A Principle of Justice in Palliative Care

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

Feb. 2010

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

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

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

Dependency on others

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

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

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

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

Decision-making

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

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

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

Is palliative care a valid subcategory of health care?

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

Endnotes

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

Caring for the Dying Buddhist, and the Buddhist Caring for the Dying

Caring for the Dying Buddhist,
and the Buddhist Caring for the Dying

by Sean Hillman
Religion Department
University of Toronto
April 2008

Introduction

Humans have always died. Many religious systems hold the view that the human life-span has been degenerating through the ages. The Hebrew texts assign the earliest patriarchs with life spans over 900 years, and amazingly show an exponential decay curve after the flood leading to an equilibrium of seventy years of age after 20 generations. ^1 Both Hinduism and Buddhism refer to our current age as a degenerate one. The "Kali Yuga" is the final phase before the world system ends. In this age, morality has hit a low point and results in shorter life spans. In Buddhist cosmology, lifetimes are shorter in comparison to those during more pure ages, times very long ago (such as those during previous Buddhas) and also during times not as long ago (during the time of our current historical Buddha Shakyamuni and thereabouts). For example, "in the age when [the] human lifespan was 20,000 years, [Lord Buddha] had been a Brahmin disciple of the [previous] Buddha Kasyapa"^2 and five hundred years after Shakyamuni Buddha, the great scholar-saint Arya Nagarjuna is said in some sources to have lived for 700 years. From the earliest time in Buddhist history, Buddhist practice and teachings have spent a great deal of time addressing impermanence and death. "In the present aeon-ending Kali-yug, [Lord Buddha] saw that by the time human lifespan has decreased to less that one hundred years, and people are increasingly tormented by poverty and strife, they are better prepared to grasp the truths of impermanence and dependent arising, and more receptive to the teachings of spiritual liberation."^2 The above excerpt shows that recognizing the reality of impermanence is a necessary component in the process of becoming liberated. In cyclic existence, the most visceral experience of impermanence is death. The Buddha told His cousin and attendant Arya Ananda that a Buddha can live for an indefinite period of time, and yet He still manifested the appearance of passing away. The texts often point to this as one of the twelve particularly crucial deeds the Buddha performed for our benefit. If a fully realised being such as the Buddha passes away, how can we unenlightened hope to escape this? Although death and dying is a constant throughout the ages, what is perhaps unique to our current time is the phenomenon of Buddhists being cared for by non-Buddhists. We have the existence of different types of institutions and organisations that provide end-of-life care: free-standing hospices, hospice outreach programmes where care is provided in the dying person's own home, nursing and retirement homes, long-term care facilities, hospitals and so on. As well, we find growing numbers of examples of Buddhists caring for non-Buddhists at death-time. These two phenomena, non-Buddhists caring for dying Buddhists and Buddhists caring for the dying, lead to two specific and important areas of Buddhist social engagement: 1) educating palliative caregivers who have Buddhist clients about the unique needs of Buddhists at death time, and 2) Buddhists actively caring for the dying as a practice. The latter often includes not only front-line, hands-on palliative care delivery, but also the activities involved in building resources to increase and ensure equal opportunity access to palliative care for those who need it.

To put end-of-life care into a Buddhist context, first we will first look at the Buddhist philosophical understanding of death. Next, although there is often cultural variety in how Buddhists deal with death, teasing out some common Buddhist practices at death will demonstrate the sensitivities needed by non-Buddhists who care for Buddhists in multifaith care-delivery environments. Finally, the attitude and inner exercises used in a Buddhist approach to caregiving will show the practical application of Buddhist mental training in the context of palliative care usually kept private within the mind of a practitioner. These three explorations, hopefully, will not only give a glimpse into the world of palliative care given to, and given by, Buddhists, but also be useful in general to anyone concerned with preparing for their own death and helpful to anyone who cares for the dying and bereaved.

Buddhist philosophical understanding of death

The Buddhist view of death actually begins with birth. When a being is born, they begin to move towards death and, inevitably, move progressively through the experiences of the four sufferings of birth, sickness, old age and death. The Four Arya Truths, the main summary of the Buddha's teachings and the content of His first public lecture, establishes the reality of suffering as the starting point for entering into the Buddhist path. This First Noble Truth is not a morbid dwelling on suffering but is presented in conjunction with the other three: that there is a cause to this suffering, there is an end to this suffering and there is a cause to the end of this suffering. Seeing all four components of this paradigm instills hope that there is true relief, and motivates the spiritual aspirant to seek this freedom and to stop creating the causes of pain. The ultimate goal of practising Buddhism is freedom from suffering, and much more. The definition of a Buddha, a fully enlightened being, is a being free of all mental and physical suffering who is both omniscient, able to directly perceive all objects of knowledge, and possesses infinite compassion: the wish to remove all of the suffering of all beings. It is no accident that freedom from suffering and omniscience abide together in the mind of a Buddha. All sufferings come from ignorance. Generally, ignorance is a wrong understanding of reality which sees things as existing inherently and independently when in fact they exist interdependently. This root ignorance (a delusion itself) breeds more delusions which in turn bring about all wrong actions of body, speech and mind and result in suffering. Conversely, removing this ignorance ends the chain of cause and effect just mentioned: no ignorance means no delusions and the wrong actions they cause, and thus no suffering result. When applied to the actions of sentient beings, this chain of cause and effect is what is referred to as karma (Skt: “action”) and its manipulation is required for improving the quality of life. The logic of karma is that all happiness comes from virtuous actions of body, speech and mind, and all misery from non-virtuous actions from these same "three doors." From the Buddhist perspective, karma is totally changeable. That we can change our future by what we do now, and purify every negativity imprinted on our mind from past misdeeds, induces hope. It is the reasoning which shores up the view that each of us has the potential to become free from all suffering. It is of crucial importance to note that sufferings, including death, are not seen in Buddhist thought as a "punishment." Karma is not controlled by any one, human or divine, but rather our experiences are the mere ripening of past actions. Considering the seemingly cold and calculating nature of the natural law of karma, one may see a reasonable basis for feeling that oneself or others "deserve" what they are getting. To be sure, the etymological root of the word "deserve," from the Latin deservire meaning "to be worthy of," supports this.^3 However, the saying "they will get what they deserve" in modern colloquial usage, although in essence reinforces the reality and efficacy of cause and effect, usually has a negative connotation. It implies that the agent will suffer and, therefore, does not accurately represent the “like cause, like effect” aspect of karma. The agent also deserves happiness as a result of past positive actions! To defeat another modern misunderstanding, instant karma is generally nonexistent, despite the wonderful song by John Lennon. Although extremely positive and negative deeds can have ripening results immediately, such as those actions directed towards powerful objects (enlightened beings or one's parents), for the most part, actions ripen long after the fact, often many lifetimes later. The "why me?" syndrome comes from the fact that beings may not be able to trace what ripens now to a cause in this life. Despite this, through logic, we do have a natural sense of the cause. It makes good sense that poverty is a result of greed, separation from loved ones is the result of causing others to separate, and so on.

