Death in Tantric Buddhism
and Modern Medicine Informing
the Harvesting of Organs from the
Buddhist
by Sean Hillman
East Asian Studies Department
University of Toronto
June 2008
Introduction
The medical principle of “do no harm” exactly matches the Buddha’s admonishment to his followers. It is of no surprise, then, that in many difficult areas of decision-making, including those around end-of-life care, "the principles governing Buddhism and the practice of medicine have much in common." 1
Both scientific researchers and Buddhist scholars have long grappled with defining death. In both the scientific and the Buddhist view, for a human to be considered alive there must be a proper basis of support for conscious or sentient life. What differs in the traditions is in the subtleties of defining what qualifies as a proper basis of support for life, and what (if anything) is supported by this basis. In modern medicine one can no longer safely say that with the presence of the cardio-pulmonary vital signs of life, pulse and respiration, the person still exists and is alive because these systems can be kept functioning artificially with no brain activity. A major shift occurred in the history of medicine when brain-centered criteria for determining death overtook the long-standing usage of cardiac-centered criteria. Cardio-pulmonary failure and a loss of heat is not required for death to be pronounced. In its secular approach, what ceases at death pronouncement, beyond the failure of biological systems and integration, is not clearly defined in medicine. In medical and ethical literature there is sometimes mention of the ‘person’ or the ‘individual,’ and sometimes ‘conscious experience.’ There is no mention of mind, as an ethereal, non-biological aspect to the living being. From the Buddhist perspective, the main characteristic for determining death is the point when the mind, or consciousness, leaves the body. Tantric and other sources, both textual and commentarial, point to this being preceded by cardiac death, and followed by the loss of bodily warmth. They seem to indicate that the mind cannot leave from a body sustained mechanically, even if there is total brain-death.
What is not at issue here is organ harvesting from living donors because there is no question as to their status. They are, by definition, alive. The main purpose of this paper is to show that by exploring the medical and Buddhist views of death, looking at the changing medical practices in harvesting organs and tissue from brain-dead donors and non-heart-beating donors (NHBD) and the Buddhist commentarial reflections on such, it is possible to tease out generalised Buddhist criteria for organ harvesting directives. There are many issues that we are confronted with in contemporary society where is not possible to say definitively what the Buddhist position is on the subject. For one, modern technologies have led to unique situations that did not exist at the time of the Buddha.
"The ancient monastic texts reveal that the Buddha resolved problematic matters on a case-by-case basis as new situations arose...the treatments described are not those of modern medicine, nor are the problems they raise identical in all respects. Given the primitive technology, for example, certain questions that have arisen today could scarcely be imagined. Nevertheless, we are not entirely bereft of guidance in the ancient sources, and although the circumstances today may be new, the moral issues that arise often turn out to be similar in principle."2
As well, having definitive Buddhist positions to complex issues is hindered by the fact that there are many different philosophical schools of Buddhist thought, and different Buddhist traditions that have arisen from both the existence of these schools and from the influence of the various cultures into which Buddhism has been assimilated.
"Since Buddhism is an amorphous movement with no clear hierarchy or locus of authority, it is difficult to make authoritative statements of the kind "The Buddhist view on issue x is..." without qualificatrion. Lay Buddhusts typically turn to their clergy for religious and moral guidance, and these in turn base their opinions mainly on canonical scriptures... Despite the variety of Buddhist schools and sects, however, it does make sense to speak of a "Buddhist view" at least as far as our present purposes are concerned. There is a good deal of consistency amongst the major schools in the field of ethics, both in terms of the dominant pattern of reasoning employed and in the conclusions reached on specific issues. It therefore seems fair to speak of a "mainstream tradition," a term which here denotes the common moral core which can be extracted from the different movements, schools and sects."2
The same applies to this exploration. As difficult as it is to pin down a specific Buddhist answer to the complicated question of whether the harvesting of organs can fit into Buddhist practice and ethics or not, specifically looking at how Tantric Buddhist sources address death and the body will help us extract principles that can help inform what, in general, might be the Tantric perspective on harvesting the human body for organs and tissue. Tantric Buddhism, as a psycho-physiological spiritual system of mental development, is most useful here because of its heavy emphasis on analysing, replicating and manipulating the death process. It is also of great interest to see how the Tantric perspective relates to the medical models of harvesting, which are based on the scientific methodology for determining death.
