Monday, August 4, 2014

Mention in "Wild Geese: Buddhism in Canada" 2010 book published by McGill-Queen's Press

Sean Hillman is mentioned in the 2010 Gill-Queen's Press book Wild Geese: Buddhism in Canada,  edited by John S. Harding, Victor Sogen Hori and Alexander Soucy. Interestingly, a year after the book was published, Sean acted as a Teaching Assistant for the author of the chapter in which he appears, “Buddhism After the Seventies” by Prof. Henry Shiu. They soon realized they had a common academic link in Prof. Leonard Priestly, an erudite scholar of Indian Buddhism, Chinese religions and Sanskrit and Chinese languages. Prof. Priestly was Prof. Shiu's doctoral supervisor and also Sean's first professor in Asian Religious Studies at the University of Toronto (Introduction to Buddhism, Introduction to Taoism, Indian Buddhism) in the early 90s. In the chapter, Prof. Shiu refers to Sean's activities in caring for the dying as well as a talk on palliative care he gave in 2006 when he was still a fully ordained Buddhist monk.

From the publisher's page for the book:
"Sociology: Canadian. History: Canadian, Religious Studies.
The most comprehensive study of Buddhism in Canada to date. Buddhism has been practiced in Canada for more than a century and in recent years has grown dramatically. Immigrant communities construct temples in Canada's urban centres, the Dalai Lama is one of the world's most recognizable figures, and Buddhist ideas and practices such as meditation, vegetarianism, and non-violence are increasingly a part of mainstream culture. More native-born Canadians are turning to Buddhism now than ever before.  The most comprehensive study of Buddhism in Canada to date, Wild Geese offers a history of the religion's evolution in Canada, surveys the diverse communities and beliefs of Canadian Buddhists, and presents biographies of Buddhist leaders. The essays cover a broad range of topics, including Chinese, Tibetan, Lao, Japanese, Korean, and Vietnamese Buddhisms, critical reflections on Buddhism in the West, census data on the growth of the religion, and analysis of the global context for the growth of Buddhism in Canada. Presenting a sweeping portrait of a crucial part of the multicultural mosaic, Wild Geese is essential reading for anyone interested in religious life in Canada."





"Bhikshu Tenzin Sherab, born Sean Hillman, a Canadian Buddhist monk ordained in the Tibetan tradition, is also a nursing assistant involved in hospice service at a hospital in downtown Toronto (Shiu 2010: 99)."

"An educational conference on palliative care, entitled 'Caring for the Dying in a Multicultural Society:  Ethical, Religious, Social and Cultural Perspectives,' took place in Toronto in April 2006, with Tenzin Sherab addressing the audience from a Buddhist perspective (Shiu 2010: 109)."

Shiu, Henry C.H. “Buddhism After the Seventies.” Wild Geese: Buddhism in Canada. Ed. John S. Harding et al. McGill-Queen's Press, 2010: 84-110.





Thursday, April 3, 2014

Health Care Decision-making in India

Sean Hillman, PhD student (Department for the Study of Religion, University of Toronto)
2013

Introduction

The concern of my overall doctoral research project is the influence of religion on adherents’ views of health and disease/illness in contemporary India and how this affects health care decisionmaking, particularly those at the end-of-life. To begin to understand the processes of health care decision-making in India, both in theory and practice and with particular concern for the players involved and the respective power they wield, I will delve into two textual genres from within law and anthropology, and subdivide the paper accordingly. They are: (1) judicial proceedings, and (2) anthropological surveys.

Judicial Proceedings

     Jyotica Pragya Kumar’s dissertation Informed Consent in Judicial Discourse: India and Canada 1996-2003 for a University of Toronto Sociology doctorate contains a chapter on “A Profile of the Doctor-Patient Relationship in India.” This section proved indispensable in beginning the process of discovering court proceedings that address the issue of health care decision-making in contemporary India. Kumar first establishes the nature of the doctor-patient relationship in India:
The relationship between the doctor and the patient is not a ‘contract of service’ - an expression which implies a master-servant relationship and involves an obligation to obey orders in the work to be performed and as its mode and manner of performance. A patient, on the other hand, cannot command the doctor to administer to him or her particular treatment if the same is not prescribed or approved by the latter. The relationship between the two is, at most, a ‘contract for service’, which signifies a contract whereby the doctor undertakes to render professional services, in the performance of which he is not subject to detailed direction and control by the patient. The doctor exercises professional judgment and uses his or her own knowledge and discretion quite independent of the patient (footnote 3: See Indian Medical Association v. V.P. Shanta and others, AIR 1998 Supreme Court 550 at 561 (para. 41) (26). 
Within the context of this relationship, “a doctor’s professional decision-making functions are broadly divided into three phases: ‘diagnosis, advice and treatment’ (f16: Per Lord Bridge in Sidaway v. Bethlam Royal Hospital Governors and others, (1985) 1 All E.R. 643 (H.L.) at 660 c.)” (29). Although Kumar determines that “out of these, the functions relating to ‘diagnosis’ and ‘treatment’ have been clearly held to fall within the ambit of professional decision-making” (29), she distinguishes them from the phase of ‘advice’:
…the term ‘advice’ is used in a wider sense to cover “information as to risk and options of alternative treatment.”… Two lines of thinking, representing two different approaches, are in vogue. One view is that the determination of the doctor’s legal duty to advise is a matter of medical judgment, the professional decision-making. The other view is that this duty to advise cannot be left to the doctor’s judgment, because it is essentially a matter that impinges upon the right of a patient to ‘personal decision-making.’ India, following the English courts, has adopted the former approach, which gives primacy to the doctor’s decision-making for the patient; whereas…the latter approach…emphasizes the autonomy of the patient’s eventual decision-making… Since India has hitherto adopted the British approach, it would be in order to take note of the decision of the House of Lords in Sidaway, which gives primacy to the decision of the doctor over the patient (31-32).
With both the interpretation of “contract for service” in the Indian Medical Association case and “advice” in Sidaway lending judiciary strength to the physician’s independence in decision-making in India, we see not only the autonomy of the patient endangered but both collaborative and heteronomous decisionmaking models rendered difficult or impossible. I construe “collaborative decision-making” as that involving at least two parties, and “heteronomous decision-making” as that involving at least three parties having particular roles. My definition and usage of these terms will be explained in more detail in our case study later. From the Supreme Court ruling in relation to another case, Achutrao Haribhau Khodwa and others v. State of Maharashtra and others (AIR 1996 SC 2377), it is made “evident that the ambit of the decision-making authority of the doctor in India is very wide and almost unrestricted. This is amply clear as a matter of law as well as practice that if, in a given case, more than one course of treatment may be available for treating a patient, it is the doctor, and not the patient, who decides which course is to be adopted” (37). With one qualifier rendered useless by context specificity, Kumar concludes that the predominant decision-making model leaves all of the power in the hands of the physician:
The only restraint is that he ‘must bring to his task a reasonable degree of skill and knowledge and must exercise a reasonable degree of care.’ For meeting the standard of ‘reasonableness’, what is expected of the doctor is neither ‘the very highest’ nor a ‘very low degree’ of care and competence, judged in the light of the particular circumstances of each case. This is ‘what the law requires’ in India, and this is the law, which has been again affirmed by the Supreme Court recently in Vinitha Ashok v. Lakshmi Hospital… We may describe this approach as ‘doctor-centric’ (37-38). 
In addition to the unclear nature of ‘reasonableness,’ the principle of ‘best interest’ is mobilized to protect doctors during litigation. During a 1991 appeal in the case of M.K. Verghese v. San Joc Hospital (39), the court’s observation “reflects the predominance of the ‘doctor-centric’ approach” since “‘informed consent’ in India just means informing the patient what the attending doctor did or intended to do in the best interest of the patient without the necessity of having any return response from him or her (patient)” (43). A trend crippling to both autonomy and collaboration in decision-making, Kumar’s “analysis of the Indian cases reveals that, hitherto, the patient’s autonomy to decide for himself or herself is completely absorbed into the decision-making authority of the doctor” (44). She notes, however, that the trend is shifting:
…the smooth functioning of doctor-patient relationship seems to be premised on the unwritten understanding of patient’s complete faith, trust and confidence in the capability of the doctor. However, cases have started coming to the courts, increasing in number, showing a questioning of doctor’s authority, which until relatively recently, was beyond reproach… [With] increasing awareness of the people at large generally, and the patient population in particular about their rights…[, there is a new] trend of asserting rights against doctors, and thereby changing their paternalistic attitude (46-47). Another judicial move found in Chandra Shukla v Union of India (AIR 1987 ACJ 628) and mentioned by Omprakash V.Nandimath of the National Law School of India University in Bangalore, has hindered the paternalism of Indian doctors:
For the fist time in India, the court ruled that however broad consent might be for diagnostic procedure, it can not be used for therapeutic surgery. Furthermore, the court observed that "where the consent by the patient is for a particular operative surgery it can't be treated as consent for an unauthorized additional procedure involving removal of an organ only on the ground that it is beneficial to the patient or is likely to prevent some danger developing in the future, where there is no imminent danger to the life or health of the patient". This proposition puts fetter upon the role of a "paternal doctor" in the Indian scenario. (344) 
In addition to Kumar’s assessment that such “development signals that the society in India has also started moving gradually in the direction of individual autonomy” (49), I hold that it also paves the way for collaborative decision-making models to make their way into Indian hospitals.
     Despite a discussion on the increase of malpractice suits against physicians, strangely Kumar does not give any examples of courts ruling in favour of patient complainants in malpractice suits against physicians, which supports her argument that although moving towards patient autonomy, consent and decision-making remains doctor-centric. However, Nandimath cites Maneka Gandhi v Union of India (AIR 1978 SC 597) in which the courts ruled in the patient’s favour. This case is very similar to many cited by Kumar where the scenario has a surgeon opening up a patient to deal with one organ in a particular way and removes another organ without consent because it is found to be unhealthy. The crucial difference in this case is the removal of the unhealthy organ led to another organ being compromised. Nandimath also attempts to broach the topic of the processes of ranking of Substitute Decision-makers (SDM) but without any evidence since judicial or institutional regulations that might control the practice are absent: “Regarding proxy consent, when the patient is unable to give consent himself, there are no clear regulations or principles developed in India. If such a situation exists, the medical practitioner may proceed with treatment by taking the consent of any relative of the patient or even an attendant” (345, emphasis added). Without a legal ranking of SDMs the danger that I can see is that relatives that are close by way of proximity rather than by relation might be treated as SDMs. In ranking SDMs, Canada’s Health Care Consent Act favours spouses, partners and relatives in descending order with regard to decisionmaking. ‘Spouses’ are defined by marriage, co-habitation, or having a child together (c.2, Sched. A, s. 59.7), whereas ‘partners’ are defined as those with a “close personal relationship that is of primary importance in both persons’ lives” (c.18, Sched. A, s. 10) and would of course accommodate same-sex couples. These relationships are given prominence by the legislation. Next, ‘relatives’ are defined by “blood, marriage or adoption” (c.2, Sched. A, s. 20.10). In theory, the logic behind privileging close kin as defined by the patient is to get as close to possible to the patient’s autonomous wishes in determining courses of action that are in their best interests. Despite such legislation, in practice I have observed too many times to count that those close to the incompetent patient in proximity are the main source accessed by health care teams during difficult decisions. Igor Pietkiewicz, a Polish medical anthropologist in Tibetan Studies, notes that “[h]ierarchy and subordination within technomedicine is expressed in the relationship between individual and institution, in which hospital routines are subject to the convenience of the medical staff, not the patient” (Pietkiewicz 39). This is often the case with regard to decisionmaking in Toronto hospitals. It is simply easier to make decisions with people physically present regardless of where they fall in the hierarchy of suitable SDMs. This practice of accessing proximal patient relations over those with degrees of closeness, which I have observed in many hospital contexts but particularly within critical care areas such as Emergency and Intensive Care where lives usually hang in the balance, is exacerbated by time-constraints, degree of seriousness of the patient condition and language barriers. Nandimath points to a conflation of spouses, partners and relatives by blood, marriage or adoption with the term “relatives” in an Indian health care context.

