First, I'd like to thank the Pontifical Council for inviting me to join this conference.
I am the chief monk of a temple called Saimyouji which is located just north of Tokyo in Japan. The temple was first built in 737 A.D. I am also a doctor of internal medicine. Saimyouji is a temple associated with one of the four main Buddhist pilgrimages in Japan. Buddhist services praying for world peace are performed for two months during October and November in the temples of our Buddhist pilgrimage. At our temple, we have several institutions for health care and for the aged, such as a hospital, a nursing home, a nursing unit that performs house calls, and two group homes.
Because I am both a Buddhist Monk and a medical doctor, today I would like to talk to you about science and Buddhism. I think that when we discuss matters which are refutable, we should use scientific knowledge for critical analysis. And, when we discuss matters which are not refutable, we should consider them in terms of humanism and with reference to the classics.
In this speech I would like to discuss two things. First I would like to talk about the issues of dying with dignity and organ transplantation, with regard to a specific case that involved our hospital. Then I would like to follow that with a scientific and humanism discussion and finish by talking a little about these things from the point of view of the Buddhist Religion.
The case involving the issues of dying with dignity and organ transplantation that I would like to present concerns a 53 year old woman who arrived at our hospital as a so-called DOA (Dead on Arrival). At around 1:00 PM, on October 9th, 1992, a woman was stung by a hornet and half an hour later she went into anaphylactic shock. Unconsciousness, convulsion and cardiac arrest occurred while she was being carried to our hospital by a neighbor's car. Cardiopulmonary resuscitation was performed immediately on arrival. Endotracheal intubation was done by a trained anesthesiologist. Intravenous fluids were administered through an I.V. drip and drugs such as epinephrine and steroids were injected. Although her blood circulation recovered, around 13 minutes had passed between cardiopulmonary arrest and the starting of resuscitation and the patients brain did not recover despite our efforts.
A deep coma continued during hospitalization. Artificial respiration by a respirator continued, and although spontaneous breathing was observed temporarily, it disappeared again. Cough reflex remained negative. Although a weak light reflex appeared temporarily, it too disappeared again. The amount of dopamine required for blood-pressure maintenance increased gradually. After one week, we had to explain to her family that recovery was impossible. And, when this diagnosis was presented to the family, the termination of life support and organ donation were proposed by the family because the patient had both an organ donors card and a living will expressing her desire to die with dignity.
However, both her desire to die with dignity and her desire to be a organ donor were met with difficulty. She was HBs antigen positive. Because she was HBs antigen positive, the regional Kidney Transplant Network judged that this patient was disqualified as a donor, and refused her donation. We could not agree with this judgement and so we did a computer search for medical papers on the subject. We searched for papers concerning Kidney Transplants and Hepatitis B on the INDEX MEDICUS and came up with 20 papers.
Of the 20 papers that we found (please see references 1 through 20 at the back of this manuscript), references 1 through 10 all concluded that the relationship between HBs antigen positivity and a recipient's prognosis were unrelated. There were no papers that declared, positively, that a person who is HBs antigen positive was unsuitable as an organ donor. It was shown in 2 papers that the prognosis was bad when the recipient was HBe antigen positive. Therefore, medically, the kidney from HBs antigen positive donors who are also HBe antigen negative can be offered for transplant.
We felt that the regional Kidney Transplant Network should not have been opposed to this view unless they had a paper that could refute this view by showing new evidence - something such as an accepted paper appearing in INDEX MEDICUS. Such a paper did not exist, at least at that time. We made contact with a university hospital outside of the area governed by the regional Kidney Transplant Network, and the organ donation became possible.
After the loss of spontaneous respiration was confirmed by an apnea test with her family present, the dopamine infusion was stopped. Blood pressure fell and the patient's pulse stopped after 10 minutes. The cardiac arrest was checked by the electrocardiogram monitor with her family present. At that point, her death was diagnosed. Then, an operation for the extraction of the kidneys was performed. The kidneys were immediately carried to the university hospital and transplanted into recipients.
The newspaper reports which followed were not so well done, I'm afraid. They were written in a way which made it easy to assume that the cancellation of treatment was due to the diagnosis of brain death for the purpose of organ transplantation! As a result, some doctors and citizens who read these newspaper articles accused and prosecuted us for murder. Of course, medical staff should not make judgments regarding brain death one-sidedly and for the sole purpose of organ transplantation. On this point we are in complete agreement with our prosecutors!
But shouldn't we ask ourselves whether or not there might be some basis on which life-prolonging treatment may be interrupted according to the patient's self-determination? Of course, there are various ideas regarding one's own death and none of them can be refuted by tests with experiments or observations. Therefore, science is not helpful in solving this problem. Hence, I would like to discuss these matters, not with reference to science and medical theory, but instead with reference to the classics - papers that have survived a long history of criticism.
The first thing that I would like to make reference to is something written by Albert Camus. At the beginning of Albert Camus's "The Myth of Sisyphus" he writes:
"There is but one truly serious philosophical problem and that is suicide... Galileo who held a scientific truth of great importance abjured it with the greatest ease as soon as it endangered his life. In a certain sense, he did right. That truth was not worth the stake."