Tantric Buddhist view of the body
The body as the indispensable basis for enlightenment
Often Buddhism is accused of neglecting the needs of the body, and even of abusing it, in the hopes of achieving spiritual attainments. The cause of this misunderstanding comes from Buddhism being essentially an ascetic tradition. A crucial part of the life story of Buddhism's mendicant founder before becoming enlightened are the extreme mortifications in which he engaged. Although he gave up such practices in the extreme, they still played a great part in his development of perfect concentration and paved a great deal of the way to the doors of liberation and omniscience. A large membership of the Buddhist religion are practitioners who engage in ongoing ascetic practices, such as celibacy, daily fasting, not touching money and wearing simple clothing, to name a few. There are even thirteen extra ascetic practices that a monk can engage in, such as living entirely outdoors only using a tree as shelter and never lying horizontally, which would necessitate sleeping upright. These are not outdated practices only done during the time of the Buddha. Modern, long-term retreatants in the Tibetan tradition often do not lie down during the course of their retreat, and spend all of their time in a box. Retreat manuals advise the meditator to refrain from stretching the legs out, although this admonishment is sometimes used as twilight language referring to the avoidance of mental distraction in general during retreat. Even a householder Buddhist, or a non-Buddhist, who receives meditation instruction will be advised to temporarily engage in the mild-asceticism of putting mind first during the course of the session by ignoring the innumerable calls from the body to address aches and pains through movement. Such a lack of movement also can also be criticised by modern medicine as a contributing factor to the development of physical problems such as deep vein thrombosis, and to be sure, there are many modern examples of yogis, such as the incredible Tibetan master Dilgo Kyentse Rinpoche, being unable to walk after years of retreat. Be this as it may, the ascetic practices of the monastic and the meditator clearly show an emphasis on depriving the body of normal leisure to assist in the strengthening of the mind. The result is a sweeping generalisation of Buddhism being a body-denying practice. An extreme example of how Buddhism's view on the place of the body in relation to spiritual practice is seen by others, we can look at how Pope John-Paul II very neatly and categorically sums up Buddhist practice in his book "Crossing the Threshold of Hope":
The "enlightenment" experienced by Buddha comes down to the conviction that the world is bad, that it is the source of evil and of suffering for man. To liberate oneself from this evil, one must free oneself from this world, necessitating a break with the ties that join us to external realities existing in our human nature, in our psyche, in our bodies. 3
Although not a very accurate barometer on the common views held by modern society, the Pope and his views surely influence millions of religious followers. Another misinterpretation of the Buddhist practitioner's relationship with the body can even be seen in pop-culture. A recent re-make of a song by the grunge band "Nirvana" has the vocalists telling us that "Nirvana means freedom from suffering...and the external world." Associating Buddhism with the goal of transcending the body (or ‘the world’ as synonymous with all things external to mind) may be traced to seeing no distinction between Buddhism and other Indian religions, such as Hinduism and Jainism, which do indeed emphasize the hindrance the body is to practice. The Jain practice of religious fasting to hasten the sloughing off of form, and Hindu stories abound of Yogis losing awareness of (or even , while in trance, entirely leaving behind) their bodies, both are examples of viewing the body as something to go beyond. The Buddhist Tantric perspective is, however, very different. This is shown in the following couplet by the eighth century Mahasiddha Saraha:
“Saraha says: It seems to me for Jains there is no freedom: the body deprived of the real only gains isolation.
The commentary explains Saraha here is mocking the Jain concern with transcending the body; as a tantrika, he believes that it is only within the body that liberation can be found; as the Hevajra Tantra (2:2, 35) remarks, "Without a body, wherefore bliss? One cannot then speak of bliss." 4
Among other texts, The Lam-Rim Chenmo by Lama Tsong Khapa makes it abundantly clear that the importance of the precious human rebirth, precious even beyond celestial forms and beings in the formless realms, is that it is only from such a form that one can achieve full enlightenment. From the Tantric Buddhist perspective, the ordinary body is manipulated and transformed in order to cause psychic experiences which lead to bliss and realisations. Although the Tantric psycho-physiological system will be explained in greater detail in the next section, here are some highlights of the scope Tantric practise, which starts off with gross and subtle form and which yields great results:
"With the completion process yogic practices, the yogin was said to encounter the transformation of the ordinary winds, channels, elements, fluids, and letters that constitututed his subtle body (vajrakaya). In particular, the winds associated with the ordinary physiological activities, known as the "karmic winds" (karmavayu), would be guided into the central channel and thereby transformed into the gnostic wind (jnanavayu), so that the varieties and attributes of gnosis envisioned by Buddhists would become attained through these yogic practices...with respect to the primary goal...the yogin was said to observe directly in a controlled manner the experiences of the dissolution of the elements, which unfold in an uncontrolled experience for those at the point of death...The completion process is said to purify death, through the union of phenomenal appearance and emptiness." 5
Not only is the body in general used in Tantric exercises to trigger special experiences, the process of death is of particular significance in seeking spiritual achievement. Again, in order to attain bliss and insight,
"a yogi seeks to cause these winds in their coarse and subtle forms to dissolve into the very subtle life-bearing wind at the heart. This yoga mirrors a similar process that occurs at death and involves concentration on the channels and channel-centres inside the body." 6
To engage in an exploration of death using Tantric literature is sensible because, as shown in the above passages, the process of death holds great importance to the tantrika, an ordained or lay-person practicing the esoteric methods of the Diamond Vehicle of Buddhism (Skt: Vajrayana). Such emphasis has led to a very sophisticated analysis of the stages of dying. The Tantric perspective is unique in seeing death as both an objective event, one that can be observed by others, as well as s subjective event with predictable components. In Tantric practise not only are gross and the subtle aspects of the death process incorporated in daily meditation and visualisation practices, which His Holiness the Dalai Lama enjoys joking about when he mentions that he dies and is reborn several times each morning and evening, but also the practitioner aims to enter consciously (even wilfully) into the actual process of death and its stages used as "grist for the mill" in the achievement of realisations. The ultimate goal for the Tantric Buddhist is liberation from cyclic existence and the achievement of the omniscience and unending compassion of a Fully Enlightened Buddha. This is the aim of every Buddhist practice, from the Bodhisattvayana (Skt: “Awakening Mind Vehicle”; sometimes called Mahayana, Skt: “Great Vehicle,” referring to the Sanskrit lineage) perspective, to which the Vajrayana belongs. This includes those practices at issue here: those which represent and manipulate the death process.