Death is the transition time where the mind leaves the body and moves onto the next life and must be seen in the context of karma and rebirth. The scriptures subdivide death into various types, as shown in Buddhaghosa's "Visuddhi Magga" (Pali: “Path of Purification”) where this prolific 5th Century Indian Buddhist commentator distinguishes between timely and untimely death:
"Timely death comes about with the exhaustion of merit, with the exhaustion of life potential (ayu), or with both. Untimely death comes about through kamma that interrupts [other, life-producing] kamma.
"Death through exhaustion of merit, here, refers to the death that comes about entirely through the finished ripening of [former] rebirth-producing kamma even when favourable conditions for prolonging the continuity of the life-potential may still be present. Death through exhaustion of life potential refers to the death that comes about through the exhaustion of the natural life potential of human beings, which amounts to only 100 years…
"Untimely death refers to the death of those whose continuity is interrupted by kamma capable of causing them to fall from their place [on a particular level of being] at that very moment…or for the death of those whose continuity is interrupted by attacks with weapons etc., due to previous kamma. All these are included under the [term] interruption of life faculty."^4

In addition to the division of death into types, the process of death itself is divided into stages which are determined by the sequential dissolution of the elements. As illustrated by the chart below, each elemental dissolution affects particular bodily functions, are accompanied by external signs and symptoms and internal visions that the dying person experiences. This happens long before clinical death and can a very useful measuring tool. For example, at the dissolution of the earth element, even if the dying person is safely supported by caregivers and bed-rails, they still have the experience of falling.
The importance of death in Buddhist practice is shown in the story of the Buddha Himself, an Indian Prince who lived 2500 years ago and who was inspired to entirely dedicate his life to becoming fully developed for the sake of others after seeing four sights: an old person, a corpse, a sick person, and a mendicant. Like for Prince Siddhartha, exposure to and contemplation of death prompts an urgent motivation for practising spiritual methods diligently and without delay. A practitioner ideally will prepare for death by contemplating it as often as possible because it is the most crucial time in one's life, since (due to karma), the last moment of one's mind in one life will determine what type of experience and existence one will have next. The inevitability of death is the great equaliser. Whether beautiful or ugly, poor or rich, all must die. It is even possible to see death as the ultimate challenge, showing how well one has prepared. Rather than a solemn and mournful event, with a worn-out body naturally comes the time to trade in the old ride for some new wheels. Normally we don’t wear old clothes because they no longer protect our body. Likewise, a broken body is no longer an effective basis for the mind. It must have a new support. This process of leaving the body is also an opportunity to practice. It is a means of purification since any suffering we have, as the experienced result of a former misdeed, is the burning off of some of our accumulated bad karma. Death is one of five events (along with sleeping, yawning, sneezing, and sexual orgasm) experienced by ordinary sentient beings where they naturally, without training, catch a glimpse of the Clear Light nature of mind. As such, the stages of dissolution at death, which are accompanied by changing states of consciousness including the arousal of the Clear Light Mind, are utilised by the Tantric meditator to develop accomplishments on the path to enlightenment. Such practices can be done long before death as well, as a practice in and of itself as well as a preparation for impending death.
"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
Death is a vital time where the difference between an ordinary person, a practitioner and a realised being is displayed. An ordinary person might enter into death out of awareness and terrified, however the practitioner at the very least has the conscious wish to not have this experience. The consciousness of both the practitioner and non-practitioner will linger in the body out of attachment. A high being, one who has achieved realisations of a certain level, will not only meditate at the time of death but also have the ability to consciously leave the body, as well as wilfully direct their rebirth. They also will linger in the body, but not out of attachment. This lingering of the mind in the body shows a distinguishing characteristic of the Buddhist exposition of death in relation to modern medicine. Clinical death is generally defined as vital signs being absent and, with the exception of determining brain-function for those on life-support, is the only thing required for a physician to note when pronouncing death. In the Buddhist exegesis the mind does not necessarily leave when vital signs are absent. Clinical death, although a sign of a particular phase in the process of death, is not actually death. The Tantric texts explain that when the mind leaves the body, actual death, a drop of blood comes from the nose and a drop of semen (for males) is emitted from the penis. Displaying the simple beauty of nature, these vital fluids coming together at conception coincide with the entrance of the consciousness into the womb, and their appearance at death indicates its departure.

