which Hindus visit in the quest for salvation through death.
Two young researchers from the West, however, are currently in Varanasi to explore the nuances of death.
Sean Hillman, a student of Religion Studies and Bioethics from the University of Toronto (Canada) and Ana Belelacqua Bjazelj, a PhD scholar in Asian Philosophies at the University of Ljubljana (Slovenia), are going through Jain scriptures in Varanasi to explore the philosophical dimensions of death.
For 13 long years, Sean was a Buddhist monk and lived in India. He is now probing voluntary death in Jainsim. The aim is to develop a secular palliative care model (particularly for hospitals) for peaceful and controlled death of terminally ill patients suffering from excrutiating pain.
Over the next ten days, Sean will explore in detail the eternal Jain Philosophy of Sallekhana and Samadhimarana - voluntary death through fasting and reduction of activity.
In fact, he is delving into monastic texts dealing with conscious death and dying, the practice and principles of bioethics at hospices. Sean aims to know how a decision can be made to end a terminally ill person's life by those close to him or her if he or she is unconscious.
"The ultimate aim of this research is to develop a secular palliative care model for having painless/peaceful and controlled death, particularly for those suffering from terminal ailments," Sean told HT on Sunday.
Ana, on the contrary, is looking more into philosophical dimensions of death (as dealth with in early Jainism and Buddhism).
Ana, who already has a Bachelor's degree in Chinese philosophy, says her research focuses on exploring [the] concept of change and identity (identity sustained even after death via rebirth).
Both Sean and Ana are part of a[n] 11-strong team of university students, teachers and professors from different parts of the world, on a ten-day summer trip to Parshvanath Vidyapeeth (PV) in Varanasi.
Parshvanath Vidyapeeth is a centre of excellence for Jain Studies and Research.
The trip has been organised under the auspices of the International Summer School for Jain Studies (ISSJS) and PV Global Centre for Ahinsa and Indic Research established at PV-Varanasi in 2008.
While Sean and Ana are researching the ultimate truth, other members of the group staying at PV-Varanasi are researching on other religious and philosophical projects.
Among them is Brianne Graham Donaldson [who is] doing [a] PhD in Process Philosophy at Claremont School of Theology and Centre for Neuroeconomics Studies at Claremont Graduate University, Los Angeles.
Brianne, during the course of research will blen science, experience, philosophy and ethics to study the human-animal divide, particularly how philosophy and religion have perpetuated it.
Another interesting [area of] research underway is by 59-year-old chaplain and PhD student from the Charles University in Prague, [Joseph Bartosek], who is aiming to promote inter-faith/inter cultural dialogue in the era of terrorism and ethnic conflicts. He is studying stories and parables in Jainism and compar[ing] it with those in European traditions (Christian and Pre-Christian traditions).
The group also includes P[rof.] Christian Haskett, a professor teaching Asian Religions at a US university.
Hasket[t] says his trip to the centre of the Jain studies in Varanasi is three-pronged: starting with collecting vital content for teaching students in one full semester on Jain studies in the spring of 2011, writing an article on how to teach Jainism and ending [with] collecting material on Sanskrit and Prakrit literature.

HANDS-ON EXPERIENCE

VARANASI: It'll not only be research and lectures which will mark the 10-day stay of 11 students and researchers from America and Europe in Varanasi.
The group will stay with Jain families to know the way they live, said Dr SP Pandey, assistant director of Parshvanath Vidyapeeth, the institution hosting the travellers from the west in Varanasi.
Varanasi houses over 500 Shwetambar and Digambar Jain families, Sharda Singh, research officer at PV-Varanasi, said, "They'll also visit and offer prayers at Jain temples in Varanasi, including Parshvanath Temple in Bhelupur and Suparshvanath Temple. Braving the scorching heat, the group visited the temple at Bhelupur on Sunday morning." PV-Varanasi director Dr SL Jain told journalists on Sunday that lectures would cover Jain icinography, art, meeting points
of Jainism and Buddhism, [the] concept of soul in Jainism and Buddhism and [a] project synopsis discussion, besides visits to Ganga Ghats and pujan.
The 11-member group, which arrived in Varanasi on June 23 and will stay here till July 3, is the third group of researchers-students from 15 foreign universities who ha[ve] travelled to PV-Varanasi this month. HTC

Sallekhana-Samadhimarana and Palliative Care

2010-06-20T08:17:00.000-07:00

Sallekhana-Samadhimarana and Palliative Care: Jain Voluntary and Controlled Death in Equanimity through Fasting and Reduction of Activity as a Model for the Dying, those Caring for the Dying and the Bereaved

COMING SOON! Completion in early July 2010.

Sean Hillman
Graduate student in 6-Week Group,
International Summer School for Jain Studies.
Delhi, Jaipur, Varanasi; INDIA
Summer 2010

Death in Tantric Buddhism and Modern Medicine Informing the Harvesting of Organs from the Buddhist

2010-04-03T10:35:00.000-07:00

Death in Tantric Buddhism
and Modern Medicine Informing
the Harvesting of Organs from the
Buddhist

by Sean Hillman
East Asian Studies Department
University of Toronto
June 2008

Introduction

The medical principle of “do no harm” exactly matches the Buddha’s admonishment to his followers. It is of no surprise, then, that in many difficult areas of decision-making, including those around end-of-life care, "the principles governing Buddhism and the practice of medicine have much in common." 1
Both scientific researchers and Buddhist scholars have long grappled with defining death. In both the scientific and the Buddhist view, for a human to be considered alive there must be a proper basis of support for conscious or sentient life. What differs in the traditions is in the subtleties of defining what qualifies as a proper basis of support for life, and what (if anything) is supported by this basis. In modern medicine one can no longer safely say that with the presence of the cardio-pulmonary vital signs of life, pulse and respiration, the person still exists and is alive because these systems can be kept functioning artificially with no brain activity. A major shift occurred in the history of medicine when brain-centered criteria for determining death overtook the long-standing usage of cardiac-centered criteria. Cardio-pulmonary failure and a loss of heat is not required for death to be pronounced. In its secular approach, what ceases at death pronouncement, beyond the failure of biological systems and integration, is not clearly defined in medicine. In medical and ethical literature there is sometimes mention of the ‘person’ or the ‘individual,’ and sometimes ‘conscious experience.’ There is no mention of mind, as an ethereal, non-biological aspect to the living being. From the Buddhist perspective, the main characteristic for determining death is the point when the mind, or consciousness, leaves the body. Tantric and other sources, both textual and commentarial, point to this being preceded by cardiac death, and followed by the loss of bodily warmth. They seem to indicate that the mind cannot leave from a body sustained mechanically, even if there is total brain-death.
What is not at issue here is organ harvesting from living donors because there is no question as to their status. They are, by definition, alive. The main purpose of this paper is to show that by exploring the medical and Buddhist views of death, looking at the changing medical practices in harvesting organs and tissue from brain-dead donors and non-heart-beating donors (NHBD) and the Buddhist commentarial reflections on such, it is possible to tease out generalised Buddhist criteria for organ harvesting directives. There are many issues that we are confronted with in contemporary society where is not possible to say definitively what the Buddhist position is on the subject. For one, modern technologies have led to unique situations that did not exist at the time of the Buddha.

"The ancient monastic texts reveal that the Buddha resolved problematic matters on a case-by-case basis as new situations arose...the treatments described are not those of modern medicine, nor are the problems they raise identical in all respects. Given the primitive technology, for example, certain questions that have arisen today could scarcely be imagined. Nevertheless, we are not entirely bereft of guidance in the ancient sources, and although the circumstances today may be new, the moral issues that arise often turn out to be similar in principle."2

As well, having definitive Buddhist positions to complex issues is hindered by the fact that there are many different philosophical schools of Buddhist thought, and different Buddhist traditions that have arisen from both the existence of these schools and from the influence of the various cultures into which Buddhism has been assimilated.