"Buddhist tantra...is aimed at stopping death..and transforming [it] into Buddhahood. This is done through a series of yogas that are modelled on the process of death...until the yogi gains such control over them that he or she is no longer subject to dying. Since these yogas are based on simulating death, it is important for the yogi to know how humans die - the stages of death and the physiological reasons behind them." 6
Tantra is an esoteric tradition. It is important to recognise this. The breaking of its secrecy has been blamed for the degeneration of the Dharma both in India and Tibet. In modern times the accessibility of Tantra is apparent both in bookstores and libraries, as well as in temples. The screening-process for involvement in Tantra has changed, for better and for worse. Someone might get involved in Tantra prematurely, without the basis of ethical discipline or even a basic understanding of the teachings of the Buddha. Alternatively, the colourful world of Tantra can be a way to draw someone towards practices that they otherwise would not have exposure to, and which could benefit their mind, and by extension, benefit those they come into contact with. There is a parallel in the wide dissemination of Jewish mysticism in the kabbalah movement. The benefit of releasing some of the secret information found in esoteric practices is that this information, which might not be found elsewhere, can be of great benefit in that it uniquely informs current, everyday situations. Particularly, in the case of exploring the process of dying from the Tantric perspective, such an elaborate description of the gross and subtle, and the physiological and psychological aspects of death, can help both those who are dying and those who are caring for the dying. For our specific purposes here, we will look at how the Tantric perspective on death might help inform decision making around the harvesting of tissue and organs from humans, an area usually reserved for the medical sciences.
The body free of mind as mere composite of elements
Unlike in Chinese and Japanese Buddhist cultures, where the integrity of the body is revered and required as part of the process of the person transforming into an ancestor, Tantric Buddhist culture sees the corpse as matter only. Non-Tantric traditions of Buddhism, both Mahayana and non-Mahayana, also share this feeling:
"Followers of Theravada and Japanese Zen emphasized that...the body is merely a collection of disposable parts that has no usefulness after death....They believed that a person's consciousness leaves the body at the time of death, so there is no arm in touch, washing or cutting the body." 7
The corpse is treated with the due respect of having been the vessel for the departed mind, but it is no longer connected to the consciousness of the dead and thus serves no remaining purpose. As a result, traditionally in Tibet, a culture based on the principles of Tantric Buddhism, a corpse is disposed of in one of two ways: cremation or sky-burial. There are practical reasons for both, because of the environment in Tibet, but the sky-burial is particularly significant in transforming the mundane act of the disposal of a cadaver into a religious event. The sky-burial involves cutting the body into pieces on a mountaintop, reducing the pieces through pounding and mixing them with flour before finally feeding the mixture to scavenger animals, such as vultures.
“Sky burial takes place after a religious specialist (lama) with a special talent for divination determines that the consciousness of the deceased has left the corpse and after the prescribed prayers, readings, and rituals have been performed. For Tibetans, to dismember the corpse and distribute it to birds and wild animals is not savage, but a deeply meaningful, spiritual act. The ritual not only helps bring closure to human relationships, but also benefits the deceased through the giving of food to numerous living beings. Because of the difficulty of burial in the frozen Tibetan soil and the dearth of firewood for cremation, distributing parts of the corpse in a final act of generosity is not considered macabre but rather a symbol of the dissolution that awaits all living things at death… sky burial is regarded as a virtuous solution to a practical dilemma.”2
Two Buddhist principles are apparent in the Tibetan practise of disposal of the body. Detachment from form and the loved one arises from seeing the body in a dramatic display of its composite nature and being an empty vessel no longer housing the departed’s mind, and the practise of generosity is performed by giving as food that which all beings consider to be most precious: the body. This Tantric view of, and approach to, the body free of mind will greatly influence our pending exploration of organ harvesting.