Anthropological Surveys

     Mining the Journal of the Anthropological Survey of India for articles related to health and decision-making yielded some interesting data spanning two decades. Articles of interest cluster in the early eighties and around the cusp of the new millennium, and I will address them chronologically. I have left spelling and grammatical errors from the original articles intact and have not indicated such mistakes save for one glaring mispelling.
     In Asha Datta’s 1982 article “A Study of Diagnostic Patterns of Mental Illness in Calcutta Hospitals and their Relation to Some Social Variables,” the investigator attempts to uncover the “belief about mental illness held by persons coming into contact with the ‘mentally ill’” since it “is of significance in proper diagnosis, prompt treatment and effective aftercare of the patients” (85). Informants were “the relatives of some of the out-patients” and “were approached to assess their belief about mental illness and their attitude towards their respective patients” (86). As was found in Nandimath with regard to the term ‘relatives’ in substitute decision-making, the various types of these relationships are not distinguished. The questionnaire results were subdivided into several models. Within the “Family model…There are many who…ascribe to the belief that the family is responsible for the illness and cure of mental patients” (93). The “Intrapersonal model” showed that some “agree that the patient is responsible for his own condition; and cure,” and in the “Social model…90% of [respondents] hold the society responsible for the treatment” (94). As shown above, the lack of symmetry in the presentation of results makes it difficult to say much other than most adhere to the ‘social model’ and people to a greater or lesser degree hold to the others. It is also not made clear what is meant by either ‘society’ or ‘responsibility.’ Does the former include private citizens, health care professionals and institutions as well as governmental bodies? Does the latter include both resources and decisions? Another statement not made entirely clear is the finding that “[t]he attitude of relatives of patients is benign,” but could mean that relatives do not begrudge the mentally ill family member for the burden their illness bears on them since “[t]he patient is viewed mostly as dependent” (95). This at least tells us that in 1982 Calcutta, decisions were more likely to be made by those other than the mentally ill patient themselves. We can surmise that competence would have much to do with this.
     Bhowmik and Pal’s 1984 “Indigenous Health Practices Among the Nocte of Arunachal Pradesh” focuses on a group that “occupies the Central part of the Tirap District of Arunachal Pradesh numbering 24, 292 according to 1971 Census” (36). Regarding “Disease and treatment … Generally the professional expert among them is consulted in case of long suffering or any complication. The medicineman prescribes material of either plant or animal origin” (41). There is no mention of any negotiation around prescriptions so it might be safe to say that such decisions for traditional treatments are made by such healers for the patient. However, in the context of the “Impact of Modernization” the investigators found that “[i]n most of the injury cases, the Nocte like stitching which is done in the hospital” and that “[n]ow-a-days the Nocte prefer injection than oral medicines. The idea prevails that in injection entire medicine is accepted in body whereas in oral medicines some may go out of body through body secretions” (51). This indicates to me some degree of autonomy exerted among this group in relation to biomedical health care professionals as they seek out particular interventions, and accept certain treatments and refuse others.
     In Kumari’s 1997 “Health Hazards among the Tribals and their Cultural Cognition for Modern Medical System: A Case Study of Rajendra Medical College and Hospital, Ranchi,” tribal use of hospital interventions is again investigated but this time in the second most populous city in the state of Jharkhand. One of the researcher’s main findings is significant to decision-making, but not surprising:
...in the hospital, there exists communication gap between the poor illiterate patients and specialists…. One of the important reasons why the tribals use folk modes of health care, because the patients and his relatives feel they can talk more freely to folk medicinemen than with modern physician. The interpersonal relationship between tribals and folk practitioners on one hand and the rural tribals and modern medical practitioner on the other hand are considerably different. Thus there exists a communication gap on emotional plane in the hospital between the patients and professionals. 
     On the contrary to the indigenous medical practices, western system of medicine is alien to the cultural pattern of the rural folk. Modern doctors fail to lounch [sic] their scientific advice in terms which fit on already existing cultural pattern creating gap on cultural plane. Thirdly, practitioners of modern medicine come from well to do families. By their education and training they tend to be sophisticated. This leave a gap between intellectual level of the practitioners and the illiterate patients. There is an enormous social distance between the two groups (83). 
In this case, patients are disempowered in decision-making processes due to several factors: lack of familiarity with biomedicine; technical language usage by physicians; and social stratification. The article concludes with the recommendation that “[t]he health care system has therefore to be deprofessionalize…to provide better services to poor masses…” and among nine suggestions gives this: “Efforts should be made to fit the practice of medicine to the role that is appropriate to social system of the tribal people. Educated young tribals of both sexes should be recruited as health staff in health centres who will able to understand their own affairs promptly” (84). Although not elaborated upon, obstacles arising from gender relations is a notable concern.
     Banerjee’s “Some Psycho-social Problems of Old Age among the Bengalis of Meghalaya” in 2000 “tries to highlight the role of Bengali aged people in the family in terms of decision-making processes” (69). It is unfortunate that health care decisions were not included in this survey. Regardless, it was found that:
It is generally believed that in changing life-style and increase in average longevity, the aged people in the present time are not enjoying the same respect and position as their predecessors used to enjoy in their days. With this view in mind we have examined in this section to what extent their opinions are being valued in family affairs like (i) financial matter, (ii) marriage of children, (iii) children’s education, iv) participation in social activities (77). 
Although not done in the article, I extrapolated the results by combining all family affairs. There is a great discrepancy based on gender. For males, 37.7% of decision-making is done by themselves, 50.6% jointly with spouse, and 11.7% by the children on their behalf. For females, 24.6% of decision-making is done by themselves, 20.7% jointly with spouse, and 54.7% by the children on their behalf. The most significant difference is between decisions made on behalf of male and female elderly by their children. Combining the results, overall for the Bengali aged at this time joint decisions are the majority (35.7%), with decisions by children coming next (33.2%) and lastly self-driven decisions (31.2%), with only a 4.5% range between them all (78). Despite the decision-making models having quite rigid boundaries, excluding combinations that would allow for collaboration between parents and children for example, the data showing that joint spousal decisions predominate, and not proxy decisions, is an impressive result.
     Bhowmik, one of the same investigators in the 1984 A.P. study, in the 2003 article “Indigenous Health Practices among the Digaru Mishmis of Arunachal Pradesh” showed only that patriarchs seek out medical treatment on behalf of family members since “[d]uring injuries and ailments of complicated nature, the professional medicine man is approached. The head of the family consult the local medical expert from among the villagers” (4).
     Lastly, Behura’s 2003 article “Health culture, Ethnomedicine and Modern Medical Services” focuses on the “Saora, a major tribal group of the Indian state of Orissa” (27) and found that “[t]here are several factors which influence the decision-making process of the Saora. The first and foremost factor is their tradition and their confidence in the age-old mode of diagnosis and treatment of disease by their medicinemen” (54). As with the Ranchi and Nocte tribals there is reliance on local healers for traditional medicine treatment regimes. And like the Ranchi tribals, we can only surmise that there is a similar lack of familiarity with biomedicine that would hinder participation in treatment decisions in such fora.