On the other hand, Tommaso Campanella defended Galileo and wrote "Apologia pro Galileo" from prison at the risk of his life. Because he willingly risked death, there must have been something that was more important to him than his own life. If there is anything valuable beyond one's own life, it could be said that that is the person's religion. Such religion is necessary if one is to care for life.
Please allow me to return for a moment to the "Dying with dignity" controversy that involved our hospital and the role of religion in it. At that time a television station from Vienna came to our hospital to cover the story. In Vienna, they said, passive euthanasia, or so called "dying with dignity," was forbidden by the instruction of Christianity. Since they had heard that dying-with-dignity was permitted in the hospital of a Buddhist temple in Japan, they came for coverage. This raises an interesting question about the relationship between religion and dying with dignity, so I would like to talk for a moment about how the two are related. I would like to quote the first part of Schopenhauer's "On Suicide" which refers to this matter.
"As far as I can see, it is only the monotheistic, and hence Jewish, religions whose followers regard suicide as a crime. This is the more surprising since neither in the Old Testament nor in the New is there to be found any prohibition or even merely a definite condemnation of suicide."
Does Buddhism accept the idea of dying with dignity? Does Buddhism accept suicide? In the Buddhist scripture Buddha accepted an affair of a monk who committed suicide. Had Buddhism encouraged suicide? Allow me to quote Durkheim's "Suicide".
"Though Buddhism has often been accused of having carried this principle to its most extreme consequences and elevated suicide into a religious practice, it actually condemned it. It is true that it taught that the highest bliss was self-destruction in Nirvana; but this suspension of existence may and should be achieved even during this life without need of violent measures for its realization."
Durkheim's interpretation of Nirvana is right. To confirm the fact that Durkheim's interpretation of Nirvana is right let's consider, for a moment, Buddha's doctrine.
It is 'the fourfold noble truths' which summarized the doctrine of Buddha. They are 'the truth of suffering', 'the truth regarding the cause of suffering', 'the truth regarding the extinction of suffering, Nirvana' and 'the truth regarding the path to Nirvana'.
"The truth of suffering" was the subject of Buddha. Here, 'suffering' is a translation of the Sanskrit word 'duhkha' that means, literally, 'to be denied what we desire.' Buddha said that there are eight sufferings. The first four are birth, aging, disease and death. These are examples of this so-called suffering, the category of things that simply are regardless of our wishes. The last suffering Buddha listed summarized all suffering. It is the attachment to oneself, which has five components. Those are, attachment to one's body, perception, conception, volition and consciousness, respectively. Attachment to the self is the fundamental suffering.
"The truth regarding the cause of suffering" indicates that the cause of suffering is passions such as the passion for sex, the passion to live and the passion to die. These three passions correspond to the three elements of life in biology, those are; reproduction, dynamic equilibrium and death.
"The truth regarding the extinction of suffering" is the state of Nirvana where those three passions are extinguished and suffering, i.e. attachment to self, is also extinguished. "The truth regarding the path to Nirvana" is the way of life where one continues to control those three passions completely. Attachment to the self is also controlled completely and hence compassion for everybody appears.
Buddhist monks are those who take the oath to walk on the path to Nirvana. As they control both the passion to live and the passion to die, they neither commit suicide nor attach to living unreasonably. That is one point that they have in common with those who decide to die with dignity. However, this is the case for Monks, and Buddhism does not recommend that all people choose to die with dignity. Having compassion for all people without attachment to oneself is the situation of the Buddhist who affirms the all others' religions equally. It allows us to support a persons decision to die with dignity or the decision to prolong life through medical intervention.
Buddha's doctrine has no purpose in and of itself. It is but the means which bring happiness to the people. And, Buddha showed, using the metaphor of a raft, that the essence of the doctrine was to leave attachments. To help you understand the metaphor, I will tell you the story told by Buddha.
Imagine a person walking down a road. He comes to a large river. The shore on his side of the river is dangerous, but the shore on the distant side is peaceful. There is neither a ship nor a bridge to take him to the other shore. Then, he makes a raft. He crosses the river using the raft and reaches the other shore. After arriving at the other shore, he considers walking on his way bringing the raft that had been useful along with him, carrying it on his head or shoulders. But, really how should he treat the raft? Should he carry the raft with him even though it has completely served its purpose? Of course not. Leaving the raft on the shore and continuing on his journey is what he should do.
Thus, in order to show us how to cross from one shore to the other, leaving attachments behind, the doctrine was taught using the metaphor of a raft. And, in this case, the raft is a metaphor for Buddha's doctrine itself! Buddha's doctrine should also be left on the other shore by those, who came to understand the doctrine through the metaphor of a raft. The raft used to cross to the shore of Nirvana from this shore of suffering is Buddhism itself. The raft is a metaphor.
Metaphor literally means "to carry over". And, Buddhism too is just a metaphor that carries people over to the other shore of happiness. The raft will be thrown away once it crosses to the other shore.
A Buddhist is not attached to Buddhism itself. The metaphor of a raft is pointing to Buddhism not being attached to itself and also non-attachment of Buddhism not being attached to non-attachment itself.