Tantric Buddhist View of the Death Process
In extracting the pith aspects of the dying process from the Tantric Buddhist perspective, we will concentrate mainly on commentaries to the Guhyasamaya Tantra (Skt: "Secret Communion"; Tib: dPal gsang-ba ‘dus-pa’i rgyud.) This text and practise is from the class of Highest Yoga Tantras, and many sources point to it as being the most crucial and earliest of the Tantric texts.
“Guhyasamaja is referred to as ‘the supreme and king of all Tantras,’…the existence of [which] is…essential for the survival of the Tantras…and [which] without relying upon…there is no way to attain supreme enlightenment.”8
Although its authorship is debated and is sometimes seen as a collection with multiple contributors, one of the founders of the Yogacara (Skt; Mind-only) school of Buddhist philosophy, the Fourth Century scholar-monk Arya Asanga, is generally credited with penning the work. The commentaries cited here are both by Yangchen Gawai Lodoe, “an eminent saint scholar of eighteenth century Tibet,” 8 and whose full titles are “Lamp Thoroughly Illuminating the Presentation of the Three basic Bodies – Death, Intermediate State and Rebirth”6 and “An Eloquent Presentation – A Port of Entry for the Fortunate Ones into the paths and Grounds of Mantra According to the Glorious Guhyasamaja of the Arya (Nagarjuna) Tradition.” 8
Generally speaking, the Tantric presentation on death revolves around the body and mind as mapped out according to the basic molecular elements of earth and water, the excited elements referred to as ‘fire,’ and a system of channels, winds and drops. The parts of the body comprised of the molecular elements of earth and water do not require mention, but not as obvious is the fact that, in this system, the “fire constituent [refers to] the warmth that maintains the body.”6 As they are terms foreign to our modern scientific jargon, the channels, winds and drops deserve expansion.
“Wind refers to currents of air or energy that perform the physical functions such as swallowing and serve as ‘mounts’ of consciousness. The channels are the veins, arteries, ducts, nerve pathways and so forth, through which flow blood, lymph, bile, wind and so on. The drops are essential fluids that course through the channels.” 6
Already we can see that the Tantric model is unique. With the very mention of ‘energy’ and ‘consciousness’ we depart from our familiar medical/scientific approach to the human as reducible to matter and electricity. This foreshadows some vastly different aspects in the traditions of Tantric Buddhism and medical science in their explanations of the process of death, and thus inevitable differences as well in the decisions and activities that are borne from these explanations.
Having laid out the context of the human being as a combination of matter, subtle matter and consciousness, we can now look at what occurs amidst this collection during the process of death.
'The process of death involves eight stages of dissolution of the elements. Initially, our earth element dissolves into the water element; then, the water into the fire element; the fire into the wind element; the wind into the element of consciousness; the consciousness into the mind of white appearance; the mind of white appearance into the mind of radiant red increase; the mind of radiant red increase into the mind of black near-attainment and subsequently the mind of the clear light of death dawns." 8
The dissolutions of the elements into one another does not actually mean that one dissolves into the other. This fact is made obvious by the simple logic that the elements actually contadict each other and cannot abide in the same location simultaneously. What occurs is the strength of the dissolving element to support that aspect of the body reduces and that of the next element increases, resulting in external and internal signs. The external signs are changes in the observable body, and the internal signs are visions experienced by the dying person. Thus, the process of death is both a physiological and a psychological one.
"The physiology of death revolves around changes in the winds, channels and drops. Psychologically, due to the fact that consciousness of varying grossness and subtlety depend on the winds like a rider on a horse, their dissolving or loss of ability to serve as a basis of consciousness includes radical changes in conscious experience."6
Most pivotal in the process of death, and for our purposes here as well, is determining what is considered the end of the death process. As with the preceding steps in the process of death, there is both a mental and physical aspect to the end-stage. The final stage of the dissolutions, as mentioned above, is the mind of clear light. His Holiness the Dalai Lama also refers to this stage and state of mind as the “final subtle mind…of death,”6 clearly showing that the Tantric Buddhist outlook holds death as also being an experiential one, rather than merely a series of catastrophic failures in the operating systems of a living organism. His Holiness describes the occurrences during the very last moments of life:
“The warmth finally gathers at the heart, from which the consciousness exits. Those particles of matter, of combined semen and blood, into which the consciousness initially entered in the mother’s womb at the beginning of the life, become the centre of the heart; and from that very same point the consciousness ultimately departs at death. Immediately thereupon, the intermediate state begins...” 6
Thus, in addition to the appearance clear light mind, there is the movement of heat and the essential drops as final physical events preceding death. There are also physical signs which follow death, after the mind and body have separated. “When the body begins to emit a foul odor, it is a sure sign that the consciousness is no longer present. In some cases, a…drop will appear at the area of the nostrils.” 7
Most sources indicate the appearance of a white drop at the male sexual organ and/or a red drop at the nostril as the strongest signs that the mind has left the body.
To summarize, from the Tantric Buddhist perspective“…it is the experience of clear light that is the factor that determines the death of an individual” 7 and death is final when the mind leaves the body.