"Since Buddhism is an amorphous movement with no clear hierarchy or locus of authority, it is difficult to make authoritative statements of the kind "The Buddhist view on issue x is..." without qualificatrion. Lay Buddhusts typically turn to their clergy for religious and moral guidance, and these in turn base their opinions mainly on canonical scriptures... Despite the variety of Buddhist schools and sects, however, it does make sense to speak of a "Buddhist view" at least as far as our present purposes are concerned. There is a good deal of consistency amongst the major schools in the field of ethics, both in terms of the dominant pattern of reasoning employed and in the conclusions reached on specific issues. It therefore seems fair to speak of a "mainstream tradition," a term which here denotes the common moral core which can be extracted from the different movements, schools and sects."2

The same applies to this exploration. As difficult as it is to pin down a specific Buddhist answer to the complicated question of whether the harvesting of organs can fit into Buddhist practice and ethics or not, specifically looking at how Tantric Buddhist sources address death and the body will help us extract principles that can help inform what, in general, might be the Tantric perspective on harvesting the human body for organs and tissue. Tantric Buddhism, as a psycho-physiological spiritual system of mental development, is most useful here because of its heavy emphasis on analysing, replicating and manipulating the death process. It is also of great interest to see how the Tantric perspective relates to the medical models of harvesting, which are based on the scientific methodology for determining death.

Tantric Buddhist view of the body

The body as the indispensable basis for enlightenment

Often Buddhism is accused of neglecting the needs of the body, and even of abusing it, in the hopes of achieving spiritual attainments. The cause of this misunderstanding comes from Buddhism being essentially an ascetic tradition. A crucial part of the life story of Buddhism's mendicant founder before becoming enlightened are the extreme mortifications in which he engaged. Although he gave up such practices in the extreme, they still played a great part in his development of perfect concentration and paved a great deal of the way to the doors of liberation and omniscience. A large membership of the Buddhist religion are practitioners who engage in ongoing ascetic practices, such as celibacy, daily fasting, not touching money and wearing simple clothing, to name a few. There are even thirteen extra ascetic practices that a monk can engage in, such as living entirely outdoors only using a tree as shelter and never lying horizontally, which would necessitate sleeping upright. These are not outdated practices only done during the time of the Buddha. Modern, long-term retreatants in the Tibetan tradition often do not lie down during the course of their retreat, and spend all of their time in a box. Retreat manuals advise the meditator to refrain from stretching the legs out, although this admonishment is sometimes used as twilight language referring to the avoidance of mental distraction in general during retreat. Even a householder Buddhist, or a non-Buddhist, who receives meditation instruction will be advised to temporarily engage in the mild-asceticism of putting mind first during the course of the session by ignoring the innumerable calls from the body to address aches and pains through movement. Such a lack of movement also can also be criticised by modern medicine as a contributing factor to the development of physical problems such as deep vein thrombosis, and to be sure, there are many modern examples of yogis, such as the incredible Tibetan master Dilgo Kyentse Rinpoche, being unable to walk after years of retreat. Be this as it may, the ascetic practices of the monastic and the meditator clearly show an emphasis on depriving the body of normal leisure to assist in the strengthening of the mind. The result is a sweeping generalisation of Buddhism being a body-denying practice. An extreme example of how Buddhism's view on the place of the body in relation to spiritual practice is seen by others, we can look at how Pope John-Paul II very neatly and categorically sums up Buddhist practice in his book "Crossing the Threshold of Hope":
The "enlightenment" experienced by Buddha comes down to the conviction that the world is bad, that it is the source of evil and of suffering for man. To liberate oneself from this evil, one must free oneself from this world, necessitating a break with the ties that join us to external realities existing in our human nature, in our psyche, in our bodies. 3
Although not a very accurate barometer on the common views held by modern society, the Pope and his views surely influence millions of religious followers. Another misinterpretation of the Buddhist practitioner's relationship with the body can even be seen in pop-culture. A recent re-make of a song by the grunge band "Nirvana" has the vocalists telling us that "Nirvana means freedom from suffering...and the external world." Associating Buddhism with the goal of transcending the body (or ‘the world’ as synonymous with all things external to mind) may be traced to seeing no distinction between Buddhism and other Indian religions, such as Hinduism and Jainism, which do indeed emphasize the hindrance the body is to practice. The Jain practice of religious fasting to hasten the sloughing off of form, and Hindu stories abound of Yogis losing awareness of (or even , while in trance, entirely leaving behind) their bodies, both are examples of viewing the body as something to go beyond. The Buddhist Tantric perspective is, however, very different. This is shown in the following couplet by the eighth century Mahasiddha Saraha:
“Saraha says: It seems to me for Jains there is no freedom: the body deprived of the real only gains isolation.
The commentary explains Saraha here is mocking the Jain concern with transcending the body; as a tantrika, he believes that it is only within the body that liberation can be found; as the Hevajra Tantra (2:2, 35) remarks, "Without a body, wherefore bliss? One cannot then speak of bliss." 4

Among other texts, The Lam-Rim Chenmo by Lama Tsong Khapa makes it abundantly clear that the importance of the precious human rebirth, precious even beyond celestial forms and beings in the formless realms, is that it is only from such a form that one can achieve full enlightenment. From the Tantric Buddhist perspective, the ordinary body is manipulated and transformed in order to cause psychic experiences which lead to bliss and realisations. Although the Tantric psycho-physiological system will be explained in greater detail in the next section, here are some highlights of the scope Tantric practise, which starts off with gross and subtle form and which yields great results:

"With the completion process yogic practices, the yogin was said to encounter the transformation of the ordinary winds, channels, elements, fluids, and letters that constitututed his subtle body (vajrakaya). In particular, the winds associated with the ordinary physiological activities, known as the "karmic winds" (karmavayu), would be guided into the central channel and thereby transformed into the gnostic wind (jnanavayu), so that the varieties and attributes of gnosis envisioned by Buddhists would become attained through these yogic practices...with respect to the primary goal...the yogin was said to observe directly in a controlled manner the experiences of the dissolution of the elements, which unfold in an uncontrolled experience for those at the point of death...The completion process is said to purify death, through the union of phenomenal appearance and emptiness." 5

Not only is the body in general used in Tantric exercises to trigger special experiences, the process of death is of particular significance in seeking spiritual achievement. Again, in order to attain bliss and insight,

"a yogi seeks to cause these winds in their coarse and subtle forms to dissolve into the very subtle life-bearing wind at the heart. This yoga mirrors a similar process that occurs at death and involves concentration on the channels and channel-centres inside the body." 6

To engage in an exploration of death using Tantric literature is sensible because, as shown in the above passages, the process of death holds great importance to the tantrika, an ordained or lay-person practicing the esoteric methods of the Diamond Vehicle of Buddhism (Skt: Vajrayana). Such emphasis has led to a very sophisticated analysis of the stages of dying. The Tantric perspective is unique in seeing death as both an objective event, one that can be observed by others, as well as s subjective event with predictable components. In Tantric practise not only are gross and the subtle aspects of the death process incorporated in daily meditation and visualisation practices, which His Holiness the Dalai Lama enjoys joking about when he mentions that he dies and is reborn several times each morning and evening, but also the practitioner aims to enter consciously (even wilfully) into the actual process of death and its stages used as "grist for the mill" in the achievement of realisations. The ultimate goal for the Tantric Buddhist is liberation from cyclic existence and the achievement of the omniscience and unending compassion of a Fully Enlightened Buddha. This is the aim of every Buddhist practice, from the Bodhisattvayana (Skt: “Awakening Mind Vehicle”; sometimes called Mahayana, Skt: “Great Vehicle,” referring to the Sanskrit lineage) perspective, to which the Vajrayana belongs. This includes those practices at issue here: those which represent and manipulate the death process.

"Buddhist tantra...is aimed at stopping death..and transforming [it] into Buddhahood. This is done through a series of yogas that are modelled on the process of death...until the yogi gains such control over them that he or she is no longer subject to dying. Since these yogas are based on simulating death, it is important for the yogi to know how humans die - the stages of death and the physiological reasons behind them." 6

Tantra is an esoteric tradition. It is important to recognise this. The breaking of its secrecy has been blamed for the degeneration of the Dharma both in India and Tibet. In modern times the accessibility of Tantra is apparent both in bookstores and libraries, as well as in temples. The screening-process for involvement in Tantra has changed, for better and for worse. Someone might get involved in Tantra prematurely, without the basis of ethical discipline or even a basic understanding of the teachings of the Buddha. Alternatively, the colourful world of Tantra can be a way to draw someone towards practices that they otherwise would not have exposure to, and which could benefit their mind, and by extension, benefit those they come into contact with. There is a parallel in the wide dissemination of Jewish mysticism in the kabbalah movement. The benefit of releasing some of the secret information found in esoteric practices is that this information, which might not be found elsewhere, can be of great benefit in that it uniquely informs current, everyday situations. Particularly, in the case of exploring the process of dying from the Tantric perspective, such an elaborate description of the gross and subtle, and the physiological and psychological aspects of death, can help both those who are dying and those who are caring for the dying. For our specific purposes here, we will look at how the Tantric perspective on death might help inform decision making around the harvesting of tissue and organs from humans, an area usually reserved for the medical sciences.