Conclusion

     With regard to judicial proceedings of malpractice suits against physicians in India, both Kumar and Nandimath agree that a paternalistic ‘doctor-centric’ model of decision-making has predominated and Kumar points to the principles of ‘reasonableness’ and ‘best interest’ being exploited for the purpose of protecting physicians from liability. The two scholars also agree that a shift towards patient autonomy is evident by an increase in malpractice suits and those that are ruled in the patient complainant’s favour. To autonomy I add that such a shift also increases the potential for more balanced collaborative decision-making. Nandimath also makes it clear that SDMs are chosen without much discrimination, which leaves open the possibility for proximal rather than closely-tied relations being chosen out of convenience rather than determining SDMs based on who would most likely have the patient’s best interests at heart.
     Studies from the Journal of the Anthropological Survey of India had various results with regard to decision-making including: a prevalence of dependency among mentally ill patients in 1982 Calcutta; some autonomy with regard to biomedical treatment decisions among the Nocte of Arunachal Pradesh in 1984; utter disempowerment of tribals in 1997 Ranchi hospital decision-making due to lack of familiarity with biomedicine, the technical language of physicians, social stratification and gender relations; a significant difference between decisions made on behalf of female and male elderly by their children (higher for females with a 53% range) and an impressive predominance of joint spousal decisions among elderly Bengalis of Meghalaya in 2000; family patriarchs among the Digaru Mishmis of Arunachal Pradesh in 2003 seeking out medical treatment on behalf of family members; and finally, reliance on local healers for traditional medicine treatment regimes and a lack of familiarity with biomedicine among the Saora in 2003. Having briefly explored two textual genres within law and anthropology to begin to uncover health care decision-making in India, I found some temporal and spatial variation but, overall, many signs that patient autonomy has increasing value and that there is room for a collaborative middle-ground between doctor-centric and patient-centric models.

Citations

Banerjee, Mrinmayi. “Some Psycho-social Problems of Old Age among the Bengalis of Meghalaya.” Human Science: Journal of the Anthropological Survey of India 49 (2000): 69-82.

Behura, N.K. “Health culture, Ethnomedicine and Modern Medical Services.” Journal of the Anthropological Survey of India 52 (2003): 27-67.

Bhowmik, D.C. and Anadi Pal. “Indigenous Health Practices Among the Nocte of Arunachal Pradesh.” Human Science: Journal of the Anthropological Survey of India 33 (1984): 35-53.

Bhowmik, D.C. “Indigenous Health Practices among the Digaru Mishmis of Arunachal Pradesh.” Journal of the Anthropological Survey of India 52 (2003): 1-8.

Datta, Asha. “A Study of Diagnostic Patterns of Mental Illness in Calcutta Hospitals and their Relation to Some Social Variables.” Bulletin of the Anthropological Survey of India Vol. XXIX (1982): 85-97.

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

Kumar, Jyotica Pragya. Informed Consent in Judicial Discourse: India and Canada 1996-2003. UMI Dissertations Publishing, 2005.

Kumari, Pratibha. “Health Hazards among the Tribals and their Cultural Cognition for Modern Medical System: A Case Study of Rajendra Medical College and Hospital, Ranchi.” Journal of the Anthropological Survey of India 46 (1997): 67-86.

Nandimath, Omprakash V. “Consent and Medical treatment: The Legal Paradigm in India.” Indian Journal of Urology: IJU: Journal of the Urological Society of India, V. 25 (3), (2009): 343-347.

Pietkiewicz, Igor. Culture, Religion, and Ethnomedicine: The Tibetan Diaspora in India. University Press of America, 2008.

Thursday, March 6, 2014

Medical Marijuana and Buddhism

Below is the full text submitted for the article "How do Buddhists view medical marijuana?" in The Medical Marijuana Review Posted on January 2, 2014 by Dave Gordon in Feature Story. http://medireview.com/2014/01/how-do-buddhists-view-medical-marijuana/#.UuffYxb0DUT  

==

Medical Marijuana and Buddhism
Sean Hillman, PhD student Religion/Bioethics/South Asian Studies
University of Toronto
Dec. 10, 2013    

     Since Buddhism is multiple, it is difficult to establish an authoritative stance on many issues. My thoughts on this particular subject are merely my opinion, informed by the study and practice of Buddhist discipline texts and caregiving in hospice and hospital settings. His Holiness the Dalai Lama's recent statement on the medicinal use of marijuana points to one of the central concerns when determining the appropriateness of Buddhists using certain medications: whether it is mood/mind/consciousness altering or not. As with other such statements on major issues, I think this is meant to address Buddhist vow-holders (householders and monastics who have chosen to keep ethical precepts, including to abstain from intoxicants) in particular and is not best served as a blanket statement applying to all since what people choose to ingest is their private business not subject to Buddhist religious scrutiny. What the individual ingests is, however, indeed under the scrutiny of the law and the health care professional that is responsible for suggesting courses of treatment for the patient. A similar tension between treating illness versus altering the mind occurs regularly with front-line Emergency Room professionals when drug addicts seek treatment. It is difficult to tease out a valid need for somatic pain relief from simple drug-seeking, and many health studies show that this complexity results in an under-treatment of pain in relation to this demographic. The concern with intoxicating side-effects when using opioids, such as morphine for example, is often based on a misunderstanding of pain management. Simply, when the pain at hand is addressed without any intoxicating side-effects, medication has been administered correctly and pain management is effective. Finding the best delivery method and dosage are the challenges. If there is intolerable pain, it is not yet managed. Going beyond this threshold can lead to side-effects, including drowsiness and even respiratory failure. This is often cited in articles on Buddhism and health care as the reason why Buddhist patients might refuse pain management when nearing death for fear that they will not be able to die with conscious awareness and thus detrimentally affect their rebirth. Earlier in my career as a Buddhist, especially while a monastic, I would likely have similarly refused pain control meds. Now, however, I know that there are circumstances in which medicinal pain management can be done properly and actually serve as an essential component for assisting the Buddhist with intractable pain to die more comfortably without loss of awareness.      

     If we apply pain management logic to the use of medical marijuana by Buddhist vow-holders, I would ask if it is possible to treat illness by this means without side-effects. It is well established that chronic cannabis users develop a tolerance which requires a certain amount to normalize, or level-out to counteract possible unwanted emotional states such as depression or agitation, and have increasing difficulty in achieving a high. In such cases of dependency it seems possible to use the drug without altering the mind. But what about someone who is not dependent and is prescribed medical marijuana for pain associated with cancer, as it often is, or asthma? And what about the differences between delivery methods, such as edibles versus smoking, or smoking versus vaporizing? I would say that in comparison to opioids where pain management can be achieved without side-effects, the side-effects from medical marijuana are more difficult to avoid. This may simply be a matter of delivery and dosage and not inherent in the chemistry of the drug. It is interesting that, as far as I am aware, patients themselves are exclusively responsible for self-administering the marijuana prescribed to them. Envision patients sitting with an IV being administered THC right into the blood-stream, or being given THC pills. The degree to which we find this fanciful might be commensurate with the degree to which we have trouble disentangling the botanical as a therapeutic intervention from it as a recreational drug.          