Medical Science’s View of Death
"...the modern era has involved an exclusion or repression of death." 11
The West in general, and the world of medical science in particular, are renowned for being death-denying in view and in practice. We used hushed tones and special vernacular when broaching the subject, and medical practitioners have great difficulty talking to families about the reality of death and often prefer to offer almost limitless life-sustaining heroics to avoid the subject. When we say “life-sustaining,” we could just as easily say “death-delaying” in futile cases where recovery is statistically low. Secularised death is seen philosophically as the absolute end of the body, mind and the person. Even when autonomic systems are kept functioning artificially, the predominant view holds that “…the person no longer ‘exists’ because of the loss of total brain function.” 12 In the hospital environment we can easily get the impression that death is seen as being inherently bad in being opposed to life and the final result of the failure to cure disease. Although consciously holding to the position of "the intrinsic badness of death" is very difficult when we know of cases where "death is welcomed and desired (that is, good)...by an autonomous patient, and where a peaceful death is clearly in the interest of the patient,"13 it still plays out operationally in the field when dealing with dying patients and their families. The frequency of futile treatment in critical and chronic care settings are a testament to this fact. In the service of sustaining life, all other aspects of the purpose of care, and the needs of the person themselves, are made secondary. Although both the medical tradition and Buddhism hold life in the highest regard, that death is held at bay at all costs may be a misunderstanding of the ethical principle of the sanctity of life. Although ideally seen in logical relation to other ethical principles,
"…[one] version of the sanctity of life principle...holds that life as such is valuable to such an extent and in such a way that, in life and death situations, preventing the death of the patient is of overriding importance [which can lead to futile treatment and to the jeopardy of the patients' well-being and autonomy, two other ethical principles]... What matters according to the sanctity of life principle, it seems, is mere biological existence. The focus is solely on whether or not a person's body is biologically alive or not. The focus is not on what has been termed the biographical life of the person whose body it is...[meaning] the life as experienced from within." 13
Even the current clinical definition of death used at the bed-side in Intensive Care Units points to the precedence given to the body, rather than the person, as determining the status of human life. When it is held that "death is an irreversible biological event that consists of permanent cessation of the critical functions of the organism as a whole," 10 the human is an organism rather than living being with a conscious experience. Despite our slant towards a secularised (free of spiritual principles which include the inner life and the continuation of mind after biological death) and materialistic approach towards death, the very existence of a system of ethics, and the debates that emerge from such important issues as those that arise around life and death (the most common and heated being those concerning abortion and euthanasia) shows that we have set ourselves up to explore reality together. We know that we need each other to make the wisest, or most beneficial, decisions. We avoid death, but ultimately we must deal with it and cannot ignore it indefinitely. New technologies have forced us to deal with new medical circumstances that have led to a
"renewed attention towards death...[that] appears perhaps most clearly in relation to the care of death and dying in...palliative medicine and in the hospice movement, in the question of active and passive euthanasia and in the definition of the brain death criteria related to the emergence of the new transplant surgery." 11
However, with the advent of increasingly subtle and powerful means of perceiving and correcting problems in the human organism,
"in a way the very purpose of health care seems to be to fight against death, inasmuch as it aim often is to prevent death or to postpone it...[and, as a result,] sometimes modern high-tech biomedicine is accused of ignoring the inescapability of death.” 14
On the other hand, it is heartening that although we, individually and as a society, tend towards hiding and avoiding even the topic of death, it is safe to say that "...when concerned with death from 'natural causes' virtually everyone agrees that...living longer does not always mean having a better life." 13
Additionally, although we can point to a predominance of relating to death with avoidance and fear, stemming from a materialistic (or biological-centered) and even nihilistic perspective towards this phenomenon, there are secular thinkers, practitioners and movements, such as those found in ethics and holistic health, who inject the debate with a more well-rounded outlook which sees the person as a interconnected combination of mind, body, non-corporeal energy (which is seen as not different from mind in Buddhism, but which is often referred to as spirit or soul by others) and relationship with the community. Here are a few examples:
“…death of an individual extends beyond the physical changes of the body and into a changing of society’s treatment of that individual and his or her corpse.” 15
”…the concept of death is not purely a biological one: death is not only a biological condition. It may be viewed as a cessation of experience, the departure of the soul from the body, or a passage into ‘another mode of existence.’” 15a
Harvesting tissue and organs from the human body
Medical criteria
“Any criteria for determining death…would have to carry not only strong clinical weight, but also be significant in its moral symbolism. This is because death alters the relationship between an individual and society, and shifts the line of what may be acceptable behaviour and action upon that individual’s body.” 15
The determination of death is the key component in the issue of organ harvesting because “for organ donation to be successful…the process of harvesting the organs must begin immediately after clinical death…”7 This requirement leads to a great sense of urgency to acquire the working organs in a timely manner. To give a sense of the haste required to maintain organ viability, “the interval between arrest and a declaration of death is as short as two minutes in Pittsburgh…or as long as five to ten minutes in most of Europe.” 17 To be sure, this anxiety over viable organ procurement is often blamed for the ever-changing definition of death, to the point where critics of both cardiac and brain-centered criteria for death determination accuse practitioners of removing organs from living donors, thus causing their death.