The body free of mind as mere composite of elements

Unlike in Chinese and Japanese Buddhist cultures, where the integrity of the body is revered and required as part of the process of the person transforming into an ancestor, Tantric Buddhist culture sees the corpse as matter only. Non-Tantric traditions of Buddhism, both Mahayana and non-Mahayana, also share this feeling:

"Followers of Theravada and Japanese Zen emphasized that...the body is merely a collection of disposable parts that has no usefulness after death....They believed that a person's consciousness leaves the body at the time of death, so there is no arm in touch, washing or cutting the body." 7

The corpse is treated with the due respect of having been the vessel for the departed mind, but it is no longer connected to the consciousness of the dead and thus serves no remaining purpose. As a result, traditionally in Tibet, a culture based on the principles of Tantric Buddhism, a corpse is disposed of in one of two ways: cremation or sky-burial. There are practical reasons for both, because of the environment in Tibet, but the sky-burial is particularly significant in transforming the mundane act of the disposal of a cadaver into a religious event. The sky-burial involves cutting the body into pieces on a mountaintop, reducing the pieces through pounding and mixing them with flour before finally feeding the mixture to scavenger animals, such as vultures.

“Sky burial takes place after a religious specialist (lama) with a special talent for divination determines that the consciousness of the deceased has left the corpse and after the prescribed prayers, readings, and rituals have been performed. For Tibetans, to dismember the corpse and distribute it to birds and wild animals is not savage, but a deeply meaningful, spiritual act. The ritual not only helps bring closure to human relationships, but also benefits the deceased through the giving of food to numerous living beings. Because of the difficulty of burial in the frozen Tibetan soil and the dearth of firewood for cremation, distributing parts of the corpse in a final act of generosity is not considered macabre but rather a symbol of the dissolution that awaits all living things at death… sky burial is regarded as a virtuous solution to a practical dilemma.”2

Two Buddhist principles are apparent in the Tibetan practise of disposal of the body. Detachment from form and the loved one arises from seeing the body in a dramatic display of its composite nature and being an empty vessel no longer housing the departed’s mind, and the practise of generosity is performed by giving as food that which all beings consider to be most precious: the body. This Tantric view of, and approach to, the body free of mind will greatly influence our pending exploration of organ harvesting.

Tantric Buddhist View of the Death Process

In extracting the pith aspects of the dying process from the Tantric Buddhist perspective, we will concentrate mainly on commentaries to the Guhyasamaya Tantra (Skt: "Secret Communion"; Tib: dPal gsang-ba ‘dus-pa’i rgyud.) This text and practise is from the class of Highest Yoga Tantras, and many sources point to it as being the most crucial and earliest of the Tantric texts.

“Guhyasamaja is referred to as ‘the supreme and king of all Tantras,’…the existence of [which] is…essential for the survival of the Tantras…and [which] without relying upon…there is no way to attain supreme enlightenment.”8

Although its authorship is debated and is sometimes seen as a collection with multiple contributors, one of the founders of the Yogacara (Skt; Mind-only) school of Buddhist philosophy, the Fourth Century scholar-monk Arya Asanga, is generally credited with penning the work. The commentaries cited here are both by Yangchen Gawai Lodoe, “an eminent saint scholar of eighteenth century Tibet,” 8 and whose full titles are “Lamp Thoroughly Illuminating the Presentation of the Three basic Bodies – Death, Intermediate State and Rebirth”6 and “An Eloquent Presentation – A Port of Entry for the Fortunate Ones into the paths and Grounds of Mantra According to the Glorious Guhyasamaja of the Arya (Nagarjuna) Tradition.” 8
Generally speaking, the Tantric presentation on death revolves around the body and mind as mapped out according to the basic molecular elements of earth and water, the excited elements referred to as ‘fire,’ and a system of channels, winds and drops. The parts of the body comprised of the molecular elements of earth and water do not require mention, but not as obvious is the fact that, in this system, the “fire constituent [refers to] the warmth that maintains the body.”6 As they are terms foreign to our modern scientific jargon, the channels, winds and drops deserve expansion.

“Wind refers to currents of air or energy that perform the physical functions such as swallowing and serve as ‘mounts’ of consciousness. The channels are the veins, arteries, ducts, nerve pathways and so forth, through which flow blood, lymph, bile, wind and so on. The drops are essential fluids that course through the channels.” 6

Already we can see that the Tantric model is unique. With the very mention of ‘energy’ and ‘consciousness’ we depart from our familiar medical/scientific approach to the human as reducible to matter and electricity. This foreshadows some vastly different aspects in the traditions of Tantric Buddhism and medical science in their explanations of the process of death, and thus inevitable differences as well in the decisions and activities that are borne from these explanations.
Having laid out the context of the human being as a combination of matter, subtle matter and consciousness, we can now look at what occurs amidst this collection during the process of death.

'The process of death involves eight stages of dissolution of the elements. Initially, our earth element dissolves into the water element; then, the water into the fire element; the fire into the wind element; the wind into the element of consciousness; the consciousness into the mind of white appearance; the mind of white appearance into the mind of radiant red increase; the mind of radiant red increase into the mind of black near-attainment and subsequently the mind of the clear light of death dawns." 8

The dissolutions of the elements into one another does not actually mean that one dissolves into the other. This fact is made obvious by the simple logic that the elements actually contadict each other and cannot abide in the same location simultaneously. What occurs is the strength of the dissolving element to support that aspect of the body reduces and that of the next element increases, resulting in external and internal signs. The external signs are changes in the observable body, and the internal signs are visions experienced by the dying person. Thus, the process of death is both a physiological and a psychological one.

"The physiology of death revolves around changes in the winds, channels and drops. Psychologically, due to the fact that consciousness of varying grossness and subtlety depend on the winds like a rider on a horse, their dissolving or loss of ability to serve as a basis of consciousness includes radical changes in conscious experience."6

Most pivotal in the process of death, and for our purposes here as well, is determining what is considered the end of the death process. As with the preceding steps in the process of death, there is both a mental and physical aspect to the end-stage. The final stage of the dissolutions, as mentioned above, is the mind of clear light. His Holiness the Dalai Lama also refers to this stage and state of mind as the “final subtle mind…of death,”6 clearly showing that the Tantric Buddhist outlook holds death as also being an experiential one, rather than merely a series of catastrophic failures in the operating systems of a living organism. His Holiness describes the occurrences during the very last moments of life:

“The warmth finally gathers at the heart, from which the consciousness exits. Those particles of matter, of combined semen and blood, into which the consciousness initially entered in the mother’s womb at the beginning of the life, become the centre of the heart; and from that very same point the consciousness ultimately departs at death. Immediately thereupon, the intermediate state begins...” 6

Thus, in addition to the appearance clear light mind, there is the movement of heat and the essential drops as final physical events preceding death. There are also physical signs which follow death, after the mind and body have separated. “When the body begins to emit a foul odor, it is a sure sign that the consciousness is no longer present. In some cases, a…drop will appear at the area of the nostrils.” 7
Most sources indicate the appearance of a white drop at the male sexual organ and/or a red drop at the nostril as the strongest signs that the mind has left the body.
To summarize, from the Tantric Buddhist perspective“…it is the experience of clear light that is the factor that determines the death of an individual” 7 and death is final when the mind leaves the body.