     If Buddhist goals are the development of a calmly stabilized mind with insight into reality and a heart concerned deeply with others for their own sake, then actions that hinder these processes, such as altering the mind with substances and potentially increasing delusions and emotional afflictions (while breaking vows to do so), are obstacles on the various Buddhist paths. Here I distinguish between Buddhists who hold a vow to refrain from intoxicants and those who do not. Even if a vow-holder would refrain from using medical marijuana if they could not establish for certain that their complaint could be successfully addressed without mood/mind/consciousness altering side-effects, this does not mean that non-vow-holding Buddhists do not use marijuana both recreationally and therapeutically. There is nobody disciplining Buddhists except for the practitioner themselves, and the natural law of karma is considered to operate whether the practitioner is aware or concerned with the process or not.          

     I have entirely avoided discussion of tantric traditions where typically forbidden substances are consumed as a subversive against pollution taboos and to demonstrate transcendence of materiality. I have also chosen to bracket the occasions of sacred usage of botanicals explicitly for spiritual purposes, such as with ayahuasca during ceremony. Both of these areas of inquiry can potentially add to the discourse around medical marijuana and Buddhism.

==
Sat. Apr. 5

Zysk's study of ancient Indian medicine in Buddhist monastic and Hindu texts shows that intoxicants were at times doctrinally acceptable (by way of sanction by the Buddha) for use in treating monastics suffering from certain conditions despite the seeming contradiction with the vow to abstain from intoxicants. There are two examples found in the case stories of disease treatment in the medicine section of the Theravada Pali monastic code.
(1)
"Affictions of Wind: The monk Pilindavaccha suffered from the affliction of wind (vātābādha). On the recommendation of physicians (vejja, Skt. vaidya) oil (tela) was decocted, combined with a weakened intoxicating drink (majja, Skt. mada, madya), and given to the monk. If the drink was too strong, an oily massage (abbhañjana) was to be administered (Zysk 1991: 92)."
(2)
"Wind in the Abdomen: The affliction of wind in the abdomen (udaravātā) is discussed two times in the Vinaya. In the first case, a monk was cured by giving a mixture of salt and a type of astringent barley wine (loṇasovīraka) to drink. This treatment was allowed to the sick (gilāna), but for those not sick (agilāna), it was permitted as a drink (pāna) when mixed with water (udakasambhinna) (Zysk 1991: 100)."
It is interesting to note that mention of the medicinal use of intoxicating substances in both cases does not have explicit reference to neutralizing the intoxicating potential, but merely calls for a 'weakened' form of the drink for the sick monastic in the first case but not in the second, and dilution of the barely wine concoction for the healthy monastic. We could assume that the 'weakened' form is prepared by dilution, but that is not entirely made clear. Nor is it clear that the 'weakened' form of the first concoction is made to no longer have the potential to cause intoxication. The many examples of special exceptions for sickness in the monastic codes, such as flexibility around eating after midday, might explain the specific use of concoctions with intoxicants for sick monastics but why would healthy monks take a diluted form of the second concoction? We could assume that the need for dilution in this case would be to prevent intoxication, and that healthy monastics would be taking it as a prophylactic treatment (not just for the sake of it), but neither of these assumptions have explicit textual support. Buddhaghosa's Vishuddhimagga ("Path of Purification"), which Zysk relies on in his study, might help clarify these points. In his commentary on these cases Zysk doesn't seem to find this fascinating tension between the competing principles in the monastic code of maintaining clear-mindedness versus treating illness at all noteworthy. I also wonder what this "intoxicating drink (majja, Skt. madamadya)" is, and if it is related to honey based on linguistic similarity. I will be looking into it.

Wednesday, March 5, 2014

Religious Rights vs the Business & Politics of Green Energy

Thoughts on the dispute between Cham Shan Buddhist Temple and the Sumac Ridge Wind Project (wpd Canada)/Ministry of the Environment over Industrial Wind Turbines in the Kawarthas 


After recent news coverage on the issue in the National Post, a post went up on the Sumeru Canadian Buddhism blog siding with the Ministry of Environment's decision to approve the building of Industrial Wind Turbines by wpd Canada in the Oak Ridges Moraine despite a lack of local support for the project. Push back by the Cham Shan Chinese Buddhist community, who have been developing a retreat centre in the area, has led to an appeal of the decision. At first glance this may seem like a clear case of choosing between green energy or the religious practice of meditation, but choosing to side with the Cham Shan Buddhist community (and other locals, including First Nations communities and the Peterborough airport) is not choosing against the environment. After some reflection, I posted a response clarifying my position. The link to the blog post and the text from my response can be found below:
   
http://www.sumeru-books.com/2014/02/national-post-catches-wind-ontario-controversy-buddhist-retreat/


"Respectfully and in the spirit of dialogue, I have to disagree with your position. The issue, in my opinion, is not green energy versus meditation as you have framed it. I find this quite misleading. No one in the Cham Shan camp is contesting the benefits of green energy and their request to overturn the decision for the wind-farm in close proximity to the retreat development is not out of accord with the Dharma. You make it seem that a decision in their favour is a decision against the environment. I refute this. As is well known, the retreat project has decades of planning and tens of millions of dollars invested, and the building has begun, whereas the proposed wind-farm can be located elsewhere. There are tracts of land not close to human habitation where this wind-farm can be placed and still help feed the area's energy grid, doubtless a positive thing despite the Sumac Ridge Wind project being a for-profit venture by the wpd Canada company. You suggest that the retreat project is not in jeopardy, but what you might not have considered is that the nature of projects by non-profit charitable organizations are such that deviation from the original plans can in fact jeopardize their funding. The retreat project is very much in jeopardy.
To me, the issue is instead arm's-length provincial political leadership versus on-the-ground local voices in decision-making. It appears as an eco-win for Liberals for the wind project to get the go-ahead, and the PCs conveniently re-affirm commitment to scrap green energy act (see http://freewco.blogspot.ca/201... ) saying that "[t]he Green Energy Act is disastrous for rural Ontarians who live near these intrusive developments." Political wrangling aside, in this particular case, the local voices of minority religious and cultural groups, the Cham Shan Chinese Buddhist community and local Aboriginal communities, were quashed by the decision to approve the wind project. Reconciliation processes might lead us to think that we have progressed beyond the historical violence against minority groups in Canada, especially First Nations, but we are still in a climate that is hardly progressive when we consider the fact that federal spending on spiritual care services for non-mainstream religions has been recently cut. Or considering the over-representation of Aboriginal people in the Canadian Justice System with First Nations people comprising over 25% of the penal population but only 4% of Canadian population. These are but two terrible examples of how far we have to go to achieve fair and equitable treatment of minority groups in Canada.
You are quite right that the resistance has to do with the community's position that the wind-farm will disrupt their practice of meditation (within which I include pilgrimage between the sites in the retreat development). This is in accord with the Dharma as there is a pan-Buddhist injunction to have a beautiful and peaceful environment as support for meditation pursuits, as seen for example in the texts of Northern School Buddhist Masters Shantideva (Indian), Tsong Khapa (Tibetan), and Zhiyi (Chinese) to name but a few. Beauty is in the eye of the beholder. Your statement that "[p]ersonally, I feel if I were there, the sight of windmills would be very uplifting" assumes that the experience of an outsider to the Cham Shan Chinese Buddhist community would be the same as theirs. It questions the validity of their experience of industrial wind turbines as an interference to their practice. They are entitled to their experience. The construction of 19 industrial wind-turbines will create noise and particulates, and their subsequent operation will create infrasound and is considered by the community as unsightly. This is a strong enough reason for their appeal, on the basis of religious rights and freedoms, without even wading into the issue of harm to humans and animals by industrial wind-turbines. The research that I have uncovered show the harms to birds as existent but statistically low, and although some qualitative research into infrasound shows disturbances to meditators, quantitative research seems inconclusive. This does not mean that there are no empirically measurable health hazards, but rather, that the phenomenon of industrial wind turbine generated energy is young and the research as to its immediate and long-term effects on life even younger.
I fully support the Cham Shan appeal for the Ministry to overturn the approval given to the Sumac Ridge Wind project. In full disclosure, I am serving as an expert witness for the upcoming tribunal. However, my view of the situation is not the result of my acting in this capacity, but rather I am acting in this capacity because of my view.
Thank you for the forum for this discussion.
Sincerely,
Sean Hillman
PhD student, Religion/Bioethics/South Asian Studies
Department for the Study of Religion
University of Toronto"

Tuesday, January 28, 2014

How do Buddhists view medical marijuana? The Medical Marijuana Review January 2, 2014. Feature Story by Dave Gordon

When the Dalai Lama recently revealed his support for the use of medical marijuana, advocates of the drug discovered they had a new ally. But are the Dalai Lama’s views on medical cannabis breaking rank with the traditional Buddhist stance? Or are Buddhists generally in favour of medical marijuana as well?

Primary to the debate is what Buddhism calls the “five precepts”: refrain from taking life, don’t take what’s not yours, avoid sexual misconduct, don’t speak falsehoods, and avoid intoxicants.

It’s the last precept that’s a sticking point when it comes to medical marijuana.

