Buddhism and Palliative Care in Japan

The manuscript for the 19th International Conference "Palliative Care" on 11-12-13 November 2004 at Vatican City New Synod Hall.

First, I'd like to thank the Pontifical Council for inviting me to join this conference.

In this speech I would first like to talk about the relation between Buddhism and palliative care. Then I would like to follow that with a discussion about palliative care in Japan.

Buddhism was started by a man who found the answer to the problem of suffering that comes from the fact that there is no escape from death. Hence, Buddhism has been related to palliative care, especially spiritually, since its birth. Buddha descended from the noble family of Shakya who shared in governing the small state of Kapilavastu which is now near the border of India and Nepal. His whole life was quite different from that of Jesus Christ. He wasn't arrested and wasn't crucified. He grew up as a wealthy aristocrat, got married, and had a child.

His happiness ended when he became conscious of the basic facts of existence. He saw old age, sickness and death. He worried that he too would grow old, sicken and die. He decided to leave his home and chose a life of homelessness, seeking salvation from suffering - such as aging, disease and dying - in the practice of Yoga. He was twenty-nine years old. After 6 years of practice, he solved the problem of suffering, reconciling with the fact that there is no escape from death. That led to a way of life where one continues to control one's egoism completely. The spiritual pain of aging, disease and dying disappeared in Buddha once he realized complete freedom from attachment to the self, which included the attachment to his own life. At the same time, the compassion not to discriminate others from oneself appeared in his heart.

Buddha was enjoying a kind of Yoga that blew away the spiritual pain related to death. He hesitated to tell people about this salvation. Telling the truth often harms a person if the truth is that their life will end. But without telling this truth, the chance that others would realize their own salvation would be missed. It is interesting to note the similarity between Buddha's hesitation to tell the truth about his salvation and telling a cancer patient the truth about their condition. To tell patients that their cancer cannot be cured could cause them spiritual pain. After an inner struggle with paradox, Buddha decided to teach others about his salvation out of compassion for humanity.

Buddha's first students were his five former ascetic companions. He told them about 'the fourfold noble truths' which are 'suffering', 'the cause of suffering', 'the extinction of suffering,' otherwise known as Nirvana, and 'the path to Nirvana'. 'Suffering' was Buddha's main concern. Here, 'suffering' is a translation of the Sanskrit word 'dukkha' which means, literally, 'to be denied what we desire'. Buddha said that there are eight sufferings. The first four are birth, aging, disease and death. The last suffering summarized all sufferings. It is the attachment to oneself. Attachment to the self is the fundamental suffering. 'The cause of suffering' is passion, 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 being; reproduction, dynamic equilibrium and death. 'The extinction of suffering' is the state of Nirvana where passions are extinguished and suffering, i.e. attachment to self, is also extinguished. 'The path to Nirvana' is where one controls passions completely. Attachment to the self being controlled compassion for all others appears.

Buddha's doctrine has no purpose in and of itself. It is but the means which brings happiness to the people. And, Buddha showed, using the metaphor of a raft, that the essence of the doctrine was to leave attachments. 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. He makes a raft. He crosses the river using the raft and reaches the other shore. After arriving at the other shore, he should leave the raft on the shore and continue on his journey. In this case, the raft is a metaphor for Buddha's doctrine itself! 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 should be thrown away once one has crossed to the other shore. A Buddhist does not attach to Buddhism itself and also the non-attachment of Buddhism does not attach to non-attachment itself.

Buddha said, what I can control freely according to my desires is mine. But, what I cannot 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, one does not discriminate others from oneself. This is the wisdom of equality in Buddhism. Having compassion for all people without attachment to oneself is the situation of the Buddhist who affirms all others' religions equally. Therefore, many personalities gradually came to be included in Buddhism, and the concept of Mandala, which encompasses all types of human life, was developed.

Buddhism as such, expanded thoughout Asia thanks to its association with medicine. In the third century B.C., Ashoka, king of India, made a medicinal herb garden which is the oldest one of its kind in the world. He sent Buddhist priests to many foreign countries to treat people with medicine from his garden. In this way they could save people from physical diseases through medicine and from spiritual suffering through Buddha's teaching. It is interesting to note that in Japan, the first national hospital was built in a Buddhist temple.