Medical Science’s View of Death

"...the modern era has involved an exclusion or repression of death." 11

The West in general, and the world of medical science in particular, are renowned for being death-denying in view and in practice. We used hushed tones and special vernacular when broaching the subject, and medical practitioners have great difficulty talking to families about the reality of death and often prefer to offer almost limitless life-sustaining heroics to avoid the subject. When we say “life-sustaining,” we could just as easily say “death-delaying” in futile cases where recovery is statistically low. Secularised death is seen philosophically as the absolute end of the body, mind and the person. Even when autonomic systems are kept functioning artificially, the predominant view holds that “…the person no longer ‘exists’ because of the loss of total brain function.” 12 In the hospital environment we can easily get the impression that death is seen as being inherently bad in being opposed to life and the final result of the failure to cure disease. Although consciously holding to the position of "the intrinsic badness of death" is very difficult when we know of cases where "death is welcomed and desired (that is, good)...by an autonomous patient, and where a peaceful death is clearly in the interest of the patient,"13 it still plays out operationally in the field when dealing with dying patients and their families. The frequency of futile treatment in critical and chronic care settings are a testament to this fact. In the service of sustaining life, all other aspects of the purpose of care, and the needs of the person themselves, are made secondary. Although both the medical tradition and Buddhism hold life in the highest regard, that death is held at bay at all costs may be a misunderstanding of the ethical principle of the sanctity of life. Although ideally seen in logical relation to other ethical principles,

"…[one] version of the sanctity of life principle...holds that life as such is valuable to such an extent and in such a way that, in life and death situations, preventing the death of the patient is of overriding importance [which can lead to futile treatment and to the jeopardy of the patients' well-being and autonomy, two other ethical principles]... What matters according to the sanctity of life principle, it seems, is mere biological existence. The focus is solely on whether or not a person's body is biologically alive or not. The focus is not on what has been termed the biographical life of the person whose body it is...[meaning] the life as experienced from within." 13

Even the current clinical definition of death used at the bed-side in Intensive Care Units points to the precedence given to the body, rather than the person, as determining the status of human life. When it is held that "death is an irreversible biological event that consists of permanent cessation of the critical functions of the organism as a whole," 10 the human is an organism rather than living being with a conscious experience. Despite our slant towards a secularised (free of spiritual principles which include the inner life and the continuation of mind after biological death) and materialistic approach towards death, the very existence of a system of ethics, and the debates that emerge from such important issues as those that arise around life and death (the most common and heated being those concerning abortion and euthanasia) shows that we have set ourselves up to explore reality together. We know that we need each other to make the wisest, or most beneficial, decisions. We avoid death, but ultimately we must deal with it and cannot ignore it indefinitely. New technologies have forced us to deal with new medical circumstances that have led to a

"renewed attention towards death...[that] appears perhaps most clearly in relation to the care of death and dying in...palliative medicine and in the hospice movement, in the question of active and passive euthanasia and in the definition of the brain death criteria related to the emergence of the new transplant surgery." 11

However, with the advent of increasingly subtle and powerful means of perceiving and correcting problems in the human organism,

"in a way the very purpose of health care seems to be to fight against death, inasmuch as it aim often is to prevent death or to postpone it...[and, as a result,] sometimes modern high-tech biomedicine is accused of ignoring the inescapability of death.” 14

On the other hand, it is heartening that although we, individually and as a society, tend towards hiding and avoiding even the topic of death, it is safe to say that "...when concerned with death from 'natural causes' virtually everyone agrees that...living longer does not always mean having a better life." 13
Additionally, although we can point to a predominance of relating to death with avoidance and fear, stemming from a materialistic (or biological-centered) and even nihilistic perspective towards this phenomenon, there are secular thinkers, practitioners and movements, such as those found in ethics and holistic health, who inject the debate with a more well-rounded outlook which sees the person as a interconnected combination of mind, body, non-corporeal energy (which is seen as not different from mind in Buddhism, but which is often referred to as spirit or soul by others) and relationship with the community. Here are a few examples:

“…death of an individual extends beyond the physical changes of the body and into a changing of society’s treatment of that individual and his or her corpse.” 15

”…the concept of death is not purely a biological one: death is not only a biological condition. It may be viewed as a cessation of experience, the departure of the soul from the body, or a passage into ‘another mode of existence.’” 15a

Harvesting tissue and organs from the human body

Medical criteria

“Any criteria for determining death…would have to carry not only strong clinical weight, but also be significant in its moral symbolism. This is because death alters the relationship between an individual and society, and shifts the line of what may be acceptable behaviour and action upon that individual’s body.” 15

The determination of death is the key component in the issue of organ harvesting because “for organ donation to be successful…the process of harvesting the organs must begin immediately after clinical death…”7 This requirement leads to a great sense of urgency to acquire the working organs in a timely manner. To give a sense of the haste required to maintain organ viability, “the interval between arrest and a declaration of death is as short as two minutes in Pittsburgh…or as long as five to ten minutes in most of Europe.” 17 To be sure, this anxiety over viable organ procurement is often blamed for the ever-changing definition of death, to the point where critics of both cardiac and brain-centered criteria for death determination accuse practitioners of removing organs from living donors, thus causing their death.
What is this ‘clinical death’ then? Rather than describing an end to either brain or cardiac activity, the term ‘clinical death,’ or

"somatic death...([which is] also known as…physical death, body death)...is characterized by the discontinuance of cardiac activity and respiration, and eventually leads to the death of all body cells from lack of oxygen, although for approximately six minutes after somatic death—a period referred to as clinical death—a person whose vital organs have not been damaged may be revived. However, achievements of modern biomedical technology have enabled the physician to artificially maintain critical functions for indefinite periods." 18

Although “in the early days of transplantation, organs were removed from recently deceased donors who were declared dead when their hearts stopped beating,” 15 in the context of modern medical science, brain-death has become the standard, crucial factor in ascertaining suitability for harvesting the human body. The definition of "brain death is the complete and irreversible loss of cerebral and brain stem function.” 10 Unlike both the cardiovascular and pulmonary systems, which can be restarted, restored and maintained interventionally, the varying degrees of brain death are irreversible. Therefore, there essentially is a one-way reliance of the cardiopulmonary aggregation on brain function and thus “in most countries and most situations, brain death is considered to be equivalent to cardiopulmonary death." 19 One reason for the favouring of brain-centered criteria in determining death is that irreversibility is easier to establish. Irreversibility, or the criterion of "’strong irreversibility’ (death beyond the reach of resuscitative efforts to restore life),” 17 is considered essential to leave no doubt that the death is not caused by the organ procurement and therefore removes the physician’s culpability for causing a donor’s death. Those who question cardiac-centered criteria in determining death point to the difficulty in ascertaining irreversibility. They

“wonder…whether the use of a cardiac standard is appropriate for use in the procurement of organs. Since…if the patient were treated, restoration of spontaneous circulation could occur, critics have questioned whether death is being declared prematurely. They argue that the waiting time between heart-stoppage and the initiation of the organ removal process is insufficient to ensure that the donor’s heart has irreversibly stopped and cannot ever be restarted. They argue that because the heart’s function may be restored for a long time after cardiac arrest, the brain should be the sentinel organ for death determination. After all, irreversible cessation of brain function occurs in a shorter time frame…” 15

The determination of brain death might seem nebulous due to the organ’s complexities and as yet unsolved mysteries concerning its functioning, however, based on vital contingencies, it is indeed measurable.

"The diagnosis of brain death can usually be made clinically, at the bed side. The criteria for brain death require certain conditions regarding the clinical setting...: the underlying cause is understood; and confounding from drug intoxication or poisoning, metabolic derangements, and hypothermia have been ruled out...also required is evidence of absence of brain function on neurologic examination...demonstrat[ing] coma, no cerebral response to external stimuli, and absent brain stem function." 19

There also is non-neurologic, physical testing methodology for measuring brain-death:

"Tests demonstrating absent blood flow to the brain are generally accepted as establishing whole brain death; it is axiomatic that the brain without a blood supply is dead... Brain death is usually accompanied by elevated intracranial pressure... When this exceeds systemic arterial pressure, there is no cerebral blood flow." 19

Brain-death is not a judgement call made on the part of the physician. “Determinations of death are not arbitrary; they are more or less precise determinations of an organism's state based upon valid concepts skilfully deployed by physicians in the interests of patients.” 17 In accepting brain-death as the main requisite for organ harvesting, as opposed to cardiac-death, the organs can be kept viable longer by keeping them fed with oxygenated blood through sustaining the cardio-pulmonary system mechanically. This allows for valuable decision-making and transplant preparation time. The haste seen in cardiac-death centered criteria scenarios, due to the small window of viability, is removed. Although there are a great many arguments against the brain-death centered criteria model, many of which we will see when considering the Buddhist perspective, it can be praised for allowing precious time for both medical practitioners and bereaved families to move to their respective next phase in relating to the deceased.