What is this ‘clinical death’ then? Rather than describing an end to either brain or cardiac activity, the term ‘clinical death,’ or
"somatic death...([which is] also known as…physical death, body death)...is characterized by the discontinuance of cardiac activity and respiration, and eventually leads to the death of all body cells from lack of oxygen, although for approximately six minutes after somatic death—a period referred to as clinical death—a person whose vital organs have not been damaged may be revived. However, achievements of modern biomedical technology have enabled the physician to artificially maintain critical functions for indefinite periods." 18
Although “in the early days of transplantation, organs were removed from recently deceased donors who were declared dead when their hearts stopped beating,” 15 in the context of modern medical science, brain-death has become the standard, crucial factor in ascertaining suitability for harvesting the human body. The definition of "brain death is the complete and irreversible loss of cerebral and brain stem function.” 10 Unlike both the cardiovascular and pulmonary systems, which can be restarted, restored and maintained interventionally, the varying degrees of brain death are irreversible. Therefore, there essentially is a one-way reliance of the cardiopulmonary aggregation on brain function and thus “in most countries and most situations, brain death is considered to be equivalent to cardiopulmonary death." 19 One reason for the favouring of brain-centered criteria in determining death is that irreversibility is easier to establish. Irreversibility, or the criterion of "’strong irreversibility’ (death beyond the reach of resuscitative efforts to restore life),” 17 is considered essential to leave no doubt that the death is not caused by the organ procurement and therefore removes the physician’s culpability for causing a donor’s death. Those who question cardiac-centered criteria in determining death point to the difficulty in ascertaining irreversibility. They
“wonder…whether the use of a cardiac standard is appropriate for use in the procurement of organs. Since…if the patient were treated, restoration of spontaneous circulation could occur, critics have questioned whether death is being declared prematurely. They argue that the waiting time between heart-stoppage and the initiation of the organ removal process is insufficient to ensure that the donor’s heart has irreversibly stopped and cannot ever be restarted. They argue that because the heart’s function may be restored for a long time after cardiac arrest, the brain should be the sentinel organ for death determination. After all, irreversible cessation of brain function occurs in a shorter time frame…” 15
The determination of brain death might seem nebulous due to the organ’s complexities and as yet unsolved mysteries concerning its functioning, however, based on vital contingencies, it is indeed measurable.
"The diagnosis of brain death can usually be made clinically, at the bed side. The criteria for brain death require certain conditions regarding the clinical setting...: the underlying cause is understood; and confounding from drug intoxication or poisoning, metabolic derangements, and hypothermia have been ruled out...also required is evidence of absence of brain function on neurologic examination...demonstrat[ing] coma, no cerebral response to external stimuli, and absent brain stem function." 19
There also is non-neurologic, physical testing methodology for measuring brain-death:
"Tests demonstrating absent blood flow to the brain are generally accepted as establishing whole brain death; it is axiomatic that the brain without a blood supply is dead... Brain death is usually accompanied by elevated intracranial pressure... When this exceeds systemic arterial pressure, there is no cerebral blood flow." 19
Brain-death is not a judgement call made on the part of the physician. “Determinations of death are not arbitrary; they are more or less precise determinations of an organism's state based upon valid concepts skilfully deployed by physicians in the interests of patients.” 17 In accepting brain-death as the main requisite for organ harvesting, as opposed to cardiac-death, the organs can be kept viable longer by keeping them fed with oxygenated blood through sustaining the cardio-pulmonary system mechanically. This allows for valuable decision-making and transplant preparation time. The haste seen in cardiac-death centered criteria scenarios, due to the small window of viability, is removed. Although there are a great many arguments against the brain-death centered criteria model, many of which we will see when considering the Buddhist perspective, it can be praised for allowing precious time for both medical practitioners and bereaved families to move to their respective next phase in relating to the deceased.