Unique Buddhist manners and rituals for dying were developed in Japan. One of the ideas that was developed is contained in a text named "The most important mystery in this life." It has 9 chapters. In the first chapter it says that while a disease can be controlled by medicine one must never give up nor accept death. Second, it says that if a disease cannot be controlled, and there is no way to be healed, one must not cling to life. From the third chapter, it describes how one should prepare for death by concentrating one's mind on one's own ideal personality of worship - which is the essence of yoga.

Next I would like to talk about how this relates to the current approach toward illness and death in Japanese medicine. The word "religion" was translated into Japanese as 2 characters, "shuu" and "kyou" which literally mean "mystery" and "doctrine". The latter half, "doctrine," corresponds to the rational part of religion which can be transmitted easily by words. The first part "mystery" corresponds to the part of religion that is outside rationality and cannot be transmitted by words and requires a master-disciple type transmission. Almost all Japanese culture developed under the influence of esoteric Buddhism and followed the formality of "mystery and doctrine" and included a master-disciple type transmission. The Japanese cultural changes that grew from this esoteric influence include the Japanese art of flower arrangement, poetry, calligraphy, painting and theatrical performances.

Also, a non-verbal communication style gradually became more important than that of open verbal communication. To understand something difficult which cannot be expressed in words easily, one needs to relive it or experience it vicariously. But, vicarious experience requires that one has already, at some point, had the actual experience. If they have not, metaphors or symbols were frequently used to help people vicariously understand these experiences. The most difficult things to understand, such as the mystery of Buddha's realization, are called "secrets." The word "secret" in Japan did not mean to hide the truth but described something that was difficult to understand by verbal communication.

To help you understand the current state of palliative care in Japan, please consider some things that have appeared in the medical journals. The May, 1988, issue of a weekly magazine called "Medical Tribune" reported that a summit conference on cancer was held using satellite communication. The chairman of the Soviet Union Cancer Society mentioned that he does not tell cancer patients their true diagnosis because it gives the patients mental pressure and that, in turn, has a negative influence on their condition. The American doctor said that he tells cancer patients their true diagnosis as a matter of course. I think it is because American hospitals have spiritual care workers that doctors there could tell their patient the truth, whereas former Soviet hospitals did not. How to prolong life depends on refutable matters so science and doctors can handle it properly. But how to live a limited life does not belong to science. So, spiritual care workers must take care of it.

In a paper ironically titled "Curable cancers and fatal ulcers: attitudes toward cancer in Japan" published in 1982, it was pointed out that Japanese patients having terminal cancer are generally not told their true diagnosis. Japanese doctors don't approach patients by open verbal communication. It points out that vagueness is an important part of Japanese culture and that there is a principle of secrecy in Japanese culture. This culture of secrecy and vagueness originated in Buddhism. Unfortunately, Buddhism was excluded from Japanese society in 1868, by the revolutionary government of the Meiji period Emperor. When Western culture was adopted to modernize Japan, the government tried to exclude Christianity from the adopted western culture. Instead, the government tried to replace Christianity with Shintoism, the religion of the Emperor. However this attempt did not succeed and the people in charge of spirituality disappeared from Japanese hospitals. After that revolution, the formal vagueness was left without any attachment to its important Buddhist spirituality. The resulting absence of spirituality, and therefore, spiritual care workers, in Japanese hospitals makes it difficult to give a true diagnosis to cancer patients.

Maintaining the principle of informed consent still isn't perfect in Japan although it has become the most important principle in medical ethics through the Helsinki and Lisbon declarations. Buddhist priests aren't doing their essential work, using the raft to transfer patients to the other shore of palliation, in present day Japan. Currently, many palliative care units exist in Japan. The main job at those palliative care units is not the relief of spiritual pain but only the relief of physical pain. The training of spiritual care workers is necessary since they are currently absent from most medical institutions in Japan. And, we hope to learn a great deal from the Vatican about how to educate our spiritual care workers. Thank you.

Masahiro Tanaka, M.D. Chief Priest at "Buddhist Temple Saimyouji", Physician at "Medical Clinic Fumon-in", Mashiko, Japan

Curable cancers and fatal ulcers: Attitudes toward cancer in Japan. Long,S.O.,Long,B.D.:Soc Sci Med,16:2101-2108,1982.