Buddhist criteria

The main concern for the Buddhist in determining death is the presence or absence of mind. With the exception of Buddhist cultures which maintain that the integrity of the body is necessary for the departed to transform into an ancestor, such as is the case in Japan and China, organ donation after it has been established that the mind has left the body is seen as a positive activity and, it can be said, even encouraged in support of the practices of generosity and the accumulation of merit. In Buddhist practice in general there is no question as to the benefit of offering any part of one’s body, while living or dead. Although

"there is no official consensus among Buddhist communities as to the determination of death or the permissibility of organ donation...most Buddhist communities permit organ donation as a matter of individual conscience and consider it an act of compassion and generosity that can serve as a condition for realizing nirvana." 16

In Tantric Buddhism the practice of Chod (Tib: “Cutting [Attachment to the Body]”) is a tool for reducing the obsessive clinging the mind has to our material form by imagining the offering of one’s body, after the mind has exited the crown of the head and has transformed into a deity, as food to unfortunate beings in the lower realms. Chod is modelled after the actions of Shakyamuni Buddha in a former life when he gave his body to a hungry tigress who, out of desperate hunger, was about to eat her cubs. Stories of such sacrifices abound in Buddhist lore. The Indian scholar-saint Atisha meditated in a cave for twelve years with no apparent results. It wasn’t until, out of compassion, he used a piece of his own flesh to coax maggots out of the festering wound of a sick dog, that he achieved a vision of the future Buddha Maitreya. It is an understatement to say that "Buddhists of various backgrounds...support...the idea of donating one's vital organs to save someone's life as consistent with Buddhist values of generosity and loving-kindness." 7
Unlike in the world of modern medicine, it is the cardiac-centered criteria that seems most suitable in facilitating the transference of consciousness, the chief Buddhist concern at death-time. One specialist in both medical and Buddhist practice concludes that “as long as there is heat in the body, and a pulse and respiration, or any reflexes, it is best to avoid disturbing the patient, in case the consciousness is present.” 7 One attorney and Zen scholar shows the primary issues for the Buddhist practitioner around post-mortem use of the body to be the gifting of any anatomical part of the body (organs, tissue, corneas) in general or specifically for research purposes, the performance of an autopsy or embalming, and disposal by burial or cremation. He offers a sample health care proxy which considers each of the above options, and for each great care is taken particularly to indicate how soon after cardiac death such events are allowed to take place according to the practitioner's advance directives. 9 If organ harvesting is hindered by a time-interval required by the wait for a sign or event to establish the absence of mind, “unless a person is extremely well-trained, the consciousness is likely to be disturbed by the surgery and it may be best to avoid organ transplantation.” 7
There is also much support for the Buddhist model of death determination following cardiac-centered criteria as a direct result of rejecting those based on brain death-centered criteria.

"Some Buddhist arguments...emphasize the body's development from an original mass, such that no particular organ like the brain should take priority in determining death. Given this lack of hierarchy, some would argue that the dissipation of heat after the last breath favours criteria based upon the cessation of cardio-pulmonary activity rather than brain-death criteria." 16

Even with the onset of any degree of brain-death, if the body is alive artificially by way of cardio-pulmonary mechanical heroics, it is widely held in Buddhism that the mind will not leave the body. Although there is much scriptural and commentarial support for this, perhaps this is too bold a statement. It may be more mild to say that “if the heart has not stopped beating and the bodily heat has not yet disappeared, there is reason to believe that the consciousness may still be present in the body.” 7 A patient in a persistent vegetative state (PVS) still meets the “minimum requirement…for assuming the existence of a person…[which] is the existence of consciousness.” 7 As a result,

"some concern does exist among Buddhists concerning the criterion of brain-stem death, to which organ transplantation from cadavers is closely linked. To declare death on the basis of this criterion seems premature to some, and not in keeping with Buddhist scriptural teachings concerning the point when death occurs. The ancient sources state that death occurs when three things - vitality, heat, and consciousness - leave the body." 2

Dividing that which is required to leave the body in the valid determination of death into three does not negate our strong premise that the main component in defining death is the departure of mind, and that Buddhists can easily rely on cardiac-centered criteria. Unlike with brain-death, cardiac death necessarily prompts the departure of mind, although some time might elapse. However, with the departure of mind, heat and vitality cannot remain.
Looking at cardiac-centered criteria as being in opposition to brain-death centered criteria gives preference to viewing death as “…the death of the whole psycho-spiritual organism rather than any one of its parts." 2 The following statement by the same author, one who is admirable in his active work in bridging Buddhism and bioethics, gives us reason to pause:

"...since the traditional Buddhist criteria for determining death are biological in nature Buddhism would reject any definition of death that focused solely on the loss of consciousness or the higher brain functions controlled by the neocortex."2

This statement is true insofar as the biological status of the human organism is the only ordinary means we have of determining the presence or absence of mind, since certain signs and symptoms give indication of the latter, which is of the utmost importance. However, declaring that Buddhist determine death using biology might lead one to believe that Buddhists rely on the functionality of the body alone. This smacks of materialism contrary to the Buddhist emphasis on experience and consciousness, in that it does not take into account that it is the status of mind that actually defines death. Any bodily state used to determine death is simply a way of perceiving indirectly what is happening with the mind, a non-physical and non-visible phenomenon. Again, the Buddhist stance that mind is the key factor in establishing death clearly informs decision-making around invasive activities, since, “from a Tibetan Buddhist perspective…any intervention before...the experience of clear light, especially in the case of a skilled meditation practitioner, is inadvisable.” 7
As mentioned earlier, there are objective signs that are agreed upon in the Tantric world as indicating the departure of mind, such as the appearance of fluid at orifices or the smell of decay. There are additional ways that traditionally are accepted as valid methods of establishing that the consciousness has left the body. Earlier we saw, in the sky-burial description, that a religious with expertise in divination has the ability to determine the mind’s departure. However, it would be more accurate to say that someone with an appropriate level of clairvoyance can perceive directly the mind which has moved into the Bardo (Tib: “In-between State”), referring to the state of existence between death and rebirth. Lastly, there is the Tantric practice of Phowa (Tib: “Transference of Consciousness”) which, if performed by a qualified master (who can either be the patient themselves or one practicing the ritual for the benefit of the patient), can act as the final push for the mind’s exit. In such a case, the exit would also be auspicious, meaning one that occurs through an upper orifice or through the crown of the head and necessarily leading to a fortunate rebirth. Any of these means of determining the departure of mind, signs, clairvoyant pronouncement or ritual, would, in general, satisfy the Tantric Buddhist that the appropriate time for organ procurement has arrived. In the absence of these, standard best practice with Buddhist patients suggests that "as far as possible, it is best to leave the body alone and in quietude for two to three days after the pulse and breathing have stopped, or until the corpse begins to decompose.”7 To harken back to the earlier discussion regarding the NHBD (non-heart-beating-donor), it is clear in the Buddhist approach that there is a great concern with how soon after cardiac death the body is manipulated in any way, especially invasively with organ procurement or autopsy, if cardiac-centered criteria dominate. There is no predictable schedule for the departure of mind. It can happen before three days pass, but it does not occur after three days with an ordinary being. The only exception to this principle is in the case of the Yogi (Skt: “hermit meditator”) who can remain in a state of meditation for more than a week with cardio-pulmonary vital signs absent. In such a case the only remaining observable signs are heat in the chest and freedom from decay and odour. The mind has not left, and any invasive activity would be inappropriate.
Interestingly, there also exists scientific research that reinforces both the cardiac-based criteria model and the Buddhist perspective which both favour the view that the brain-dead patient is not deceased:

“Studies of brain dead patients, some of whom have been kept "alive" for long periods, suggest that in fact the brain is not essential to many aspects of organismal integration and that bodily integration may not be best thought of as localized to a particular organ. If this is so, the notion of brain-mediated bodily integration does not offer a reason to suppose that brain dead patients are really dead.”17

Based on many sources, it is safe to say that the Buddhist stance leans more towards time elapsed after cardiac death as the crucial factor to ensure that the consciousness has left, and following this is the only appropriate time to perform invasive activities with the corpse because there is no longer a danger of disturbing transmigration. To say that the departure of mind is the point-of-no-return in the death process, and the mind does not leave until after multi-organ failure which is caused by, or accompanies, cardiac death is in line with the scientific definition of death as "an irreversible, biological event that consists of permanent cessation of the critical functions of the organism as a whole."10 Because the mind can remain in the body of the patient experiencing brain-death with cardio-pulmonary assistance, it is the multi-organ failure brought about by cardiac death which, despite a varying time-lag, necessarily brings about the movement of the mind into the in-between state.