Common Buddhist Practices at death

It is important to emphasize that what is taught by the Buddha and what is understood, or even accepted, by a Buddhist don't always match. Buddhism, as a practise of mental and emotional development that is based on logical reasoning and not a system of tenets, is a religion that promotes questioning and healthy skepticism. The Buddha encouraged His students to check out the teachings "as a metal-worker burns gold to remove impurities." In Buddhism, we find not a system of belief, but rather methods that bring about ever-increasing mental and emotional stages leading toward the direct realisations of reality and compassion. Everyone has the freedom to practise as they wish, so the ways that people’s personal practices manifest are quite diverse. Suffice to say, the overriding theme with death practices is to ensure a peaceful and virtuous state of mind for both the dying and everyone around them, including spiritual and health caregivers and the bereaved.
There are some religious practices that are applied, or encouraged, in all cultural forms of Buddhism and some that are done only in some traditions. Starting with those that are common to both the Southern and Northern schools of Buddhism, many practices at death are mental exercises and some of these, in spirit, are common to other faiths as well. Generating virtuous states of mind such as love and compassion can come from analytical contemplation or even the mere remembrance of such qualities and those who embody them. Purification practices can be performed inwardly as well with such practices as the Four Opponent Powers during which one engages in recognizing past mistakes, feels remorse, resolves to discontinue harm and applies a virtuous counter-action. The Northern school often uses visualisation and mantra recitation (Skt: “mind protection” in the form of mnemonic formulas) to purify as well. As it was for the Buddha, for any practitioner, one's own or other's illness can be used as an opportunity to generate empathy. Feeling such things as "may no one suffer like this," or “may I experience this suffering on their behalf” are powerful means to both strengthen concern for others and generate merit. The First Panchen Lama verbalised such feelings of exchange in his Guru Puja text (Skt: “Offering to the Religious Master”):
"As no one desires even the slightest suffering nor ever has enough of happiness, there is no difference between myself and theirs; therefore, inspire me to rejoice when others are happy.
"Cherishing myself is the doorway to all downfalls, while cherishing my mothers is the foundation for everything good; inspire me to make the core of my practise the yoga of exchanging self for others.
"Therefore, O Venerable Compassionate Gurus, Bless me that all karmic obscurations and sufferings of mother migrators ripen on me right now, and that I may give others my happiness and virtuous deeds in order that all sentient beings have happiness." ^8
As in the merit generated by developing empathetic concern, merit can be generated internally by any virtuous mental practice. Concentration (Skt: Shamata), analytical (Skt: Vipassana) and visualisation meditation are practices found in most Buddhist contexts. The Seven Limb practice, although some of which is Mahayana specific, contains elements that are found in most traditions and can be recited inwardly or outwardly. It includes taking refuge in the Three Jewels of Buddha, Dharma and Sangha, making offerings, confessing past mistakes, rejoicing at one’s own and other’s virtues, requesting Dharma teachings, requesting the religious teacher to remain and dedicating the merit for the benefit of all beings. Making offerings can be done mentally but is a very strong external practice in every Buddhist community. Offering can be seen in every environment, from temple to the hospice, and can go from being as elaborate as offering up pleasing objects for each of the five senses, to being as simple as arranging some flowers and fruit. The same goes for virtuous verbal recitation and chanting. Almost every Buddhist will engage in, and resonate with, some form of recitation of scripture, prayers and mantras. Most religions will have some form of virtuous verbalisation before, during and after the death of a member, but in Buddhism it is of crucial importance for helping the mind of the dying person. It is held in Tantric texts that the last sense faculty to cease to function is that of hearing. When the mind leaves the body, the in-between state (Tib: Bar-do) is also described as one where the being has a subtle body that has the same faculties as in life, and thus can also hear. For these reasons, recitations are used to both trigger virtuous states of mind in the transmigrating being, as well as to guide them through the stages of transmigration, both in aid of a smooth transition. The famous “Tibetan Book of the Dead,” written by the Indian pandit Guru Padmasambhava, is used in the Tibetan tradition to navigate the bardo being through the tumultuous experience of being in between bodies. The Tibetan tradition has appropriated some other practices from the Indian tradition as well, well-suited to the time of death. Transmitted secretly, Phowa (Tib: “transference of consciousness”) is a very popular Tantric visualisation exercise involving both the red Buddha of longevity Amitabha as well as a wrathful, red female Buddha in the form of a yogini, or female tantrika. One projects one’s consciousness out of the crown with the purpose of going to Buddha Amitabha’s Pure Land, which is a refined plane of existence where becoming enlightened is the main activity. This practice, like all death practices, can be done at any time and is not reserved for the time of death. A common theme in Buddhist practice, it is something to be mastered in life in anticipation for death. Growing out of the tradition of mentally exchanging oneself for others, found in the Indian texts of both Arya Nagarjuna and Arya Shantideva, Tonglen (Tib: “giving and taking”) is aimed at transforming one's own and other's suffering. Visualising other people’s problems as black smoke, one takes it into one’s heart where it becomes light that, in turn, radiates out to the afflicted. They are then imagined to be free of all problems. One might wonder how, and for what purpose, a person who is afflicted themselves would imagine taking on more suffering. The suffering is not absorbed, but rather is transformed, and the overwhelming emotional event that occurs is the arising of exceptionally strong compassion. It is safe to say that this practice in general, and at death-time in particular, is one that is held in the highest of esteem in the Tibetan tradition because of its ability to make remarkable mental changes with a very simple method. Lastly is another practice that, although having some precedence in the Southern schools, manifests uniquely and with great fervour in the Tibetan and the Indian tradition that it arose from. Life-extension practices, often tantric and very often involving longevity deities such as the tantric aspect of Amitabha known as “Amitayus,” are used both to ward off untimely deaths caused by interference from other karma that would interrupt life, and also to ward off death caused by the exhaustion of life-enhancing merit by generating more of such. One very simple life-extension practice is in the saving and caring for other beings, such as in releasing bait to save their lives or caring for the sick and dying, because the karmic ripening result of such practices is long life.
Despite Buddhism being a non-theistic religion, one which is based on self-development and personal responsibility, often times a Buddhist will call on the Buddha for assistance, despite the Buddha Himself saying that "a Buddha cannot remove suffering like rain washes away dirt; only one's own effort can remove suffering." Although the result will not be the removal of suffering of one by another, such a plea at least directs the mind towards the Buddha and is therefore necessarily, from the Buddhist perspective, virtuous. It is even said that feeling anger towards the Buddha is still virtuous because of the limitless beneficial power of the Awakened One.

A Buddhist Approach to Caregiving

In general, caregiving emanates from our natural predisposition to care for one another. Because of this, all traditions, both cultural and religious, have developed methods over time to address the problem of illness and death. Some of the activities of a Buddhist who engages in caregiving as a part of their practice will be similar, if not identical, to those found elsewhere. That being said, there are some strong themes found in Buddhist caregiving that of course grow out of Buddhist practise and philosophy in general, and Buddhist death-practices in particular. Unlike the Christian monastic tradition of nursing, Buddhist monastic caregiving has historically been reserved for monks caring only for fellow monks. This comes from the admonition in the monastic discipline texts (Skt: Vinaya) against monks nursing, or providing medical treatment for, householders. Perhaps due to the overriding influence of the Bodhisattva texts and vows in the Northern schools of Buddhism, which place a greater emphasis on helping others as much as one is able, there is a new historical precedent of Tibetan monks becoming doctors and Western monastics in the Tibetan tradition engaging in caregiving in every possible way, to people of every background, including non-Buddhist householders who are dying. There may be a greater accessibility for Buddhist caregivers to deliver care to non-Buddhists, especially in the area of hospice, because of a lack in very strong family and religious community organisational infrastructure found in traditional Buddhist communities. Another possibility is that the statistically high number of Tibetan Buddhists engaging in hospice and caregiving with the sick might be the result of the Tibetan community being one that is oppressed within their borders, and composed of struggling refugees outside. Thus lacking the cohesive individual and systemic infrastructure found in more stable Buddhist communities, there is a greater need for, and more opportunity to, help.
Musings aside, as with the common Buddhist practices mentioned earlier, there are some aspects to Buddhist caregiving that are shared by every tradition, and some specific to the Northern school. As a practicing Buddhist, the Buddhist caregiver will be engaging in personal, inner development in some capacity. They will already have within their mind a habit of developing, feeling and expressing love and compassion to some degree. However small, they have some sense of wanting the recipient of their care to be happy and free from suffering. They will also have spent some amount of time contemplating death and impermanence, and thus will have done some preparation for their own death. Working on one’s own feelings about death will naturally help others approach it more realistically and with less fear if they are at all influenced by the caregiver. The Buddhist caregiver has at least heard about the inevitability and unpredictability of death, if they haven’t realised it yet, and they may even see themselves reflected in the dying person. They may even go farther and, through analysis, come to realise that since they themselves must definitely die, there is essentially no difference between the dying person and themselves. This is a simple form of selflessness. Another common practice will be seen across the tradition, and that is equanimity. The caregiver who is familiarised with equalising their feelings towards those close to them, those distant or against and those of neutral status, will have an easier time having affection for the dying person they are caring for. If the Buddhist caregiver takes the advice of the Buddha to develop a concern for others as a mother does for their only child, one can imagine the potential for very deep concern being generated in the caregiver’s mind.