Buddhist criteria
The main concern for the Buddhist in determining death is the presence or absence of mind. With the exception of Buddhist cultures which maintain that the integrity of the body is necessary for the departed to transform into an ancestor, such as is the case in Japan and China, organ donation after it has been established that the mind has left the body is seen as a positive activity and, it can be said, even encouraged in support of the practices of generosity and the accumulation of merit. In Buddhist practice in general there is no question as to the benefit of offering any part of one’s body, while living or dead. Although
"there is no official consensus among Buddhist communities as to the determination of death or the permissibility of organ donation...most Buddhist communities permit organ donation as a matter of individual conscience and consider it an act of compassion and generosity that can serve as a condition for realizing nirvana." 16
In Tantric Buddhism the practice of Chod (Tib: “Cutting [Attachment to the Body]”) is a tool for reducing the obsessive clinging the mind has to our material form by imagining the offering of one’s body, after the mind has exited the crown of the head and has transformed into a deity, as food to unfortunate beings in the lower realms. Chod is modelled after the actions of Shakyamuni Buddha in a former life when he gave his body to a hungry tigress who, out of desperate hunger, was about to eat her cubs. Stories of such sacrifices abound in Buddhist lore. The Indian scholar-saint Atisha meditated in a cave for twelve years with no apparent results. It wasn’t until, out of compassion, he used a piece of his own flesh to coax maggots out of the festering wound of a sick dog, that he achieved a vision of the future Buddha Maitreya. It is an understatement to say that "Buddhists of various backgrounds...support...the idea of donating one's vital organs to save someone's life as consistent with Buddhist values of generosity and loving-kindness." 7
Unlike in the world of modern medicine, it is the cardiac-centered criteria that seems most suitable in facilitating the transference of consciousness, the chief Buddhist concern at death-time. One specialist in both medical and Buddhist practice concludes that “as long as there is heat in the body, and a pulse and respiration, or any reflexes, it is best to avoid disturbing the patient, in case the consciousness is present.” 7 One attorney and Zen scholar shows the primary issues for the Buddhist practitioner around post-mortem use of the body to be the gifting of any anatomical part of the body (organs, tissue, corneas) in general or specifically for research purposes, the performance of an autopsy or embalming, and disposal by burial or cremation. He offers a sample health care proxy which considers each of the above options, and for each great care is taken particularly to indicate how soon after cardiac death such events are allowed to take place according to the practitioner's advance directives. 9 If organ harvesting is hindered by a time-interval required by the wait for a sign or event to establish the absence of mind, “unless a person is extremely well-trained, the consciousness is likely to be disturbed by the surgery and it may be best to avoid organ transplantation.” 7
There is also much support for the Buddhist model of death determination following cardiac-centered criteria as a direct result of rejecting those based on brain death-centered criteria.
"Some Buddhist arguments...emphasize the body's development from an original mass, such that no particular organ like the brain should take priority in determining death. Given this lack of hierarchy, some would argue that the dissipation of heat after the last breath favours criteria based upon the cessation of cardio-pulmonary activity rather than brain-death criteria." 16
Even with the onset of any degree of brain-death, if the body is alive artificially by way of cardio-pulmonary mechanical heroics, it is widely held in Buddhism that the mind will not leave the body. Although there is much scriptural and commentarial support for this, perhaps this is too bold a statement. It may be more mild to say that “if the heart has not stopped beating and the bodily heat has not yet disappeared, there is reason to believe that the consciousness may still be present in the body.” 7 A patient in a persistent vegetative state (PVS) still meets the “minimum requirement…for assuming the existence of a person…[which] is the existence of consciousness.” 7 As a result,
"some concern does exist among Buddhists concerning the criterion of brain-stem death, to which organ transplantation from cadavers is closely linked. To declare death on the basis of this criterion seems premature to some, and not in keeping with Buddhist scriptural teachings concerning the point when death occurs. The ancient sources state that death occurs when three things - vitality, heat, and consciousness - leave the body." 2
Dividing that which is required to leave the body in the valid determination of death into three does not negate our strong premise that the main component in defining death is the departure of mind, and that Buddhists can easily rely on cardiac-centered criteria. Unlike with brain-death, cardiac death necessarily prompts the departure of mind, although some time might elapse. However, with the departure of mind, heat and vitality cannot remain.
Looking at cardiac-centered criteria as being in opposition to brain-death centered criteria gives preference to viewing death as “…the death of the whole psycho-spiritual organism rather than any one of its parts." 2 The following statement by the same author, one who is admirable in his active work in bridging Buddhism and bioethics, gives us reason to pause:
"...since the traditional Buddhist criteria for determining death are biological in nature Buddhism would reject any definition of death that focused solely on the loss of consciousness or the higher brain functions controlled by the neocortex."2
This statement is true insofar as the biological status of the human organism is the only ordinary means we have of determining the presence or absence of mind, since certain signs and symptoms give indication of the latter, which is of the utmost importance. However, declaring that Buddhist determine death using biology might lead one to believe that Buddhists rely on the functionality of the body alone. This smacks of materialism contrary to the Buddhist emphasis on experience and consciousness, in that it does not take into account that it is the status of mind that actually defines death. Any bodily state used to determine death is simply a way of perceiving indirectly what is happening with the mind, a non-physical and non-visible phenomenon. Again, the Buddhist stance that mind is the key factor in establishing death clearly informs decision-making around invasive activities, since, “from a Tibetan Buddhist perspective…any intervention before...the experience of clear light, especially in the case of a skilled meditation practitioner, is inadvisable.” 7