Conclusion

We can now say assuredly that the Buddhist stance on organ harvesting is within the fine balance of two issues: offering body parts as an encouraged and powerful practice of generosity which not only helps others but helps one’s own spiritual development, and ensuring that the transmigration of the mind at death is not disturbed. We will also take for granted, based on the Buddhist proscription against taking life, that any activity that causes the premature death of a patient, not by withdrawal of treatment but by invasive procedures, is out of the question. Although modern medicine has moved away from cardiac-centered criteria for determining death, the long-established usage of this model can still be very useful to its proponents. There are many indications that this model is more representative of what a Buddhist needs at death time, as opposed to the brain-death criteria model of death determination. Simply, our Tantric sources require the gathering of heat at the heart before the departure of consciousness, which mutually contradicts the scenario of determining death based on loss of brain activity with an otherwise functioning body, mechanically supported or not. In such a case, the heat of the body remains and therefore the mind has not departed. Some might argue that the example of the Tantric yogi in death meditation is counter to the cardiac-centered criteria model of death determination because, despite the yogi being considered not-dead, the cardio-pulmonary signs have ceased. This can be refuted by considering that the Buddhist model of cardiac-centered criteria for death determination is unique in having additional requirements accompanying cardiac-pulmonary failure to determine death. These are: heat departing the body; and either the appearance of the prescribed biological signs (orifice drops, odor of decay), or the defined time-period after cardiac death elapsing (2-3 days), or particular spiritual events (ritual performance or clairvoyant pronouncement of mind departure). Care must be given to these idiosyncrasies when using the cardiac-centered criteria model of death determination in the context of organ harvesting with the Buddhist. We see these needs built into the contemporary Buddhist proxies which give full autonomy to the decision maker who initiates the advance directives of post-mortem care, which can be the patient themselves or their representative. These documents are a very helpful resource as they clearly tackle not only whether or not certain post-mortem invasive procedures are allowable by the Buddhist, but also when these activities can appropriately take place after cardiac-death.

Bibliography

1) The Dictionary of Medical Ethics; Duncan, Dunstan & Welbourne, 1981

2) Keown, Damien Buddhism and Bioethics (Religious Perspectives in Bioethics); Taylor and Francis 2004

3) John Paul II, Pope; Crossing the Threshold of Hope; Knoph 1995

4) Jackson, Roger; Tantric Treasures: Three Collections of Mystical verse from Buddhist India; Oxford University press 2004

5) Davidson, Ronald M. Indian Esoteric Buddhism (A Social History of the Tantric Movement);
Columbia University Press, 2002

6) Lati Rinbochay and Hopkins, Jeffrey. Death, Intermediate State and Rebirth
in Tibetan Buddhism. Ithaca: Snow Lion, 1979

7) Tsomo, Karma Lekshe; Into the Jaws of Yama, Lord of Death (Buddhism, Bioethics and Death); State University of New York Press 2006

8) Lodoe, Yangchen Gawai. Paths and Grounds of Guhyasamaja (According to Arya Nagarjuna). Library of Tibetan Works and Archives, 199

9) Frank, Casey Living Organs & Dying Bodies (Tricycle: The Buddhist Review); Fall 1997

10) Wijdicks, EFM. Brain Death; Lippicott Williams and Wilkins, Philidelphia 2001

11) Sorenson, Anders Draeby The Problematization of Death in Modern Medicine; (Ethics, Rights and Death in Modern Medicine) Philosophia Press 2002

12) Thomasma, David C. The Ethics of Organ Retrieval (from The Ethics of Organ Transplantation); Elsevier Science 2001

13) Kappel, Klemens; The Morality of Euthanasia; (Ethics, Rights and Death in Modern Medicine) Philosophia Press 2002

14) Anderson, Svend; The Right to a Good Death; (Ethics, Rights and Death in Modern Medicine) Philosophia Press 2002

15) Ozark, Shelly; De Vita, Michael; Ethical Issues in Non-Heartbeating Cadaver Donors (from The Ethics of Organ Transplantation); Elsevier Science 2001

15a) Catherwood, J.F.; Rosencrantz and Guildenstern are “dead”?; Journal of Medical Ethics 18
1992

16) Shelton, Wayne; Balint, John; ( Editors) The Ethics of Organ Transplantation; Elsevier Science 2001

17) Huddle, Thomas S.; Schwartz, Michael A; Bailey, F Amos, Bos, Michael A; Death, organ transplantation and medical practice; (Philosophy, Ethics, and Humanities in Medicine 2008, 3:5 (4 February 2008)

18) Dyer, Kirsti A. MD, MS, FT; Death; The Columbia Encyclopedia, Sixth Edition. 2001-05.

19) Young, G Bryan MD, FRCPC Diagnosis of Brain Death; Up To Date Inc. 2008

A Principle of Justice in Palliative Care

2010-02-10T15:54:00.000-08:00

A Principle of Justice in Palliative Care, by Sean Hillman
MA student, Religion (Buddhist Studies)/Bioethics
University Of Toronto
Department and Centre for the Study of Religion
Joint Centre for Bioethics

Feb. 2010

The fair equality of opportunity principle of justice as proposed by John Rawls in "Theory of Justice" does not provide sufficient grounds for the distribution of palliative care entitlements. Norman Daniels bases his arguments for health care distributive justice on the fair equality of opportunity principle in "Just Health Care," but in so doing, fails to properly account for the special case of distribution of resources for palliative care within the greater context of health care. From the perspective of this principle of justice, it is at times questionable whether palliative care even meets the requirements to warrant belonging under the umbrella of ‘health care’ and this problem will be addressed within. Regardless, establishing palliative care as a special case in resource distribution entitlements is crucial because that which makes palliative care special is exactly what causes it to not be amenable to support by the fair equality of opportunity principle of justice. Rawls makes ‘opportunity’ the open access to positions, or offices, and careers or jobs. ‘Positions’ can be either political or institutional but can be seen simply as employment positions, with varying degrees of power, in general. There is some overlap between the two but careers can be seen that which affords an individual the opportunity to have ‘success’ with the accumulation of wealth or income, an endeavor which forms a key part of this principle of justice. ‘Equality’ for Rawls has two aspects: disregard for social background on the one hand, and a firm regard for both predisposed talents and skills and the intention to exert effort to seize opportunity, which he calls ‘willingness.’ Daniels then extends and applies the fair equality of opportunity principle to justify resource entitlements in the context of health care based on the premise that the aim of such care is to return individuals to ‘normal-species functioning’ to ensure full participation in society over the course of an entire lifetime. Where Rawls’s fair equality of opportunity principle of justice fails in justifying palliative care entitlements is in the fact that the main recipient of palliative care, the dying human, is no longer participating in the active pursuit of positions or income. This can be contested in the case of the individual who receives palliative care over a length of time, such as in the case of someone who takes a while to die. We can reduce this argument by restricting the palliative period to the average length of stay of a palliative patient, measured in weeks, or to the time spent by an individual actively dying, measured in days or hours. Where Daniels’s application of the fair equality of opportunity principle of justice fails in justifying palliative care entitlements is in the fact that, unlike health care in general, the purpose of palliative care is not the return to normal-species functioning but, rather, to achieve comfort. Full participation in society over the course of an entire lifetime is no longer relevant because the lifespan is at an imminent end. The adjacent recipients of palliative care, those close to the dying human, those close to the dead human or the bereaved, and the remains of the dead human, must also be considered. There will be room as well to discuss some interpretive variances when we look at some of the parts of the fair equality of opportunity principle of justice individually, with respect specifically to a dying human: motivation, success and talents and skills.

First I will look at the reasoning in support of treating the phenomenon of palliative care as a special case within resource distribution in health care by taking recourse in the universality of the experience of dying, and pointing to the universality of the unique aspects of that experience for the dying human and those close to them. My selection of two unique aspects of the dying experience include: the total dependency of the dying human on the care of others, and an increased need for decision-making. I intended to look also at the increased reliance on spirituality but brevity prohibited this. Using these unique aspects, I will argue that they demand entitlements and that the fair equality of opportunity principle of justice does not provide sufficient grounds to support such entitlements.

