Buddhist Deaths in Hospital: Narratives and Case Analyses

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

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

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

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(As of August 31 2007)

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

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Kalghatgi, Dr. T. G.; Jaina View of Life.
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Upadhye, Dr. A.N; The Brhat Kathākosa of Āchārya Harisena
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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).