Buddha said that what I can control freely according to my desires is mine. But that what I can not control freely according to my desire is not mine. We do not have control over our bodies as far as birth, aging, disease and dying are concerned. So, in order to control ourselves we must recognize that our bodies are not our own. There is nothing that can be said to be mine or myself because even this body does not belong to me. If a person considers oneself thus, that person does not discriminate others from oneself. This is the wisdom of equality in Buddhism. And the deed or act of mercy that one would apply to the suffering of another is the same as the mercy that one would apply to oneself. Buddha's teaching is based on this principle and the purpose is to help those who are on the shore of suffering to reach the other shore of happiness. There is no discrimination at the arrival point of the way to non-attachment that the Buddhist monks walk. All ways of life, namely a person's religion, are affirmed equally. It is proper to give advice and help patients to make their own decisions when we, as Buddhist Monks are called on. The position of Buddhism regarding organ transplants is the same, too. We Buddhist monks should participate in donor registration on the one hand, and on the other hand support the position of those who receive an organ transplantation.
Finally I'd like to quote the words of Schopenhauer and to offer them as a lesson to Buddhist monks.
"A genuine (Buddhist) monk is exceedingly venerable, but in the great majority of cases the cowl is a mere mask behind which there is just as little of the real monk as there is behind one at a masquerade."
Buddhist: Masahiro Tanaka, M.D.
Physician at "Medical Clinic Fumon-in", Chief Priest at "Buddhist Temple Saimyouji", Mashiko (Japan)
(1) Kim YS, et al: Renal transplantation is not contraindicated in hepatitis B surface antigen positive patients. Transplant Proc (UNITED STATES), 24: p1541, 1992.
(2) Chan PC, et al: The impact of donor and recipient hepatitis B surface antigen status on liver disease and survival in renal transplant recipients. Transplantation, 53: p128, 1992.
(3) Lai MK, et al: Renal transplantation in hepatitis B carriers: comparison of azathioprine- and cyclosporine-treated recipients. Clin Transpl, p281, 1989.
(4) Ranjan D, et al: Factors affecting the ten-year outcome of human renal allografts. The effect of viral infections. Transplantation, 51: p113, 1991.
(5) Rivolta E, et al: Prognostic significance of hepatitis B surface antigenemia in cadaveric renal transplant patients. Transplant Proc, 19: p2153-4, 1987.
(6) Friedlander MM, Kaspa R T: Chronic hepatitis in kidney allograft recipients [letter; comment] Lancet, 335: p1465, 1990.
(7) Sengar DP, et al: Long-term patient and renal allograft survival in HBsAg infection: a recent update. Transplant Proc, 21: p3358, 1989.
(8) al-Khader AA, et al: Renal transplantation from HBsAg positive donors to HBsAg negative recipients [letter] BMJ, 297:p854,1988.
(9) Chan MK, et al: Renal transplantation from HBsAg positive donors to HBsAg negative recipients. BMJ, 297: p522-3, 1988.
(10) Garcia G, et al: Hepatitis B virus infection and renal transplantation. Hepatology,8:p1172,1988.
(11) Sandrini S, et al: Viral hepatitis in HBsAg-positive renal transplant patients treated with cyclosporin and steroids. Nephrol Dial Transplant, 5: p525, 1990.
(12) Fairley CK, et al: The increased risk of fatal liver disease in renal transplant patients who are hepatitis Be antigen and / or HBV DNA positive. Transplantation, 52: p497, 1991.
(13) Marcellin P, et al: Redevelopment of hepatitis B surface antigen after renal transplantation. Gastroenterology, 100: p1432, 1991.
(14) Rao KV, et al: Variability in the morphological spectrum and clinical outcome of chronic liver disease in hepatitis B-positive and B-negative renal transplant recipients. Transplantation, 51: p391-6, 1991.
(15) Stempel C, et al: Effect of cyclosporine on the clinical course of HBsAg-positive renal transplant patients. Transplant Proc, 23: p1251, 1991.
(16) Scott D, et al: Hepatitis B and renal transplantation. Transplant Proc,19:p2159,1987.
(17) Degos F, Degott C: Hepatitis in renal transplant recipients. J Hepatol, 9:p114, 1989.
(18) Gottesdiener KM: Transplanted infections: donor-to-host transmission with the allograft. Ann Intern Med, 110: p1001-16, 1989.
(19) Dienstag JL: Renal transplantation and hepatitis B. Gastroenterology, 94:p235, 1988.
(20) Takahara S, et al: Prospective study and long-term follow-up of liver damage in renal transplant recipients. Transplant Proc, 19: p2221-4, 1987.
(21) Albert Camus "The Myth of Sisyphus" Translated by Justin O'Brien. Penguin Books. 1955.
(22) Schopenhauer "Parerga and Paralipomena Vol 2 chapter 13 On Suicide" Translated by E.F.J. Payne. Oxford University Press. 1974.
(23) Emil Durkheim "Suicide" Translated by J.A. Spaulding and G. Simpson. The Free Press. 1979