Death is experienced by every sentient being, and thus every human being must necessarily die despite there being a vast variation in the manner in which this can occur. There are timely and untimely deaths, based on our conception of a typical lifespan. This can be specific to a geographical group in the sense that their standard of living, access to resources including health care, and technological advancement will influence the average lifespan within that geographical group. Regardless of average lifespan variances, it is safe to say that death which occurs at a chronological age approaching either side of pubescence would be agreed upon by most to be untimely. There are innumerable diseases which can interrupt life either by themselves, as in the case of a terminal disease, or combined and/or cumulative disease that ends in the catastrophic failure of an essential system in the human organism. This variation in the manner in which humans die does not defeat the idea that death is a universal human experience. A disease is merely an indirect cause of death. Ultimately it is the cessation of respiratory, circulatory or brain function (and cessation of any one of these necessarily makes for the cessation of the others) that causes death. This must occur to every human organism. Although this can be disparaged for being a statement of the obvious, it is important ground-work for what is to follow.

Dependency on others

Next, we must look at how palliative care is special because of the universality of the unique aspects of the experience for the dying human and those close to them. Firstly, the dying person becomes a dependant. Childlike in their vulnerability, it most often happens that they must be in diapers once again. Of course, this does not occur in the case of instantaneous death such as that which occurs with some traumatic injuries, but there is no need to mention instantaneous death because in looking at palliative care, we are dealing with a dying process of some length, even if very short. A discussion regarding resources designated for the treatment of the remains of the deceased and caring for the bereaved would still be relevant in the case of instantaneous death, but we will save that discussion and not pursue it in this paper. One might say that it is not very unique that the dying human becomes dependant because some of those that are disabled are also dependant. This is a true and an important point. Dying will always be intimately connected to any ideas formed around disability because one necessarily becomes disabled during the process of dying. Based on this fact, we can refute Daniels’s statement that “no one, except children or the congenitally handicapped, would have a claim on social resources to meet health-care needs”1 and include the dying since they share with children and the congenitally handicapped a vulnerability and varying degrees of mental and physical incompetence (which will be qualified in the decision-making section) which makes their very survival dependent on the care of others. We can avoid the refutation by including the dying in the category of the congenitally handicapped. A discussion around the reasoning behind Daniels’s exclusion of the handicapped from acquired injuries from such entitlements must also be shelved for now. Instead, we can state that, by definition, the ‘congenitally handicapped’ have a disabling condition present from birth which impedes normal species functioning and full co-operation in society over the course of a lifetime. From this perspective, death can be seen as a congenital condition, since to be born requires that one must die, at the very least after the natural degeneration of organs crucial for maintaining the living human organism results in their irreversible failure. This death from natural decay, colloquially put as "dying of old age" or a “dying naturally”, seems to not be the statistical norm. Even in the case of death from acquired injury, having a congenitally acquired human body makes the human organism susceptible to internal and external harm that can result in death. With the gift of the human body received from our parents comes a guarantee which is not a disease per se but a condition that, like some diseases, results in death. Have we established death and dying as congenital handicaps? Our inevitable demise comes as part and parcel with the human organism from birth, and impedes normal species functioning and full co-operation in society but not over the course of a full-lifetime. To be sure, death ends that very course of a lifetime, but one cannot say that death is an impediment over the course of a full lifetime. We cannot even begrudge death’s uncertainty and unexpected arrival at any possible point on the chronological timeline of a human life, potentially occurring from the time spent in the womb all the way to the limits of normal aging in this epoch. For there to be an automatic claim on social resources, such as in the case of the congenitally handicapped, do we have to meet the requirement of there being an impediment to normal species functioning and full co-operation in society over the course of a full-lifetime? No, because children are slated in this category by Daniels and the period of childhood, like the period of dying, is temporary. Perhaps, then, any impediment to normal species functioning and full co-operation in society gives entitlement to claims on resources. In this way, if with the fair equality of opportunity principle “individual variations in talents and skills determine…fair shares of the normal opportunity range…[and one] assum[es] these [variations] have already been corrected for the effects of social and natural disadvantages”2, dying as a natural disadvantage to social participation would, like childhood and congenital handicap, give automatic entitlement to resources. But this seems weak. From Rawls we know the correction made for social disadvantage in distribution questions. With regard to “social circumstances and such chance contingencies as accident and good fortune…distributive shares” should not be “improperly influenced by these factors so arbitrary from a moral point of view.”3 Ignoring, for the moment, his qualifications regarding similar talent, skill and willingness, generally people “should have the same prospects of success regardless of their initial place in the social system, that is, irrespective of income class into which they are born.”4 What correction, then, occurs to account for natural disadvantage? Also, perhaps the term “natural disadvantage” can be misused to include too many circumstances, such as merely being “down on one’s luck.” How far should it be extended? Perhaps, also, we should reject the inclusion of “dying” in the category of “congenital handicap” because it meets some but not all of the requirements of its definition, and reject the designation of dying as a natural disadvantage because unlike the other disadvantages, it occurs to everyone. Despite pervasive and systemic denial of death in some societies, no one would reasonably reject the reality of death. Is that enough to require entitlement? It appears as though the dependent status of the dying person would not move Rawls to require palliative resource entitlements, as Martin and Reidy’s following statement suggests:

“Rawls seemed to the critics to have inappropriately bracketed the family off from the wider concerns of social justice. As a result of this bracketing, they argued, his conception both of the citizen and of the human person was male-oriented, and beyond that was modeled almost exclusively on the fully formed and “normal” adult. One important feature, then, of Rawls’s focus was his relative neglect of what might be called dependent status (children, the old, the sick, the permanently disabled) and of those (largely women) who are their main caregivers.”5

Daniels does, however, account for dependency by suggesting entitlements for two of many categories of dependents, children and the congenitally handicapped. By extension, I hold that despite ‘dying’ not necessarily meeting all the requirements of the definition of ‘congenital handicap’ it should be included under dependency for entitlements. This is not defeated by Rawls’s neglect of dependency. I hold also that palliative resource entitlements are additionally strengthened by seeing dying as a natural disadvantage, even though it occurs to everyone. Although the time of its occurrence is not predictable, death’s inevitable occurrence is definite and not random in the way other disadvantages might be seen. The fair equality of opportunity principle of justice is thus not strong enough to justify palliative care entitlements because of the logical gymnastics needed to squeeze dying into Rawls’s and Daniel’s frameworks.

An alternate route to try and justify palliative care entitlements with the fair equality of opportunity principle is to look at palliative resources for those close to the dying and the dead (the bereaved). As established earlier, since the dying human is a dependent, like the child who is unquestionably a dependent, the entitlements afforded to the family based on their participation in society because of the fair equality of opportunity principle can extend to include the dying family member, in the same manner in which entitlements are extended to include dependent children. This is a satisfactory approach for certain circumstances, but it does not provide enough support for palliative care entitlements as a whole because it does not account for dying individuals who have no kin. Here we could also mention the heartbreaking phenomenon of pediatric palliation. Is a dying child, with compounded dependency, more entitled to resources? Perhaps. Such tragic situations certainly inspire emotional favor over other palliative care contexts.

Decision-making

Moving from the dependency of the dying human, next we look at another unique aspect of the dying experience: an increased need for decision-making. Necessarily, in a health care institution, a medical or nursing practitioner will need to determine the wishes of the client with a higher risk of mortality (increasing illness, invasive procedures, untreatable fatal disease and so on) in relation to what treatments and life-extending heroics they do and do not want under changing circumstances. Some common questions concern cardio-pulmonary resuscitation, intubation and ventilation among others. What makes palliative decision-making unique as compared to that occurring in health care in general is urgency and sensitivity. Due to the fact that circumstances can change quickly and dramatically in the case of a person with an increasing risk of mortality, difficult questions must be broached in advance. With a rapid turn of events, where there is no time to ask the person themselves what treatments they would or would not want under certain circumstances, sometimes an advance directive can be relied upon. We assume that the principle of autonomy is esteemed. The relevance of this unique decision-making context in palliative care, with increased risk of mortality leading to urgency and tackling the sensitive subject-matter of continuing or ending the operation of basic systems in the human organism, is found with the question of competency. There exist cases where a dying individual maintains their full capacity to reason until death, and thus can fully participate in informed decision-making about their care. However, since disease and the process of dying can detrimentally affect the human’s mental faculties, many individuals are unable to make informed decisions. There also may be situations where the individual may be able to reason clearly, but is physically unable to communicate. In both cases, ignoring advance directives or decisions by proxy, it is impossible to know the wishes of the individual. We will look at both possibilities: that in which an individual’s wishes are known as with those who are competent and communicative, and that in which an individual’s wishes are not known as with those who are incompetent or uncommunicative, and see if the fair equality of opportunity principle justifies resource entitlements that would require distribution as the outcome of the decisions made.