The Buddhist caregiver from a Northern tradition, or rather with a Bodhisattva intention, will have some unique aspects to their caregiving approach. For starters, although there are many examples in the Southern tradition of usage of the logic of infinitely regressing rebirths to prove the connection each being has with all other beings, it is highly emphasised in the Northern schools. So much so that texts, such as the Guru Puja quoted earlier, refer to sentient beings as “mother beings.” Seeing the dying person as related to oneself is a very powerful way to provide care that is both genuine and powerfully beneficial. What is perhaps more difficult is seeing every recipient of care as loveable! Here, logic again comes in handy for the practitioner-caregiver. Since every being has been loved by at least one person, their mother, they must necessarily have some loveable characteristics. With difficult and resistant people, to find these traits is the challenge of the Buddhists caregiver. In such a case, there are a few very powerful means that come from the Northern tradition of mind-transformation (Tib: Lo-jong). The first is the life-altering practice of seeing problems and negativity as useful tools to develop our own inner qualities. With this approach, no matter what is happening in the environment, or even within one’s own mind, one can see it as an opportunity to train the mind. This means that the more difficult the situation or person is, the greater the potential to develop good qualities! This has very far-reaching implications and completely destroys the idea that one needs to remove oneself from problematic circumstances in order to be happy. The practice of taking problems onto the path is peerlessly summarised in these lines from the Eight Verses for Training the Mind by the Tibetan scholar-monk Geshe Langri Thangpa, which state:
“I will learn to cherish beings of bad nature and those oppressed by strong negativity and suffering as if I had found a precious treasure very difficult to find.”9 Another Lojong technique is to not expect appreciation, sometimes referred to as “giving up all hope of reward.” This, along with the former practice, is not to encourage others to be disrespectful towards their caregivers. Instead, it places the caregiver in a strong mental position where the mind can remain content and happy regardless of how the caregiver is treated. Otherwise, the caregiver’s emotional state is moved according to the whims of the dying person, which means that their locus of control is without rather than within. As is commonly said about the difference between practicing in isolation versus in the marketplace, it is easy to not get angry on the mountaintop while locked away in retreat. It is very difficult to not get angry when confronted with other beings, and being able to maintain one’s integrity when in relation with others is the greatest testament as to the strength of one’s training.

Conclusion

We live at a time, and in a place, where caring institutions must engage in multi-faith care delivery. People of every type of background need care at the time of death, and likewise, those who provide such care are equally diverse. In keeping with this shift, Buddhists are receiving care outside of the traditional circle of their familial and religious community, from both Buddhists and non-Buddhists, and Buddhists are taking care of people of every possible background. Everyone is coming into contact with views and practices that are different from, and unfamiliar to, their own. Although there are more similarities than differences between the various cultural and religious traditions, such as the common effort to become better humans who are more loving and who develop an ever-increasing understanding of how things work, it nevertheless remains important not to negate fundamental differences. These do not need to be a bone of contention but can instead be a happy source of variety. It is good to recognise and accept these differences, but it is possible to even go as far as to enjoy these differences and learn from one another. In the field of caring for the dying, what is crucial is providing the best possible care, equitably, to all who need it. In general what is most important is not the manner in which this care is given, but rather ensuring that there is the deep wish for the highest benefit for the dying person, and those connected to them. In the words of Geshe Langri Tangpa: “With a determination to accomplish the highest welfare for all sentient beings, who surpass even a wish-granting jewel, I will learn to hold them supremely dear.” 9 This will beatify all caregiving activities and will especially help during difficult times.


References

1. Mendez, Sr., Arnold C. WHY did people live longer BEFORE Noah's Flood than they did after it?
Bible Study Web Site

2. Akester, Mathew; Twelve Principle Deeds of Lord Buddha, Nagarjuna Institute, 2006

3. Harper, Douglas; Online Etymological Dictionary 2001

4. Buddhaghosa; The path of purification : Visuddhimagga; Shambhala Publications, 1976

5. Marilyn Smith-Stoner, RN, PhD, CHPN Phowa: End-of-Life Ritual Prayers for Tibetan Buddhists, Journal of Hospice and Palliative Nursing, Vol. 8, No. 6, Nov/Dec/ 2006

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

7. Tricycle Buddhist Review Fall 1997

8. Chokyi Gyaltsen, Panchen Losang; Guru Puja (Lama Choepa), Library of Tibetan Works and Archives 1979

9. Sonam Rinchen, Geshe; Eight Verses for Training the Mind Snow Lion Publications; 2006

By the merit of this research paper, and the accumulated virtue of the three times and ten directions, may all beings have boundless happiness, and especially for those who suffer from illness and the process of death and those that care for them, may they be free from all pain and may all be auspicious.

Sarva Mangalam

Buddhist End of Life Care in Toronto: Ritual Practice to Social Engagement, by Helen Craigie

Buddhist End of Life Care in Toronto: Ritual Practice to Social Engagement,
by Helen Craigie
[Masters Student in Religion (Buddhist Studies)/Bioethics, University of Toronto]
April, 2008

(based in part on an interview with Sean Hillman; transcript of full interview coming soon; much appreciation to Helen Craigie for allowing me to post her excellent paper on a subject dear to my heart)

Buddhist end-of-life care is a unique form of socially engaged Buddhism that has made a home in Toronto’s health care institutions. The compassionate practice of caring for the terminally ill is distinctly ritualistic in that it was part of the Buddhist tradition well before Buddhism made its way to the West. On the other hand, in the Western world there are examples of Buddhist palliative care participating in social activism at the ground level. Palliative care in the West has even developed into group movements to create centres for care that exist outside social healthcare institutions. Considering that there are elements of engagement from both sides of the extreme, where does this place Buddhist palliative care in Toronto within socially engaged Buddhism as a whole?

In Ken Jones’ work “Emptiness and Form”, he outlines different forms of Buddhist social engagement: “Two kinds of engagement can be arranged along a continuum. At one end Buddhist compassion is expressed in public and organized forms of service and caring – therapy, healing and healthcare (especially with the terminally ill)... At the other end of the Engaged Buddhist spectrum is an activism directed towards radical social change” (p. 2). Jones’ description places Buddhist engagement in healthcare at one end of the Engaged Buddhist spectrum, while radical social change is found at the opposite end. Bearing this in mind, Jones categorizes Western Buddhist focused palliative care in this manner because of its roots in upholding Buddhist ritual practice. However, because there are examples of groups creating separate social models for care, it can be argued that it belongs at other end of the spectrum as radical social change. In Christopher Queen’s collection of studies in engaged Buddhism entitled Action Dharma, he makes a clear distinction between social action and ritual action: “social action (caring for the sick or joining a peace march, for example), which is typically undertaken to relieve other’s suffering, and ritual action (meditation and devotional rites, for example)” (p. 2). Buddhist end-of-life care is unlike other forms of Buddhist social engagement in that the line between social action and ritual action is blurred. Its social action aims to reproduce Buddhist ritual practice in a Western situation. Its ritual action is through its connection with Buddhist traditional methods. Essentially, what transfers to our healthcare guidelines in Toronto is that basic understanding of Buddhist rituals used at the time of death is to be recognized by healthcare professionals. The Ontario Multifaith Council and the Trillium Health Centre understand a Buddhist idea of death to be a time of transition from one life to another (p. 9). In her book, Caring for Dying People of Different Faiths, Julia Neuberger describes the Buddhist's acceptance of death as `striking', noting that it may be difficult for care givers to fully comprehend their attitude (p. 70). What Neuberger found strikingly different about caring for the dying Buddhist is the Buddhist's attitude at this time of transition. Buddhists hold that the way in which a dying man or woman is cared for is crucial to the spiritual process. They will accept their death, and may request to be drug free. At the time of death, a Buddhist will need a calm atmosphere, and may request spiritual guidance. Neuberger notes: “the only certainty when caring for a Buddhist who is dying is that he will require as much time and space for meditation as possible”(p. 67). She points out that, although it may be difficult to meet these needs in a care facility, that mental preparation for the period of transition is crucial and should be respected as much as possible. To create a more accurate understanding of how this practice plays out in palliative institutions in Toronto, further research for this essay is sourced predominantly from a revealing interview with a Tibetan Buddhist who works as a nurse’s aid in palliative care in Toronto.