Rev. Dr. Bhante Saranapala, a Buddhist monk and preacher working at the West End Buddhist Temple and Meditation Centre in Mississauga, Ontario, contends that the fifth precept forbids marijuana in any form.

“The five precepts are moral principles, and one of them is to refrain from intoxicants. If any substance leads to heedlessness, or could make one unconscious, you have to refrain, regardless of whether you think it’s good,” he says. “It alters the pure nature of the mind.”

The possibility exists, he added, that “you would not understand what you’re doing, or what you’re saying (while high). That’s why this is distinct.”

Historically there are few, if any, references in Buddhism regarding marijuana as a medicine, according to an article on Beliefnet.com.

Yet, the San Francisco Patient and Resource Center notes that Buddhists have used cannabis in tandem with meditation practices “as a means to stop the mind and enter into a state of profound stillness, also called Samadhi.” They add: “Various spiritual texts, including the Buddhist Tara Tantra, list cannabis as an important aide [sic] to meditation and spiritual practice.”

One source notes that Buddha himself believed cannabis was a cure for rheumatism.

Brian Ruhe, of the Theravada Buddhist Community of Vancouver, sides with the Dalai Lama on the issue.

“I’m in favor of [medical marijuana] as well. I explain it by saying the idea of medical marijuana is reducing suffering, and reducing suffering is good. In this case it’s reasonable, showing intelligent use for that situation,” he adds.

Ruhe has been a practicing Buddhist for 22 years and spent seven months as a Buddhist monk in Thailand in 1996.

“Medical marijuana is OK because Buddhism is a path of intelligence, discernment and compassion, not just following rules,” he contends.

“The Buddha said his teachings were not internally inconsistent because sometimes he would say one thing to a person, and something else to someone else. This is an example.”

Ruhe, also the author of two books on meditation and a teacher of university-level courses on Buddhist philosophy and meditation, emphasizes that the medicinal aspect is key. “You should avoid recreational marijuana, to avoid deluding thoughts.”

Sean Hillman, a Buddhist scholar-practitioner and a University of Toronto doctoral student in Religion, Bioethics and South Asian Studies, says that “it is difficult to establish an authoritative stance” on many issues.

As such, “what people choose to ingest is their private business, not subject to Buddhist religious scrutiny,” Hillman notes.

He spent 13 years as a Buddhist monk, ordained by the Dalai Lama. His research straddles religious studies and medical anthropology, with a strong interest in the interaction between religion and end-of-life decision making.

“Simply, when the pain at hand is addressed without any intoxicating side effects, medication has been administered correctly and pain management is effective,” he states.

“Finding the best delivery method and dosage are the challenges. If there is intolerable pain, it is not yet managed. Going beyond this threshold can lead to side effects, including drowsiness and even respiratory failure. I would ask if it is possible to treat illness by this means without side effects.”

The real challenge, therefore, may not be inherent in the chemistry of the drug. Unwieldy side effects are “obstacles on the various Buddhist paths,” as Hillman puts it.

Ajahn Punnadhammo, a Buddhist monk ordained in Thailand in 1992 who runs the Abbot of Arrow River Forest Hermitage in the Thunder Bay, Ontario, region, says most Buddhists would find medical marijuana acceptable because the use of opiates as painkillers for severe injury or illness has already been around for decades and Buddhists don’t oppose that medicine.

“Recognizing that any of these substances are open to abuse, most Buddhists would accept their proper medical use with due caution,” Punnadhammo adds.

==

How do Buddhists view medical marijuana?
The Medical Marijuana Review
Posted on January 2, 2014 by Dave Gordon in Feature Story
http://medireview.com/2014/01/how-do-buddhists-view-medical-marijuana/#.UuffYxb0DUT

Monday, May 6, 2013

Fair Distribution in Jain Monastic Food Acquisition


Sean Hillman B.A., M.A.
Doctoral student, Religion/Bioethics/South Asian Studies
Department for the Study of Religion
Joint Centre for Bioethics
Centre for South Asian Studies
University of Toronto 

This paper began as a textual investigation into the normative prescriptions on the procurement and eating of food in three Indic monastic codes of discipline: the Jain Ākāraṅga Sūtra, the Pali Buddhist Vinaya, and the Swaminarayan-Vaishnava Shikshapatri Bhashya. However, as the research unfolded, it became clear that there was far too much material in these three codes, and their commentaries, for a paper of this size. As such, the focus will be squarely on Jain monastic food orthodoxy as found in a close reading of two primary texts that have ascetics as their main intended audience: the Ākāraṅga Sūtra and Ācārya Amitagati's Yogasāra-prābhṛta (Gift of the Essence of Yoga). The latter includes a contemporary commentary by the translator Dr. C.S. Jain. Along with a textual analysis of the primary texts, some ethnographic sources will help demonstrate if contemporary Jain food orthopraxy is in agreement or at odds with the orthodoxy of the texts.
There are endless discussions about what Jains normatively can and cannot, and descriptively do and do not, eat. The forbidden foods, and proper ways of preparing and eating food, are well documented. The central issue I chose to explore within this paper, however, is the doctrinal restrictions related to the procurement of food and drink by Jain monastics. As such, the scope of the study was initially narrowed down to two main questions: (1) Under which circumstances can the Jain monastic receive and not receive food? And, (2) From whom can the Jain monastic receive and not receive food? I also began to comb the texts to discover whether Jain monastics can ask for food verbally or indicate hunger by physical gestures. Again, there was an overabundance of material. These removed sections will be grist for a future study.
I aim to demonstrate that the Ākāraṅga Sūtra contains a more subtle approach to non-violence (ahimsa) than by way of mere restrictions that are meant to protect humans, animals, insects, plants, microscopic organisms and elemental beings from physical harm and that which threatens life. Unlike the Yogasāra-prābhṛta, the author(s) and redactors of the Ākāraṅga Sūtra are proponents of the fair distribution of resources, demonstrated by numerous precepts designed to protect donors, other Jain monastic and non-Jain alms recipients from resource deprivation by requiring the monastic to not divert food to themselves that would otherwise rightly go to another.