To effectively bring in this principle of justice, we need to look at the dying person’s participation in decision-making. For the competent and communicative dying individual, we can include their participation in decision-making as the continued participation in society as part of the normal-species functioning over the course of a lifetime. This would be supported by Daniel’s approach, and even Rawls speaks of the importance of individuals being “normal” and “fully cooperating members of society”6 as the outcome of health care. We can easily extend the importance placed on normalizing and integrating people who are experiencing obstacles such as pain and illness to the context of palliative care, not as its outcome but as a standard. If such a person wishes for a treatment, such as using whatever means required to effectively harvest their organs for donation after brain-death, or the cessation of any further treatments except for pain management, we can see no obstacle to justifying entitlement to the resources that each trajectory requires. Where we run into complications is with Rawls’s equality scheme. Rawls often expresses the importance of disregard for social background to ensure equality, but requires the grouping of people into like levels of talents and skills, and having people grouped together with those of a similar level of willingness to participate in the pursuit of opportunity: “In all sectors of society there should be roughly equal prospects of…achievement for everyone similarly motivated and endowed.”7 Do we consider the talents and skills of the dying person fully participating in palliative decision-making? We could. If we see intelligence as predisposed and not acquired, according to the Rawlsian scheme we would have to group people of similar intelligence together when determining distribution entitlements. These different levels of intelligence could possibly have varying degrees of effective decision-making capabilities. Does this mean that these groups have different entitlements? Are groups having greater intelligence and more effective decision-making abilities more entitled? This seems unconscionable. What about other skills and talents that can be utilized by the competent and communicative dying person? We can see how it may be useful to have endurance, calmness, and empathy (for their loved ones who are suffering from anticipatory grief, perhaps). The idea of a dying person supporting their family might seem odd given their own suffering, but is a phenomenon which often occurs, as expressed by the disabled anthropologist Robert Murphy in his auto-ethnography “The Body Silent.”8 Murphy indicates that families and health care staff have expectations of the patient, such as keeping a happy front, not complaining and being compliant to treatment. When we consider endurance or calmness, we can see that these qualities may help the individual. When we consider compliance or non-complaining, such qualities may compromise autonomy. Should there be a difference in entitlements between groups of dying individuals who have varying degrees of positive inner qualities such as endurance or lack of anxiety? Looking at talents and skills this way, it is hard to see how having certain endowments can help determine entitlement to palliative resources. How about willingness, then? All else being equal, if we have two dying people and one is willing to participate in autonomous palliative decision-making and the other is not, do they have different entitlements? Certainly we cannot force anyone to assert and claim their opportunity to be an autonomous agent. We cannot threaten to withhold resources as a means of bullying an individual into making decisions. We can, however, inform the dying person that if they do not make a decision, a decision will have to be made on their behalf and it may not be in accord with their wishes. Degrees of willingness, also, does not seem to be a strong method of determining distribution. Rather than focusing on varying degrees between dying individuals, with Rawls’s statement that those with “similar abilities and skills should have similar life chances”9 we can go so far as to group those needing palliative care together, as a group containing those who have similar circumstances and who thus are in need of similar resource entitlements.

For the incompetent or uncommunicative dying individual, participation in decision-making is obstructed. With clear and extensive advance directives, autonomy and full participation in decision-making by the individual is ensured, despite their natural withdrawal from normal social interaction. Using Daniels’s framework, we could justify resource entitlements that would result from such decisions based on the individual’s continued participation over the course of a lifetime, albeit passive and without the remainder of normal-species functioning. Rawls might point to such a person’s skill in having the foresight to set up such personal advance directives, and their willingness to participate in the opportunity of affirming their autonomy even when not able to do so actively. Without such directives we normally turn to decision by proxy. This is a very complicated area of palliative ethics, one in which I see much folly and neglect in practice and, thus, demanding resources for further research. I myself am committed to such a pursuit. Who is the proxy decision-maker? Although meaning alternate or substitute, it is interesting that ‘proxy’ and ‘proximate’ appear to have the same etymological origin, and in practice we do look first to closeness of kin for a proxy. Closeness of kin can be difficult to ascertain because it might not be biological. It also can be confused with locational proximity of kin versus kin with closeness of ties, such as in the case of closely tied kin being abroad and more distantly tied kin being at hand. Nevertheless, we can assume that closeness of kin is esteemed, but not how this closeness is determined. Is it based on the family hierarchy? In establishing the original position, an ideal theoretical paradigm to serve as the basis for a theory of justice, Rawls states that“…we may think of the parties as heads of families, and therefore as having a desire to further the welfare of their nearest descendents.”10 Is the family head the best proxy decision-maker? Even if we determine a valid proxy, there can also be difficulties in maintaining the autonomy of the dying individual because the proxy might have very different ideas regarding possible courses of action. They may even say that what they think is aligned with what the dying person wishes, even if it is not the case. Without intending harm, the proxy may truly think that they know what the dying person wants and be mistaken. Without directives, or in the case of there being no other family members to consult, there is no way to check such assertions. The palliative care team can either take the word of the proxy, or take the proxy’s position as suspect and combine it with, or compare it to, the logic of the harms and benefits of different courses of action from the team’s multidisciplinary perspective. I don’t see how the fair equality of opportunity principle accounts for resource distribution entitlements in such circumstances, where there is no normal species functioning of the individual at all, except to appeal again to their dependency on kin and/or the health care team naturally demanding resource entitlements. It is hard to not see the importance of using whatever means to ensure an effective process of decision-making on behalf of the dying individual if we have esteem for the principles of autonomy and non-malevolence.

Is palliative care a valid subcategory of health care?

I have one last attack on the fair equality of opportunity principle as a way to justify palliative care resource entitlements. As a subcategory of health care in general, it could be argued that it is redundant to treat palliative care as a special case if health care is already treated as “special and should be treated differently from other social goods.”11 Here it is useful, then, to show that, according to the justice theory used by Rawls and Daniels, palliative care does not qualify as a subcategory of health care at all. We can say that dying is within the “normal opportunity range”12 because it is a normal part of every human life in bringing about it its conclusion. Naturally, Daniels sees that “health care needs increase later in life…”13 and we know intuitively that they culminate at death. Yet Rawls and Daniels both see the basic function of health care identically. Rawls sees health care as "treatment that restores persons to good health, enabling them to resume their normal lives as cooperating members of society."14 Daniels also sees health care serving to “maintain, restore…normal species functioning. ”15 To return the human to normal species functioning is not the purpose of palliative care. If the fair equality of opportunity principle is able to provide justification for health care entitlements, and the purpose of health care is not the same as that for palliative care, then this is yet another reason to reject this particular principle of justice as a basis for justifying palliative care entitlements. I concur with Daniels that there are many functions of health care16 and extend that statement to palliative care. However, it is often cited that the main function of palliative care is to provide comfort.17 Daniels holds that, of the many functions of health care, that of “reducing pain and suffering is not a general enough function to explain the importance of health care.”18 I hold that, for palliative care, it is.

Endnotes

1. Daniels, Norman; Just Health Care
Cambridge [Cambridgeshire] ; New York : Cambridge University Press, 1985.
p.20
2. Ibid. p.52
3. Rawls, John; A Theory of Justice
Cambridge, Mass. : Belknap Press of Harvard University Press, c1971.
p.72
4. Ibid. p.73
5. Martin, Rex; Reidy, David A. (Editors); Rawls’s Law of Peoples: A Realistic Utopia?; Malden, MA; Blackwell Publishing, 2006.
pp.14-15
6. Rawls, John; Political Liberalism
New York, Columbia University Press, 1993.
p.184
7. Rawls 1971: p.73
8. Murphy, Robert F.; The Body Silent New York: Henry Holt, 1987.
9. Rawls 1971: p.63
10. Ibid. p.28
11. Daniels, 1985: p.19
12. Ibid. p.33
13. Ibid. p.52
14. Rawls, John; Kelly, Erin (Editor); Justice as Fairness : A Restatement
Cambridge, Mass. : Harvard University Press, 2001.
p. 174
15. Daniels 1985: p.32
16. Daniels 1985: p.49
17. Hickey, Joanne V.; The Clinical Practice of Neurological and Neurosurgical Nursing; Philadelphia, PA: Lippincott Williams & Wilkins, 2009.
p. 28
18. Daniels 1985: p.49