Sean Hillman is a former Tibetan Buddhist monastic. Since leaving the order he has returned home to Toronto and is now working in as a nursing assistant in palliative care at St. Michael’s hospital. Hillman sees his work as a socially engaged Buddhist in Toronto as a natural choice as he wanted his livelihood to be able to support his practice (par. 2). Studying and becoming a monastic in [India], as well as working with the dying in Toronto makes Hillman an ideal authority on Buddhist social engagement in end-of-life care in Toronto. When Hillman was asked whether there are ritualistic or social aspects of engaged Buddhist practice in the area of palliative care, he responded by saying that there are elements of both. His experience in trying to meet the ritual needs of dying Buddhists has required that he take social action. He explained that because of obstacles when trying to fulfill the religious wishes of his patients he has been in situations where he had no choice but to get involved at some level (par. 4). He identified unfamiliarity as a main contributor to the resistance from his peers. In his experience, palliative care practitioners had no experience with the types of requests they received from the patients. Hillman provided examples of how this has played out in his time at St. Michaels hospital:

“If you try to make something happen that is unusual, like spending a day chanting around a body in hospital, through familiarization it is becoming less unusual. If my patient's family says that they want to spend, let's say, 10 hours with the body, I have no choice but to get involved with whoever can make that happen” (par. 4).

Considering Buddhist palliative care practice in Toronto’s institutions, Hillman was then asked whether in modern Western healthcare it is the ritual practice, the Buddhist philosophy or something different [that has] carried over from the East? Hillman’s response to this question came from his knowledge of Tibetan Buddhism:

“The only thing that I can think of is the personal liberation vows that come from the time of the Buddha, which can in some ways be seen as specific to that time, where there are things that exist now that didn’t exist at that time like vehicles and electronic communication and so on, yet the spirit is still there. I think that the principles in the Buddhist teaching and also in practice can easily be applied to a modern situation, even though some of the situations are new” (par. 18).

In Hillman’s perspective, it is the basic principles of Buddhist philosophy that are being brought forth. He maintained that how these principles play out in modern situations differ depending on the individual’s background, karma, environment and predispositions. Even though the situation in which these principles are applied is new, the essence of Buddhist teachings remain the same.

Examples of Buddhist end-of-life care in the West show that engaged practitioners are not typically planning peace marches or protests to make social change. Instead, compassionate practitioners are typically active in working with the terminally ill and dying. In the context of palliative care in Toronto, as a place that recognizes religious diversity, what type of activism is necessary? Working in the palliative care unit at St. Michael’s hospital, Hillman has experienced barriers that have lead to him become actively engaged. In upholding policy that recognizes multi-faith palliative care [delivery], his means of engagement have played out through appealing to higher levels of power. Hillman was asked, “What is your means for peaceful change?”

“Through dialogue and through talking to all the levels of power. I’d say in a hospital environment there were times when I had to, for example, go to the head of the spiritual care department because going to the head of the nurses of this particular area wasn’t working to make the situation change when there was an obstacle with palliative care delivery for a certain patient”(par. 8).

Hillman explained one example where he was compelled to become active. The circumstances involved a palliative patient who was not competent enough to express his wishes. According to his charts, the patient was a long standing Buddhist yet the [staff] were continuously taking him to Christian mass. Hillman saw this situation as “obviously a breach of the rights of the individual, particularly to a vulnerable patient who is palliative” (par. 8). To address this situation, Hillman had to go above the heads of his peers and appeal to a higher level of authority. Drawing from his Tibetan Buddhist background, Hillman rationalized this particular set of events: “There are these worldly attitudes that we as practitioners are supposed to reduce and one of them is caring whether we are liked or not . . . And if I cared more about being liked more than caring about making change happened, then I wouldn’t have done it” (par. 9). It is with this frame of mind that made up-keeping moral standards take priority over his concern for how his peers would react: “I was just so enthusiastic about making this change happen that it overrode any sort of concern about how people would perceive me. Because in the end the result was achieved. And it made me happy” (par. 10)

Ken Jones makes reference to further manifestations of engaged Buddhism that are far more radical then most types of socially engaged Buddhist movements (p. 3). Jones provides examples of socially engaged Buddhist movements that share the goal of creating Buddhist alternative social models. In other parts of the world, Buddhist end-of-life care fits into this model of social activism in that the common goal is the creation of centres for alternative care outside of the normal system of care. Examples are found in Buddhist hospices like Amitabha Hospice in Auckland New Zealand, or the Zen Hospice in San Francisco. By building alternative models of health care, such as hospices outside of the hospital institutions, these groups aim to ensure a certain level of Buddhist integrity in end-of-life care. Hillman commented on the situation in Toronto: “We don’t have a freestanding Buddhist hospice in Toronto. We have budding hospice movements or groups, there is a growing interest and a growing awareness. [As] part of that, we look at what other groups are doing for palliative care for Buddhists” (par. 16). In reference to his experience in Toronto, Hillman goes on to say that a natural extension of looking into other situations similar to ours in other parts of the world, is that we reflect on what works and what doesn’t in our own system. We then understand why in other parts of the world the logical extension of this thought is to have a freestanding Buddhist hospice that delivers Buddhist specific care. Since multi-faith sensitive end-of-life care is already part of our social healthcare system in Toronto, it seems that there would be less necessity for reform. Hillman maintains that multi-faith sensitive care is already in government policy and reform is necessary for governments to uphold what is already intended to exist within the system (par. 16). Considering we don’t have a freestanding Buddhist hospice in Toronto, as an alternative way to experience Buddhist palliative care, is what is already practiced in Toronto’s institutions enough? Do we need a separate social model? Although his experience has encountered some obstacles, Hillman’s faith in Toronto’s healthcare policies remains optimistic:

“Things have progressed so much in our healthcare institutions now. There are things that you will find in Buddhism in our hospital now. There are meditation groups, there are alternative practitioners that come in and engage in alternative therapies in our own hospitals. Some of these barriers that might have in the past have needed a completely alternative system for alternative therapy to even be considered, I don’t think that we need now, given that our system is more open minded and has more experience with non-allopathic, non-Western traditional medical approaches to health and illness in palliative care. I think that we need a place that has a different approach but I think that we can do this within our system” (par. 16).