The Texts
The Ākāraṅga Sūtra and Yogasāra-prābhṛta generally frame the usage of food quite differently. In the initial section of the former, we find food consumption normalized: “As the nature of this (i.e. men) is to be born and to grow old, so is the nature of that (i.e. plants) to be born and to grow old…as this needs food, so that needs food” (Jacobi 10). In the latter, engagement with food is villainized: “A yogī, established in detachment, does not entangle (himself) in the obstructions caused by…the food… For one indulging with indolence in activities like taking food…continued violence has been described” (vs. 14-15 Jain 2003, 175-176) Despite such disagreements, both texts give guidance to the Jain monastic on how to properly acquire food.
My choice of the Ākāraṅga Sūtra is based on the primacy given to it as a monastic discipline text in the Jain traditions. It is “[t]he first Aṅga” or ‘limb’ from among the eleven still extant (out of the original twelve) (Jaini 52) and is “appropriately called Āckāra (Conduct), [as it] forms the law book for Jaina monks and nuns. It regulates their conduct by delineating the obligatory vows…and also by giving specific instructions pertaining to permissible methods for obtaining such requisites as food, clothing, lodging, and medicine” (Jaini 52-53). Relevant to an investigation into textual Jain monastic food regulations, it is also a text that includes both monks and nuns in its discussions. Two sections are of greatest relevance to our topic: the first book’s seventh lecture on ‘Liberation,’ and the second book’s first lecture on ‘Begging of Food,’ with a heavier emphasis on the latter. As for the Yogasāra-prābhṛta, I find the text quite compelling despite several difficulties including the fact that it was written exclusively for male monastics to the complete neglect of nuns. Jain’s translation and annotations are also fraught with constant grammar and spelling errors, and his commentary is only distinguished by paragraph indentations rather than more typical and obvious markers (explicit mention of a commentarial section, font changes etc.) He also adds words and phrases to the root text within parentheses, presumably to clarify the meaning, but does not explicitly indicate that they are his additions. At times these additions seem to be considerably and alarmingly interpretive.
The most concerning feature of the Yogasāra-prābhṛta is the manner in which it unabashedly deprecates females. I fear my potential for releasing a tirade as my (albeit modern) feminist sensibilities are deeply offended, and cannot restrain myself from at least briefly mentioning the misogyny of the author and translator/commentator. Both writers hold that women have both physical and mental obstacles that block them entirely from becoming liberated (Jain 187-189). Amitagati lists seven problematic mental states that all women suffer from, ‘indolence’ being the main one which Jain unpacks as fifteen types of ‘psychoses.’ Next, Amitagati tells the reader that certain parts of the female body are prone to the “generation of subtle jīvas” (Jain 188) such as under the breasts, in the armpits and genetalia. Due to this, he concludes that “the (necessary) restraint is not possible in women” (Ibid.). I fail to see how this does not similarly occur under the arms and genetalia of males, but there is no symmetrical mention of this fact. Strangely, Amitagati then allows for women to practice as monastics in the immediately following verse, and Jain assures us that this can only at best lead to a male rebirth. Although men are not made out in the text to be particularly prone to any mental or physical problems based on gender, Jain attempts to temper his misogynistic position by stating that “all male human beings are also not so qualified, as only a few of them get liberation after undergoing the course of necessary discipline” (Jain 188). It is also the position of many Jains that it is impossible for any human being to become liberated in this age and our particular cosmographical location. Regardless, the bias against females is undeniable and cannot be ignored.
As difficult as it is to suspend one’s disbelief in this matter, for this paper the focus is on food regulations within a singular chapter in the Yogasāra-prābhṛta that explicitly addresses monastic discipline, as the introduction states: “Chapter-8: This chapter deals with the conduct of the truth seeker, which has to be essentially observed by him” (Jain 2003, xvi).
Dating both texts is a difficult task. Starting with the Aṅga texts, the Indian Historiographer Dr. Jyoti Prasad Jain suggests that those who would become the Digambara began redacting and writing their canon around the end of the first century B.C.E., “preserving the bulk of the twelfth Aṅga...together with fragments from the other Aṅgas” (Jain 2006: 182), whereas those who would become the Śvetāmbara resisted canonical writing until the late fifth century C.E. They preserved “substantial parts of the remaining eleven Aṅgas (Ibid.). One might think that the Digambara emphasis on orthopraxic discipline would mean that they would be intent on preserving the Ākāraṅga Sūtrabut the evidence as to when and which sect wrote the first Aṅga seems lacking. A wide window of time, no doubt, we can at best say it is from the late urban/early classical period with the lower limit of its composition as first century B.C.E. and sometime after the late fifth century C.E as its upper limit.
            Locating Ācārya Amitagati's Yogasāra-prābhṛta temporally is made difficult by the fact that there are two Jain scholar-monks by the same name, and that our author “has not mentioned the date of the composition of his work” (Jain 2003, xiii). The one indicator that remains is that one of the two Ācāryas mentions the other: “Amitagati-II has immensely praised Amitagati-I, in his work, Śubhāṣita-Ratna-Sandoha, which was composed by the latter in the tenth century A.D. when Muñja was in throne” (Jain 2003, xiii). The Encyclopaedia of the Hindu World describes this Amitagati as a “Sanskrit poet, who was a Digambara Jain ascetic and pupil of Mādhavasena. He is the author of the Subhāṣitaratnasandoha ‘Collection of Jewels of Happy Sayings’ (A.D. 1014)” (Gar 384). The dates given have a discrepancy of a century. Sen’s Ancient Indian History and Civilization confirms the reign of the Paramara King Munja as “between A.D. 970 and 973” (319). This still doesn’t tell us which period is correct in placing the text that retroactively mentions our Amitagati. Is Jain’s suggestion more accurate because he has a dynastic reference? It is unclear. We can say at best say it is an early medieval text composed sometime around or before the cusp of the tenth and eleventh centuries C.E.

Jain Monastic Food Acquisition
     In discussing Jain food pujas, Indologist John E. Cort states that “[f]ood is necessary to maintain the physical body which is both an obstacle to liberation and a symbol of bondage… food is part of the physical fuel that drives the round of rebirth” (2001: 78). Immediately we can see an inherent tension in the life of a Jain monastic: dependence on food for survival prevents liberation. This is because Jains hold that every single action and interaction, physical, verbal and mental, causes some relative degree of harm to others and oneself and thus binds the subtle substance of karma to the soul, especially the interactions involved with procuring and consuming food since “[f]ood fuels the calamity of bodily existence, and is also associated with the sins inevitably occasioned by its production and preparation” (Cort 1998: 158). Cort also states that “[b]ecause of the spiritual hazards of eating, fasting is central to both lay and monastic practice among Jains” (Ibid. 152). As such, Jain monastics aim to eventually quit the desire for, and eating of, food altogether with ritual/voluntary fasting unto death (sallekhana), a feat that we might call the ultimate austerity. Among the Jains I have encountered, sallekhana is held in the highest of esteem by monastics and lay-people alike and those who do and have done the practice are publicly revered with great pageantry during the event, and with shrines and glowing storytelling post-mortem. There are monastics still engaging in the practice today and although theoretically possible for lay-people, their engagement in sallekhana is quite a rare occurrence. Most will expressly hope to be able to perform the ritual sometime in this or in future lives. Eating and drinking, as the most important of the physical needs, are also the most difficult to renounce. To stop the influx of karma, throughout their religious career Jain monastics train for total mental equanimity and inaction in many ways, including restricting the frequency of eating and types of foods consumed, and various lengths of fasting. With these aims, and in relation to procuring the food and drink necessary for “keeping the body going while on the road to liberation” (Cort 1998: 158), monastic texts and practice serve to minimize the negative results of physical, verbal and mental actions through prescription and proscription. Although not perfectly avoiding all activity, such regulations ensure “[t]he mendicant recipient is protected by asceticism” (Ibid.).
There is some variation in the sources as to the manner and frequency that Jain monastics go out to beg for, or receive, food. With regard to this, the late German Indologist Hermann Georg Jacobi references the Kalpa Sūtra: “The Gaina monks collect food in the morning or at noon… They generally but once in a day go out begging; but one who has fasted for more than one day may go a begging twice a day (f7. Kalpa Sūtra, Rules for Yatis, 20)” (xxv). In contemporary practice, variation in the way of, and the number of sessions for, receiving food seems to be based on sectarian differences. In brief, Cort found that “[t]he Mūrtipūjak [Śvetāmbar] procedure of gocarī contrasts sharply with the much more formally ritualized practice of āhār-dān or gifting of food among the Digambar Jains,” (Cort 2001: 107) where some monastics in the former sect collect on behalf of fellow monastics and request alms with a verbal cue, and the latter sect only ever collect their own alms and indicate hunger by a mere physical gesture. British Historian William Dalrymple noted that his monastic informant “Prasannamati Mataji belonged to the order of “white-clad Digambara nuns, or matajis” (2). Of the two major Jain sects, the Digambara are renowned for their strict religious life: “probably the most severe of all India’s ascetics” (Ibid.). As such, this nun reported that during her ordination ceremony her Guru “told us clearly what was expected of us…to take food only once a day” (21) and that “[f]or many years, I fasted, or ate at most only once a day” (4). It was also observed that “[a]t ten o’clock each day, Prasannamati Mataji eats her one daily meal (11). Cort observed a different approach among Śvetāmbar Jain monastics, who received food three times daily: “Late morning is time for another food-gathering round… Late afternoon is the time for the final food-gathering round and meal, eaten before sunset (2001: 103). That there is no discernable pan-Jain standardized requirement as to the number of alms-rounds will not at all hinder this investigation.
We will next proceed to fair distribution in Jain monastic food acquisition in two thematic sections: (1) not taking the food of others while receiving food; (2) not taking the food of fellow monastics after receiving food on their behalf.