As mentioned earlier, there are objective signs that are agreed upon in the Tantric world as indicating the departure of mind, such as the appearance of fluid at orifices or the smell of decay. There are additional ways that traditionally are accepted as valid methods of establishing that the consciousness has left the body. Earlier we saw, in the sky-burial description, that a religious with expertise in divination has the ability to determine the mind’s departure. However, it would be more accurate to say that someone with an appropriate level of clairvoyance can perceive directly the mind which has moved into the Bardo (Tib: “In-between State”), referring to the state of existence between death and rebirth. Lastly, there is the Tantric practice of Phowa (Tib: “Transference of Consciousness”) which, if performed by a qualified master (who can either be the patient themselves or one practicing the ritual for the benefit of the patient), can act as the final push for the mind’s exit. In such a case, the exit would also be auspicious, meaning one that occurs through an upper orifice or through the crown of the head and necessarily leading to a fortunate rebirth. Any of these means of determining the departure of mind, signs, clairvoyant pronouncement or ritual, would, in general, satisfy the Tantric Buddhist that the appropriate time for organ procurement has arrived. In the absence of these, standard best practice with Buddhist patients suggests that "as far as possible, it is best to leave the body alone and in quietude for two to three days after the pulse and breathing have stopped, or until the corpse begins to decompose.”7 To harken back to the earlier discussion regarding the NHBD (non-heart-beating-donor), it is clear in the Buddhist approach that there is a great concern with how soon after cardiac death the body is manipulated in any way, especially invasively with organ procurement or autopsy, if cardiac-centered criteria dominate. There is no predictable schedule for the departure of mind. It can happen before three days pass, but it does not occur after three days with an ordinary being. The only exception to this principle is in the case of the Yogi (Skt: “hermit meditator”) who can remain in a state of meditation for more than a week with cardio-pulmonary vital signs absent. In such a case the only remaining observable signs are heat in the chest and freedom from decay and odour. The mind has not left, and any invasive activity would be inappropriate.
Interestingly, there also exists scientific research that reinforces both the cardiac-based criteria model and the Buddhist perspective which both favour the view that the brain-dead patient is not deceased:
“Studies of brain dead patients, some of whom have been kept "alive" for long periods, suggest that in fact the brain is not essential to many aspects of organismal integration and that bodily integration may not be best thought of as localized to a particular organ. If this is so, the notion of brain-mediated bodily integration does not offer a reason to suppose that brain dead patients are really dead.”17
Based on many sources, it is safe to say that the Buddhist stance leans more towards time elapsed after cardiac death as the crucial factor to ensure that the consciousness has left, and following this is the only appropriate time to perform invasive activities with the corpse because there is no longer a danger of disturbing transmigration. To say that the departure of mind is the point-of-no-return in the death process, and the mind does not leave until after multi-organ failure which is caused by, or accompanies, cardiac death is in line with the scientific definition of death as "an irreversible, biological event that consists of permanent cessation of the critical functions of the organism as a whole."10 Because the mind can remain in the body of the patient experiencing brain-death with cardio-pulmonary assistance, it is the multi-organ failure brought about by cardiac death which, despite a varying time-lag, necessarily brings about the movement of the mind into the in-between state.
Conclusion
We can now say assuredly that the Buddhist stance on organ harvesting is within the fine balance of two issues: offering body parts as an encouraged and powerful practice of generosity which not only helps others but helps one’s own spiritual development, and ensuring that the transmigration of the mind at death is not disturbed. We will also take for granted, based on the Buddhist proscription against taking life, that any activity that causes the premature death of a patient, not by withdrawal of treatment but by invasive procedures, is out of the question. Although modern medicine has moved away from cardiac-centered criteria for determining death, the long-established usage of this model can still be very useful to its proponents. There are many indications that this model is more representative of what a Buddhist needs at death time, as opposed to the brain-death criteria model of death determination. Simply, our Tantric sources require the gathering of heat at the heart before the departure of consciousness, which mutually contradicts the scenario of determining death based on loss of brain activity with an otherwise functioning body, mechanically supported or not. In such a case, the heat of the body remains and therefore the mind has not departed. Some might argue that the example of the Tantric yogi in death meditation is counter to the cardiac-centered criteria model of death determination because, despite the yogi being considered not-dead, the cardio-pulmonary signs have ceased. This can be refuted by considering that the Buddhist model of cardiac-centered criteria for death determination is unique in having additional requirements accompanying cardiac-pulmonary failure to determine death. These are: heat departing the body; and either the appearance of the prescribed biological signs (orifice drops, odor of decay), or the defined time-period after cardiac death elapsing (2-3 days), or particular spiritual events (ritual performance or clairvoyant pronouncement of mind departure). Care must be given to these idiosyncrasies when using the cardiac-centered criteria model of death determination in the context of organ harvesting with the Buddhist. We see these needs built into the contemporary Buddhist proxies which give full autonomy to the decision maker who initiates the advance directives of post-mortem care, which can be the patient themselves or their representative. These documents are a very helpful resource as they clearly tackle not only whether or not certain post-mortem invasive procedures are allowable by the Buddhist, but also when these activities can appropriately take place after cardiac-death.
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