In addition to seeing positive changes in his workplace, Hillman attributes his motivation to work within the current system to Tibetan Buddhist wisdom. He said that in the earliest Buddhist teachings monastics were instructed by the Buddha to follow the law of the land. Hillman argues that this philosophy applies today in that “[W]e need to work within the context of our culture within our socio-political systems” (par. 14). Following this view, if we find gaps in our system of palliative care, our approach should be to insist on the system following through with its intention to benefit everyone equally. Working as a Tibetan Buddhist in palliative care in Toronto has provided Sean Hillman with remarkable insight into real world models of engaged Buddhism. Throughout the interview, Hillman addressed contemporary concerns with a combination of timeless Buddhist doctrine and real life experience in one of Toronto’s palliative care departments.

Considering that there are examples from both ends of the Buddhist activism found in Western Buddhist palliative care, it would be impossible to place this form of engagement into one category over another. Sean Hillman’s experience supports the belief that social activism is intertwined in Buddhism at its root principles. Hillman brought to light that palliative care in Toronto’s healthcare system is a compassionate practice that emphasizes the importance of recognizing the different rituals and practices in various religions. It is faith in this system and its policies in multi-faith palliative care that deters Hillman from resorting to radical Buddhist activism. On the ground level, however, the system is not perfect. There is still resistance to what practitioners are not used to and might deem ‘unusual’. It is in these situations where activism and engagement become necessary to uphold the integrity of our multi-faith respecting policies.

References:

Amitabha Hospice Service. (n.d.). Amitabha Hospice Service. Retrieved March 28, 2008 from Amitabha Hospice Service: http://www.amitabhahospice.org/

Hillman, S. (2008, March 9). Engaged Buddhism and End-of-Life Care in Toronto. (H. Nuttall, Interviewer) Toronto, ON, Canada.

Jones, K. (Unlisted). Emptiness and Form. Retrieved February 12, 2008, from Buddhist Peace Fellowship: http://www.bpf.org/tsangha/jonesform.html

Neuberger, J. (204). Caring for Dying People of Different Faiths Third edition. London, England: Radcliffe Medical Press.

Ontario Multifaith Council on Spiritual and Religious Care and Trillium Health Centre. (2008, April). How Different Faiths Approach Death and Dying. Toronto, ON, Canada.

Queen, C. (2003). Action Dharma New Studies in Engaged Buddhism. (C. P. Christopher Queen, Ed.) New York, NY, USA: RoutledgeCurzon.

Zen Hospice Project. (n.d.). Zen Hospice Project. Retrieved March 28, 2008, from Zen Hospice Project: http://www.zenhospice.org/

Jainism and Social Consciousness Conference 2010: University of Ottawa

Sallekhana-Santhārā-Samādhīmaraņa and End-of-life Care: Jain Voluntary and Controlled Death in Equanimity through Fasting and Reduction of Activity as a Model for Secular Health Care

Pt. 1 in a series
Choosing to die: autonomy and assistance

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

The three-fold process of Jain voluntary death practice, Sallekhana-santhārā-samādhimaraņa, has brought benefit to Jain practitioners for millennia and holds the potential to bring future benefit to both Jains and non-Jains. Among those who are non-Jains, some will embrace transmigration (or some other version of a post-death continuity of existence) and karma as part of their world-view and some will not. Are there aspects of Jain death practice that can be maintained without such religious ideas? The goal of this paper, in addition to clarifying some aspects of death brought on by the stoppage of oral intake and activity both in Jainism and in secular end-of-life care, is to show that there are some powerful Jain ideas and practices that can potentially help the dying and the bereaved without reliance on religion. Although secular bioethics is not amenable to some aspects of Jain voluntary death practice, I will attempt to show that in secular end-of-life care settings (not only palliative/hospice environments but also emergency, chronic, acute and critical care settings where many people also die) the Jain emphasis on: (1) voluntary and autonomous decision-making to withdraw treatment, including (but not limited to) nutrition and hydration, conjoined with (2) interdepedent decision-making with qualified co-decision-makers, and (3) qualified assistance and separation from objects of attachment, have great potential to assist the dying and bereaved in the pursuit of an improved experience during life’s most difficult time. To accomplish this I will use Jain monastic texts such as the Ācārānga Sūtra, Ācārya Amitagati I's Yogasāra-prābhrta (Gift of the Essence of Yoga) and the Bhagavatī Ārādhanā, as well as the Catholic Health Ethics Guide and the Health Care Consent Act.

A Buddhist Perspective on Mental Health & Caring for Buddhist Mental Health Patients

A Buddhist Perspective on Mental Health & Caring for Buddhist Mental Health Patients

(summary of presentation for Cultural Diversity and Mental Illness conference; 10/29/09)

Sean Hillman, B.A. East Asian Studies; Master’s Student, Buddhism/Bioethics, U of T

The Buddha’s teachings, and Buddhist practice and study in general, are ultimately aimed at one thing: achieving a state of perfect mental health. This state is not seen as an ephemeral ideal, but rather, one that has been actually developed by many other humans in addition to the historical Buddha Himself, and one that every person has the potential to fully actualize. What does this perfect mental health look like? It is an enlightened mind. A Fully Enlightened being has both omniscience and unending great compassion. This infinite wisdom and unbiased concern for all sentient beings not only leaves its possessor with indescribable bliss, but, most importantly, it allows for flawless skill and ability in helping others to move away from the unenlightened state of suffering. The suffering that a Buddha leaves behind arises from delusions and manifests as afflicted emotions. How does Buddhist practice move the practitioner towards an enlightened mind? The path resembles its result, and thus can be fit into those practices which cultivate wisdom, and those which cause compassion to grow. Although Buddhism is often equated with meditation, and is an important factor, to be sure, it is only one of many concurrent practices. The texts subdivide Buddhist practice into three categories: concentration, wisdom and ethics. The calm-abiding and insight forms of meditation can help in the development of the first two, but it is important to note that the tidy categorization and listing that one finds in Buddhist texts may sometimes obscure the fact that all of the practices can be incorporated and mutually complement each other. In the context of mental health, the benefits that come from calm-abiding and insight meditation, such as more stability and an increased understanding of one’s own mind, will not be effectively seen if done independent from the third training of ethics, or restraining from harm and engaging in helpfulness. It is often said that ethics are the foundation upon which all spiritual practices are based. Simply, if one is causing trouble for others, how can one then expect to sit on a cushion with a settled mind? The disturbance caused to others comes from one’s own inner disturbance, and will result in more! Harming others mainly affects the one engaging in harm. In that moment the mind of the harmer must be in a state of suffering, and in the future the harm will return full-circle to the harmer. The interdependence of the practices that we see with the incorporation of the three trainings is mirrored by the interdependence encouraged in Buddhist thought in relation to how we interact to others. In changing our behaviour towards others it is necessary to change our view of actions and their results. One can boldly say that the contemplation of karma, or cause and effect, is the most powerful way to change behavior in light of the fact that wholesome actions lead to happy results, and harmful actions lead to miserable results. At the bedside, interdependence is a living reality in that the caregiver’s emotions have a strong influence on the patient, and vice versa. We might come across Buddhist mental health patients, and health care providers know already from their practice in a diverse cultural setting that none will be alike. It is helpful, regardless, to know that they might have a unique openness to such ideas as past and future lives, the existence of enlightened beings (and the potential to become one), and the law of cause and effect.