Not Taking the Food of Others While Receiving Food
The Ākāraṅga Sūtra holds the resources of others as deeply valuable, and deploys an impressive number of strategies to protect them from going to Jain monastics inappropriately. The monastic is told to avoid public celebrations that offer food since “[w]hen a man goes to a much-frequented and vulgar entertainment…he receives what should be given to others” (vs 4 Jacobi 95-96). There is also one verse which shows a specific concern for ensuring that the Jain monastic does not divert resources earmarked for the householder themselves: “there are some faithful householders …who will speak thus:… let us give to the ascetics all food…that is ready for our use, and let us, afterwards, prepare food for our own use.’ Having heard such talk, the mendicant should not accept such-like food” (vs. 1 Jacobi 111). Monastics are also not to go on alms-round to homes while food is being prepared:
A monk or a nun desirous to enter the abode of a householder, should not do so, when they see that the milch cows are being milked, or the food…is being cooked, and that it is not yet distributed. Perceiving this, they should step apart and stay where no people pass or see them. But when they conceive that the milch cows are milked, the dinner prepared and distributed, then they may circumspectly enter or leave the householder's abode for the sake of alms. (vs. 3 Jacobi 98)
This verse appears to serve a dual purpose. Like the previous example, we see here another effort to not lead the devoted Jain layperson to give what has already been portioned off for their personal use. Additionally, following this precept is an attempt to uphold another major requirement of Jain food orthodoxy and orthopraxy: ensuring that no food has been prepared specifically for the monastic, as this would directly implicate them in the karmic accumulation from any harms done to living beings during such preparation. Anne Vallely, an anthropologist of South Asian religions with a particular focus on Jainism, found this in the contemporary practice of Jain nuns who informed her that “food must never have been prepared expressly for them” (Vallely 3).  
Another intriguing verse offers a special scenario:
If a householder should fetch fossil salt or sea salt, put it in a bowl and return with it, a monk or a nun on a begging-tour should not accept it… But if he has inadvertently accepted it, he should return with it to the householder, if he is not yet too far away, and say, after consideration: ‘Did you give me this with your full knowledge or without it?' He might answer: 'I did give it without my full knowledge; but indeed, O long-lived one! I now give it you; consume it or divide it (with others)!' Then being permitted by, and having received it from, the householder, he should circumspectly eat it or drink it (vs. 7 Jacobi 116).
Such food items are worrisome possibly because they are rare and costly. First and foremost, our authors attempt to ensure that a householder does not mistakenly give something that they either do not wish to give, or are in need of for themselves. Checking with the donor is out of respect for both of these possible valid reasons for not giving them. They are not made to be forbidden items, but must be eaten clandestinely presumably so others do not see a monastic taking precious food which would be considered unseemly by some and harm the reputation of the order.
There are many verses, indicating a much greater textual concern, which aim to ensure that the Jain monastic does not divert resources from others who similarly rely on donated food, including non-Jains. Five of these are explicit about avoiding this. One is generic: “A monk or a nun on a begging-tour should not accept food…which for the sake of another has been put before the door” (vs. 7 Jacobi 113). Two mention particular recipient-types; one of which is found in the concluding lines of the begging of alms lecture: “the seventh rule for begging food. A monk or a nun may accept food…which is not wanted by bipeds, quadrupeds, Sramanas, Brahmanas, guests, paupers, and beggars” (vs. 9 Jacobi 118); and the other is the first mention of five recipient-types that are given great importance by the text: “A monk or a nun should not accept of food …which they know has been prepared by the householder for the sake of many Sramanas and Brāhmanas, guests, paupers, and beggars” (vs. 12 Jacobi 91). Next: “When a monk or a nun on a begging-tour knows that a Sramana or Brāhmana, a guest, pauper or beggar has already entered (the house), they should not stand in their sight or opposite the door. The Kevalin says: This is the reason: Another, on seeing him, might procure and give him food” (vs. 5 Jacobi 101). Lastly: “When a monk or a nun on a begging-tour perceives that a Sramana or Brāhmana, a beggar or guest has already entered the house, they should not overtake them and address (the householder) first” (vs. 6 Jacobi 102). The presence of “Sramanas and Brāhmanas, guests, paupers, and beggars” at food-related events is a frequently repeated refrain to continually reinforce the concern of not taking the due share of these others and to cover various possible scenarios, such as with the following: when such folk “are entertained with food” (vs.1, Jacobi 92); during “assemblies, or during offerings to the manes, or on a festival… when on such-like various festivals” (vs.3, Jacobi 92-93) these people are given food, but the prohibition is waived if “all have received their due share, and are enjoying their meal” (vs. 4 Jacobi 93); “a wedding breakfast in the husband's house or in that of the bride's father” and “a funeral dinner or to a family dinner where something is served up,” unless no such people are there and, further, the waiving of this prohibition “applies, according to the commentator, only to sick monks, or such as can get nothing elsewhere” (vs. 2 Jacobi 98); when “the first portion of the meal is being thrown away (f1: In honour of the gods) or thrown down, or taken away, or distributed, or eaten, or put off, or has already been eaten or removed” since such people may  “go there in great haste” (vs. 1 Jacobi 99). At first glance we might assume that these restrictions are displaying a non-sectarian motivation. However, it is also possible that such textual moves are intended to avoid the Jain monastic order from gaining the reputation among the community-at-large and the others who similarly rely on the kindness of others, including those of other sects, of interfering with others’ alms.   
The purpose of one particular precept is not made explicitly clear but follows directly after a verse that prevents the Jain monastic from diverting the due share of other beggars, which might indicate that it, too, is for the same purpose. In this case, however, the recipients are animal scavengers: “When a monk or a nun on a begging-tour perceives that many hungry animals have met and come together in search of food, e.g. those of the chicken-kind or those of the pig-kind, or that crows have met and come together, where an offering is thrown on the ground, they should, in case there be a byway, avoid them and not go on straight” (vs.1 Jacobi 102-103). There is another verse in this lecture on begging of food that recommends steering clear of animals, but has to do with protecting the mendicant and other life from harm (vs.3, Jacobi 100). Based on the context of the verse in question, and the unlikeliness that the monastic would take up such food from the ground (since taking up food “placed on the earth-body”( vs.4 Jacobi 106) is prohibited and the “monk or a nun may accept food which had been taken up from the ground” only if “placed in a vessel or in the hand” (vs. 8 Jacobi 118)), I conclude that the concern is not the taking of such food by the monastic. In walking close to the animals, there is the potential for them to scatter out of fear and lose the opportunity to partake of the food. An even more nuanced possibility is that after scattering the animals may very well return, as we all have observed in nature, but the original and natural order of arrival to the food would be disturbed by the monastic. A variation on the theme of not depriving others of what would be rightfully theirs, this would be a very subtle approach to non-harm, indeed. There is another verse that may depict a similar interest in the needs of animals: “A monk or a nun on a begging-tour should not accept any such-like raw unmodified substances as sugar-cane, which is full of holes, or withering or peeling off or corroded by wolves” (vs. 12 Jacobi 110). Its contextual placement has more to do with avoiding food items that are still growing or potentially teeming with life, such as with tiny beings that take up residence or are born in the small spaces within plant-life. Also, ideally the cane would not have been procured specifically for the monastic. However remote, these points do not eliminate the possibility of a multi-purposed verse interested in protecting plants, plant-dwelling beings, and wildlife food sources.     