BOOK REVIEW: Buddhist Rituals of Death and Rebirth

BOOK REVIEW:
Buddhist Rituals of Death and Rebirth:
Contemporary Sri Lankan Practice and its Origins
(Rita Langer)

by Sean Hillman
Religion Department
University of Toronto
Dec. 2009

Rita Langer's dissertation on death, funerals and post-funeral rites in Theravada Buddhism skilfully integrates the usage of texts, both Buddhist and pre-Buddhist, with current ethnographic data from Sri Lanka. She sets out to show the influence of both Buddhist and pre-Buddhist (or non-Buddhist) death and dying practices and principles, as found in the texts, on contemporary Buddhists and is quite successful and convincing in her conclusions. A lecturer in Buddhist Studies at the University of Bristol, UK, this study fits into the broader context of her research into Theravada death rituals in Southeast Asia and China. Let us explore her methods and findings.

First and foremost, Langer relies heavily on texts in her analysis. She goes to the Buddhist Canonical texts, including all of the genres in the Pali "Three Baskets" (Tripitaka): Vinaya (discipline), Nikayas (discourses) and Abhidhamma (logic, metaphysics, psychology). Excerpts from the Vinaya give examples of monastic death activities, and those from the Nikayas include events in the Mahaparinibbana Sutta which concern the passing away of the Buddha. These are both relevant in establishing Buddhist norms around death practices, and Langer puts them beside the earliest Hindu beliefs and practices as found in the Vedas, Upaniṣads and Brāhmaņas in her search for remnants of Hindu belief and practice in Buddhism. The textual component of this search is not as compelling as that of her enthnography. For example, Langer does not make a strong case when she points to a lingering sybolism of the funeral pyre as a sacrifice. 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. It is a stretch. She belabours the point and spends far too long tangentially explaining Hindu practices unrelated to Buddhism, to no end. Actually, at one point Langer entirely reproduces full sections of her study word for word. The sections concern the fascinating connection in Buddhist practice with Hindu ideas of purity as found in practices of sifting bone from ash in remains. Fascinating, yes, but made redundant by the author. As well, for all of her extensive combing through the texts, which is the obvious result of an enormous amount of labour, Langer sometimes misses some key symbolism in both the Hindu and Buddhist texts. One Brāhmaņa passage refers to a sacrificial fire and Langer eagerly assumes that it refers to a funeral pyre and then extrapolates that, since the poor could not afford cremations (timber was costly), this would mean that such people could not ascend after death. However, in many Hindu and Buddhist esoteric texts the fire actually refers to life-energy itself, which defeats her later reasonings (anyone can ascend!). Such narrow readings are coupled with more blatant missed symbolic references, such as in the narrative of Indian king who laments the loss of his 84 000 cities at death, and his Queen's consolation that he should abandon desire for them. The number 84 000 is often and explicitly mentioned in the texts as the total number of existent delusions in the mind, and so, the Queen is actually asking her King to abandon delusions.

Textually, possibly the most impressive accomplishment in this study is Langer's extensive and impressive presentation on the process of the transformation of consciousness at death. Distilled, clear and easy to follow, she particularly sheds light on the complicated concepts of ripening and throwing karma as found in the Abhidhamma. The mental states that ripen at death, which also serve to throw the consciousness into the next rebirth, are likened to bulls in a pen. Strong bulls are habitual tendencies, and bulls near the gate are merely those that achieve pole position by their proximate location to the exit, like mental states that arise close to death-time for whatever reason. Although it is most likely that the strong bulls will escape first, a weak bull near the gate has a good chance as well. The story of the great Indian Dharma King Ashoka at death reinforces the metaphor, as Langer describes his feelings of remorse near his death (weak bulls near the gate, or proximate ripening mental states) throwing him into a lower realm for a brief time only (the bulls were weak). The King quickly ascends to a celestial realm for a lengthy span (strong bulls, or habitual ripening mental states) because of the strength of his previous vast, and ongoing, good actions. This imagery is a most powerful way for this complicated exposition of death-consciousness to be introduced and is useful at every level of familiarity with the Buddhist presentation on mind and mental factors.

Next is the ethnographic aspect of Langer’s study. During her 6 months stay in one particular Sri Lankan village Langer observed several events, including funerals and post-funeral activities which included an offering ceneromy six days post-funeral, and a religious discourse event seven days post-funeral. She also gathered information on the community's beliefs through interviews and questionnaires done with both monastics and householders. Noted during the interviewing process was an interesting difference in the openness of the informants depending on the language used and the subject matter at hand. Using English, rather than Sinhalese, and covering sensitive material, such as the existence of ghosts, both made for more guarded responses. This forced some reliance on secondary literature, with good effect, and a call for future study into how language choices affect the quality of interviews. Both the interviews and questionnaires find trends in modern practice and the views held by the community, but Langer also takes the opportunity to include interesting anomalies in the responses. She mentions the one person who says that people pray in advance to have a good last thought before death, and also points out one person who organizes a ceremony to dedicate merit to pets, much to the chagrin of the rest of the community. Such examples add perspective and also a lightheartedness to the dissertation. Here again, this time in enthnographic mode, we find Langer’s continued search for Hindu remnants in Buddhism as she compares modern Hindu and Buddhist death practices. In relation to the funeral, Langer observes both that “it is customary and expected that Brahmins are paid for their services” 1 and that “Buddhist monks replaced brahmins in their ritual function.” 2 Naturally it follows, then, that “any offering to the monks could be viewed in the light of a symbolic payment for the monks’ services at the funeral” 3 since “a monk who comes to a house for chanting or preaching never leaves empty-handed and there seems to be an unspoken understanding about which services require more substantial donations that others.” 4 Interestingly, but unmentioned by Langer, another Buddhist scholar independently notes this as well and this scholar also happens to be one that Langer herself relies on in this study. Gregory Schopen’s archaeological evidence of monastic practices, particularly those having to do with funeral practices, is a major resource for Langer’s section on Buddhist funerals. In regard to the monastic-lay relationship I found that, like Langer, Schopen refers to the “client relationship between monks and lay-brothers” 5 when monks are compelled to meet the request of laity, and the “exchange relationship” 6 when funeral duties are performed and the order receives something in return.

Langer makes an important finding when she noticed two symptoms systemic in the community which, Langer discovered, arise from the Sri Lankan confusion over the status of the dead. One is linguistic and the other ritualistic. The terms prēta and preta in Sanskrit, peta in Pali, and prētayā in Sinhalese are all from a similar etymological root but are used with interchangeable meanings of ghost, troublesome ghost (resembling a poltergeist), deceased, hungry ghost, deceased relative who is a hungry ghost, intermediate being, and ancestor. 7 Langer spends a great deal of time on this and it remains a tricky task to tease out all of the elements leading to this “conflation,” as she calls it. “On a conscious level prēta/peta is understood as a particular being belonging to a specific gati [realm], but on a practical, emotional level, the categories of ‘hungry ghost’ and ‘ancestor’ merge.” 8 The ritualistic symptom of the confusion over the status of the dead shows up with various contradictory customs Langer observed around the funeral, some in an attempt to keep the dead from returning and some to have them return. Digging holes along the funeral procession path is an example of the former, and a verbalised invitation and laying out of the deceased’s belongings is an example of the latter. About this issue she concludes: “In Sri Lanka (and Thailand) there appears to be a gap between the official Theravada doctrine of instantaneous rebirth, and popular practices which seem to suggest the belief in a liminal period after death.” 9 Apparently the result of confusion over what happens after death, Langer successfully shows this to be a Hindu remnant of spirit belief and/or a lingering pre-Buddhist custom of ancestor worship.

Langer’s dissertation is the result of a great deal of textual and ethnographic effort. It adds greatly to the study of Buddhism, death and dying and the Buddhist perspectives on such. It is an excellent resource and I have already used it personally in a recent research paper entitled “Tension Between the Buddhist Monastic Order and Buddhist Laity at Funerals Degrading the Holding of Monastic Precepts.” There are some weaknesses, however: excessive meanderings regarding Hindu practices beyond proving a relevant point related to Buddhist practices; repeated sections of content; difficult usage of foreign terminology lacking clear definition and her inconsistent interchanging of terms that may or may not be synonymous. On the other hand, I might be bold enough to say that her concise exposition on the Buddhist view of consciousness at death from the Abhidhamma might be unparalleled in Western scholarship. Langer also makes very useful connections that can be applied to modern times. In one Sutta commentary the idea that wrong view at death will detrimentally affect rebirth is presented, and there is the caution that even if one has developed sophistication in one’s views throughout one’s life, at death one can instinctively revert to the views of childhood. She suggests that this is a textual tool to both warn and encourage the practitioner. In the context of palliative care, a personal affinity of mine, there is a precedent at the bedside of patients reverting to their original tongue when approaching death. Here we see that principles in the ancient texts can be found to hold true here and now, and can serve to provide insight here and now, in a practical and powerful way. Langer’s findings regarding remnants of Hindu thought and practice in Buddhism are strong and deserve even more attention. The gist of this lingering pre-Buddhist influence on death activities is well captured by Holt: “Buddhist interpretations of death did not originate in an historical vacuum. Conceptions of…the prescribed behaviour relating to the dead…were modified adaptations of prevailing Brāhmaņical patterns of belief. This is especially apparent when we examine the beliefs and practices of the early Buddhist...” 10

Endnotes

1) Langer, 2007. 87
2) Ibid. 183
3) Ibid. 87
4) Ibid. 154
5) Schopen, c1997. (a) 74
6) Schopen, c2004. (b) 96
7) Langer, 2007. 150
8) Ibid. 159
9) Ibid. 82
10) Holt, 1981. 1

Sources

Holt, J.C. 1981. Assisting the Dead by Venerating the Living: Merit Transfer in the Early Buddhist Tradition, Numen XXVIII, 1-28.

Langer, Rita. 2007. Buddhist Rituals of Death and Rebirth: Contemporary Sri Lankan Practice and its Origins; London ; New York: Routledge

Schopen, Gregory; c1997. Bones, Stones, and Buddhist monks: Collected Papers on the Archaeology, Epigraphy, and Texts of Monastic Buddhism in India. Honolulu : University of Hawai'i Press a) The Ritual Obligations and Donor Roles of Monks in the Pali Vinaya, 72-85.

Schopen, Gregory; c2004. Buddhist Monks and Business Matters: Still more papers on Monastic Buddhism in India. Honolulu : University of Hawai'i Press
b) Deaths, Funerals, and the Division of property in a Monastic Code, 91-121.

Thoughts on tantra for a beginner

Sept. 18, 2010

Many non-Buddhists and beginner Buddhists consider attending tantric empowerments. Here are a few brief thoughts that I sent to a colleague regarding how secret tantra and wrathful practices fit into the path. I specifically make reference to the practice of Chod, or 'Cutting off the Self.'
http://www.bodhicitta.net/Chod.htm

Tantra traditionally requires extensive foundational practices such as refuge, ethics, purification etc. Its effectiveness also relies on some experience of Bodhicitta and emptiness (some say at least a good intellectual understanding). It is seen by many as a completion practice, not an introductory one. Historically, entrance into tantra would be determined in conjunction with a qualified teacher. Nowadays, there is a lot of tantra...everywhere you go you can get empowerments, grab books off the shelf...even before doing any other training...and it is hardly secret. We could see this as a degeneration of the system, or a necessary adaptation. His Holiness the Dalai Lama sometimes says that exposure to things like tantric chanting and ritual plants seeds on people's minds, at this point where we are not really qualified to enter into tantra, following the karmic logic that the seeds will ripen in the future and make it easier for us to enter tantra (which some texts say is required to achieve full enlightenment) in the future when we are ready. This is how Kundun justifies tantric monk tours and His own conferring of so many initiations, especially Sri Kalachakra. One also definitely makes a karmic connection with the tantric Guru. One needs to consider carefully if one wants this connection because it has implications for future lives.

There are different ways to approach it. Often tantric masters require students to have taken refuge, have bodhisattva vows (both of which can be done in advance and is often repeated during the ceremony proceedings), and require the taking of tantric vows and a commitment to do a daily practice, before allowing them to receive an empowerment. This is if one is taking the initiation fully. One can also receive empowerments as a blessing, and the requirements of the student are reduced. Lastly, one can sometimes just merely witness the ceremony. This could be out of a sense of curiosity or even, by extension, as an ethnographer. In these latter 2 approaches, a Buddhist might see such an act in the way that Kundun mentions...from the exposure, there is the planting karmic seeds on the mindstream for future ripening under the right causes and conditions.

Chod is a wrathful practice. I mention it because it can be quite shocking and even seem barbaric at the surface. One is offering the parts of one's corpse to different categories of beings in the cosmos...especially those most in need. I personally think the practice is profoundly powerful...it reduces attachment to the 'self' and body which can lead to realizations now and in the future, and prepare us for death most effectively. I have great reverence for Padampa Sangye (the Mahasiddha who brought the tradition to Tibet from India) and Machig Lhadron, his chief Yogini disciple. Fortunately, the best teachers will give great context to the practice so that people approach it in awareness and knowing the purpose of this novel and seemingly violent technique.

A book i found really helpful to clarify how to approach tantra in this age is a book on the Kalachakra by Alexander Berzin. I think you can read it all here:
http://www.berzinarchives.com/web/en/archives/e-books/published_books/kalachakra_initiation/pt1/kalachakra_initiation_02.html