Not Taking the Food of Fellow Monastics Having Received Food on their Behalf
While researching Jain ritual/voluntary death (sallekhana) in India in the summer of 2010, many of my interlocutors informed me that a Jain monastic is not an appropriate person to be the donor of any items because of their adherence to non-possession (aparigraha). As such, “the mendicant is dependent upon the laity for food and all the other necessities of life” (Cort 2001: 105). Such ethnographic accounts might lead us to believe that Jain monastics do not give food to other monastics but there are both textual and anthropological evidence that show certain circumstances whereby the Jain monastics distribute food to other monastics. Our two texts disagree as to whether a monastic can give away food that has been given to them. Verse 64 of the Yogasāra-prābhṛta states: “The morsel of food placed in the hand (of a saint) is not fit to be given to any other (person) (by the saint). If it is given so, the saint should not take food (thereafter). If he takes (food) (even then), the saint commits blemish (for himself)” (Jain 2003, 194). Jain adds in his commentary that “[t]he saint must partake of food as offered by the householder… He must not meddle with it or spare it for use by others. This rule should be observed very strictly by him or he will incur sin for himself” (Jain 2003, 194). The verse taken alone does seem to allow for the monastic to give away food that has been given to them, under the requirement that they do not eat any more. I assume this to mean during that session of eating, and not forever and always. A negative karmic result is said only to come if, having given food away, the mendicant eats again and not by the mere act of giving food away. The commentary has a stricter position than the verse. It does not allow for the food to be given to another as the negative karmic consequence comes from any act other than partaking of the food as it is. The commentary also seems to suggest that the food offered must be eaten in its entirety and not altered, such as with making small piles with the fingers to more easily place food in the mouth.
Although there is a verse in the Ākāraṅga Sūtra that forbids monastics from giving food to fellow monastics, it is only under very specific circumstances: “A monk or a nun on a begging-tour should not give, immediately or mediately, food…to…a monk who avoids all forbidden food, to one who does not” (vs.10 Jacobi 90). This prevents cross-contamination between those whose food practices differ. Otherwise, there are many situations outlined where it is permissible, and even required, to give food to fellow monastics (and even non-Jains). We find the following admonishment in the “Begging of Food” lecture of the Ākāraṅga Sūtra:
A monk or a nun, having received a more than sufficient quantity of food, might reject (the superfluous part) without having considered or consulted fellow-ascetics living in the neighbourhood, who follow the same rules of conduct, are agreeable and not to be shunned; as this would be sinful, they should not do so. Knowing this, they should go there and after consideration say: 'O long-lived Sramanas! this food…is too much for me, eat it or drink it! After these words the other might say: 'O long-lived Sramana! we shall eat or drink as much of this food or drink as we require; or, we require the whole, we shall eat or drink the whole.’ (Vs. 6 Jacobi 112-113)
Here, giving leftover food to fellow Jain mendicants is made to be a requirement, with the fault lying in not attempting to give the leftover food to them. If we consider this verse and verse 64 from Amitagati’s text, the root verses alone, it appears as though: (1) having leftovers is anticipated and a faultless possible outcome, and (2) having such leftovers and giving them away to another Jain monastic, after the mendicant themselves has completed eating what they require, is also at least not a breach in conduct. The chronologically later text has thus amended the earlier textual requirement to seek an appropriate recipient of leftover food.
There is another verse in the same lecture of the Ākāraṅga Sūtra which shows the monastic as one who receives food and distributes it to fellow Jain monastics:
A single mendicant, having collected alms for many, might, without consulting his fellow-ascetics, give them to those whom he list; as this would be sinful, he should not do so. Taking the food, he should go there (where his teacher…is) and speak thus: 'O long-lived Sramana! there are near or remote (spiritual) relations of mine…forsooth, I shall give it them.’ The other may answer him: ‘Well now, indeed, O long-lived one! give such a portion!' As much as the other commands, thus much he should give; if the other commands the whole, he should give the whole ’ (Vs. 1 Jacobi 113).
Again we see a discrepancy between our two texts. In this case, for fear of the mendicant making distribution decisions based on attachment, they are required to consult their teacher for permission and guidance. The texts suggests that the teacher may well answer agreeably to the request, but leaves room for the teacher to suggest otherwise in the service of fairness. This practice of collecting alms on behalf of other monastics is supported in ethnographic accounts of contemporary Jain practice. As briefly mentioned earlier, in the Digambar ār-dān food gifting “each mendicant, no matter how senior, performs his or her own food-gathering round” (Cort 107), whereas Śvetāmbar monastics do collect on behalf of other monastics. In a section entitled The Daily Routine of a [Śvetāmbar] Murtipujak Mendicant under ‘Gifting’ (Cort 2001: 100), the ethnographer describes how “some of the mendicants go to the nearby homes of Jain laity to collect food and water in their wooden bowls, a ritualized action known as gocarī” (102) and, while doing so, “[h]ow much the mendicant takes depends upon the number of mendicants for whom he or she is collecting food” (107). The potential for favouritism mentioned in the Ākāraṅga Sūtra verse above is solved in contemporary Śvetāmbar practice not by consultation with senior monastics but by equal distribution to all mendicants (103).
The “scholiast says that [it] should only be resorted to under pressing circumstances” (Jacobi 102), but the Ākāraṅga Sūtra text does have an allowance for the Jain monastic to not only divide up donated food according to his best discretion, but also to give to non-Jain beggars:
Another man may bring and give him food…and say unto him : 'O long-lived Sramana! this food…has been given for the sake of all of you; eat it or divide it among you.’ Having silently accepted the gift, he might think: 'Well, this is just (enough) for me!' As this would be sinful, he should not do so. Knowing this, he should join the other beggars, and after consideration say unto them: ‘O long-lived Sramana! this food…is given for the sake of all of you; eat it or divide it among you.’ After these words another might answer him: ‘O long-lived Sramana! distribute it yourself.’ Dividing the food…he should not (select) for himself too great a portion, or the vegetables, or the conspicuous things, or the savoury things, or the delicious things, or the nice things, or the big things; but he should impartially divide it, not being eager or desirous or greedy or covetous (of anything) (vs. 5, Jacobi 101-102).
Despite the scholiast offering the escape clause that this applies only in times of dire need, it is an impressive verse nonetheless. Firstly, giving food to a monastic under the same rule is one thing, and our texts disagree (to some extent) as to the appropriateness such a practice. Giving food to non-Jains, who may or may not even be mendicants, is another matter entirely! It is surprising since many verses allow the monastic only to “share with his fellow-ascetics in the neighbourhood, who follow the same rules of conduct, are agreeable, and not to be shunned” (vs. 7 Jacobi 116). The food is not only to be portioned out equally, but the recipient who has the unusual charge of dividing up the food is asked to leave the worst for themselves. There seems to be an internal contradiction in these final lines since they both call for negative partiality, giving the best and leaving the worst, as well as impartiality which would mean that every recipient would get equal amounts of both the best and worst foods. Both principles are evident but the competing injunctions for fair distribution and abandoning desire in this excerpt seems to be won by the latter, if the word-count is any indication of emphasis. A similar warning is given for ordinary circumstances as well:  “A single mendicant, having received some food, might eat what is good, and bring what is discoloured and tasteless; as this would be sinful, he should not do so” (vs. 3 Jacobi 114). When there is enough to distribute, eating before returning to the religious community does not seem to be problematic, nor is the equal distribution of portions mentioned here. Rather, the act of eating what is best and leaving the dregs for fellow monastics is proscribed. The verse leaves room for two possibilities: the recipient (a) eats the dregs themselves and leaves the best for others, or (b) ensures that every monastic (including themselves) gets an equal amount of both the best and worst parts of the food.
Lastly we have two examples of monks concealing food by various means in order to divert them for their own use. The first has the recipient monastic disguising the food to deceive others as to its quality:
A single mendicant, having collected agreeable food, might cover it with distasteful food, thinking: 'The teacher or sub-teacher…seeing what I have received, might take it himself; indeed, I shall not give anything to anybody!' As this would be sinful, he should not do so.
Knowing this, he should go there (where the other mendicants are), should put the vessel in his out-stretched hand, show it (with the words): 'Ah, this! ah, this!’and hide nothing. (vs. 2 Jacobi 114)
Using the hermeneutics of suspicion we can surmise that this sleight of hand was known to our author(s) in a historical context where living off of the kindness of others, both by religious practitioners and ordinary folk, is a long-standing practice. It likely did not arise out of pure imagination and they hoped to nip this trick in the bud. What complicates this scenario is the potential for the teacher to disregard the code and take the best for themselves! Going by the spirit of the law, the authors might hope that the teacher would follow the same repeated principle of not taking the best food. The next and final example has mendicants giving food for the sake of fellow mendicants who are sticken with illness via an intermediary monastic:  
Some mendicants say unto (others) who follow the same rules of conduct, or live in the same place, or wander from village to village, if they have received agreeable food and another mendicant falls sick: 'Take it! give it him! if the sick mendicant will not eat it, thou mayst eat it.’ But he (who is ordered to bring the food) thinking, ‘I shall eat it myself’ covers it and shows it (saying): ‘This is the lump of food, it is rough to the taste, it is pungent, it is bitter, it is astringent, it is sour, it is sweet; there is certainly nothing in it fit for a sick person.’ As this would be sinful, he should not do so. (vs. 1 Jacobi 116)
This is among the few concluding verses of the ‘Begging of Food’ lecture and features the particularly despicable possibility of a monastic hiding food items and lying about the nature of those items in order to eat food meant for a sick mendicant. I think it is significant that this section of the Ākāraṅga Sūtra ends on such a note. It gives a special emphasis on ensuring a fair share of food for the most vulnerable members of the Jain monastic order. 

Conclusion
In discussing the relationship between Jain monastics and lay-people, the Ākāraṅga Sūtra gives great value to the resources of householders. It also holds fair distribution in esteem, in both the contexts of Jain monastics among themselves and between Jain monastics and others who depend on food donations, both of human and animal species. I propose that this is a very subtle manner of practicing non-violence that comes from a deep concern for the well-being and integrity of Jain ascetic practitioners and those they come into contact with over the course of their religious careers. Having pored over every verse related to the topic of food in this text, the sheer quantity of verses that push for protection of the due share of non-Jain dependents betrays an anxiety that likely has to do with protecting the reputation of the Jain monastic community.  This is also supported by the constant mention of various activities that are ultimately allowable but which should be done in secret rather than in full view of watching eyes. There is some indication that the Ākāraṅga Sūtra considers the reduction of desire in the monastic as a more weighty requirement than fair distribution. As for the conduct chapter of Ācārya Amitagati’s Yogasāra-prābhṛta, despite leaning away from the idea, it does leave room for the monastic to give food to other monastics. A similar emphasis on fair distribution as we see in the temporally earlier Ākāraṅga Sūtra is entirely absent.

Citations

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__________. Jains in the World: Religious Values and Ideology in India. Oxford University
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Dalrymple, William. “The Nun’s Tale.” Nine Lives: In Search of the Sacred in Modern India. Bloomsbury (2009): 1-28. Print.

Gar, Gaṅgā Rām (Ed.). Encyclopaedia of the Hindu World: Ak-Aq. New Delhi: Ashok Kumar Mittar,  1992. Print.

Jain, Dr. C.S. (Tr. & annotations); Ācārya Amitagati's Yogasāra-prābhṛta (Gift of the Essence of Yoga). Bharatiya Jnanpath, New Delhi; 2003. Print.

Jain, Dr. Jyoti Prasad. Religion and Culture of the Jains. New Delhi: Bharatiya Jnanpith, 2006. Print.

Jaini, Padmanabh S. The Jaina Path of Purification. Motilal Bariarsidass, 1998. Print.

Jacobi, Hermann (tr.). Jaina Sutras Part I: The Ākāraṅga Sūtra, The Kalpa Sūtra. Oxford University Press, 1884. Motilal Bariarsidass, 1964. Print.

Sen, Sailendra Nath. Ancient Indian History and Civilization: 2nd Edition. New Delhi: New Age International Publishers, 1999. Print.

Vallely, Anne. Women and the Ascetic Ideal in Jainism. Doctoral Dissertation, Department of Anthropology: University of Toronto,1999.