Buddhist Views of Suicide and Euthanasia,
By Carl B. Becker

Philosophy East and West
V. 40 No. 4 (October 1990)
pp. 543-555

Copyright 1990 by University of Hawaii Press


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BIOETHICS AND BRAIN DEATH: THE RECENT DISCUSSION  IN JAPAN

Japanese scholars of ethics and religions have been slow to come to grips with issues of bioethics, suicide, and death with dignity. Although the practical problems are frequently addressed in the popular press, and scattered citizen groups are beginning to draw attention to the issues, few people outside of the medical community have seriously addressed these issues.[1] As one recent representative example of this situation, consider the 39th annual meeting of the Japan Ethics Association (the academic association of ethicists from the entire country) held at Waseda University in October of 1988. The title of the annual meeting, in deference to the late Emperor's ailing condition and the growing urgency of bioethical issues, was "Life and Ethics." ostensibly, this was a chance to further the discussion among medical, religious, and philosophical ethicists on topics such as euthanasia and death with dignity. In fact, more than half of the presentations discussed classical views of life, such as those of Hippocrates, Confucius, Vico, Kant, Nietzsche, and so forth. The periods planned for open discussion were entirely usurped by the panelists' overtime reading of such papers. To their credit, however, there were a few Japanese scholars who boldly attempted to establish some more-Japanese views on the topics in bioethics, particularly euthanasia and death with dignity. While not without their problems, these presentations displayed less a Buddhist than a popular Japanese approach to the issue. The majority agreed with Anzai Kazuhiro's[a] early presentation that brain death should not be equated with human death.[2] Anzai's reasoning runs as follows: If brain death implies human death, then, by contraposition, human life must imply conscious (brain) life. Now there are clearly segments of our lives in which we are alive but not always conscious. Therefore it is wrong to conclude that a human is dead because he or she lacks consciousness. of course, this argument can be faulted for collapsing conscious life and brain life, and for failing to distinguish periods of unconsciousness with the expectation of future revival (like deep sleep) from periods of unconsciousness with no expectation of future revival (like irreversible coma). But it is representative of a widely seen Japanese rejection of brain-death criteria.

This rejection comes partly from the Japanese association of brain-death criteria with organ transplantation. Many Japanese continue to manifest a distaste for organ transplantation, a distaste which dates back to Confucian teachings that the body, a gift from heaven and from one's parents, must be buried whole, and never cut. For this reason, dissections and autopsies were late in coming to Japan, not widely permitted until the nineteenth century.

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The modern Japanese practices of universal cremation, of surgical operations, and of flying to other countries to have organ transplants all have superseded the old Confucian prejudice against body-cutting. However, there remains a fear that if brain-death criteria were widely accepted, less conservative elements of society might abuse it for the sake of the "distasteful" practice of organ transplantation.

In his keynote address about Buddhist ethics, Tsukuba Professor Shinjo Kawasaki[b] implied that this rejection of brain-death criteria may also be grounded in a Buddhist view of life and death.[3] He cited the Visuddhimagga, which indicates that life energy (ayus[c]) is supported by body warmth[d] and conscious faculties[e] (broadly interpretable to include reflexes).[4] If either body heat or reflexes remain, then a person cannot be considered dead. Now Buddhism admits situations (such as meditative trances or hypothermia) in which neither body warmth nor reflexes are externally detectable, but the subject is not yet dead. So lack of warmth and reflexes is a necessary but not sufficient indicator of death; if either persists, it can be said that the body is not yet dead. In other words, Buddhism does not equate life with warmth and reflexes, but holds that body heat and reflexes are the "supports" of life, and therefore life cannot be empirically measurable except through such variables. Kawasaki also reaffirms the widespread Japanese Buddhist view that death is not the end of life, but merely a brief transition to another state, commonly thought to last for forty-nine days, intermediate between life in this body and life in the next. The reluctance to dismiss a body as "dead" prior to its loss of warmth and reflexes is not based on a fear of personal extinction or annihilation, but rather on a Buddhist view of the basic components of the life system.[5]

Chiba's Iida Tsunesuke[f] expands this view by arguing that "persons are not merely the meaningless 'subjects of rights,' but personalities, 'faces' embodying the possibilities of fulfilling the dreams of their parents or loved ones . . . recipients of love, and therefore worthy of honoring."[6] This argument begs the question of "possibilities," since in the case of brain-dead victims, it is precisely such possibilities which are missing. Logically speaking, the "possibilities" argument has long ago been laid to rest by philosophers like Mary Anne Warren, who have demonstrated that we need not treat potential presidents as presidents, potential criminals as criminals, or potential humans as humans.[7] (Japanese society might differ in this respect; until recently, suspicion of crime or likelihood of committing crime were sufficient grounds for arrest, and children of nobles (potential lords) were often honored or killed as real lords.)[8]

However, Iida's argument is important less for its logical persuasion than for its revelation of the Japanese attitude: that persons are not subjects with rights and individual free wills, but rather objects of the attentions of others. (Japanese treatment of infants and children reinforces this view that Japanese

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children are seen not as persons but as possessions of their parents; this was the legal as well as philosophical status of women and servants as well as children prior to the twentieth century.)

This position is further developed by Ohara Nobuo[g], who argues that "although a body may be treated as a 'thing' or a corpse by physicians, it remains a body of value and meaning, and in that sense, a person, to members of its family.... In this sense, even vegetative humans and brain-dead corpses can give joy to other people."[9] Of course this point of view is pregnant with problems which Ohara himself seems loath to acknowledge. Only in the most metaphorical of senses can a corpse "give" anything to anyone; rather, it is the family who may derive some sense of joy by beholding the face of one dear to them, even though that person is incapable of ever being conscious in that body again.

This attitude is akin to the Japanese reverence for pictures, sculptures, and myths; it provides no useful guidelines whatsoever to the medical faculty as to when to continue or desist from what kinds of treatment for the patient. To the question "When does a body stop being a person?" the Oharan answer, "It never stops being a person to those who love it," may be psychologically correct for some people, but is a dead end in medical ethics, for it fails to answer the question, "When should a body be treated not as a living person but as a dead body?"

Moreover, even if it were thought to have some utility in the case where relatives or "significant others" remain alive and concerned with the fate of the deceased, it values the person (or corpse) entirely in terms of his value to others. In cases where old people die alone and uncared for, the absence of concerned others leaves the medical practitioner utterly without guidelines. (This is consistent with the frequently noted proposition that Japanese without social contexts seem morally at a loss.)[10]

This position also presumes a wishful naivete on the part of the parent or family, a failure to distinguish between a living human with a potential for interaction and a dead body with only the resemblance of a loved one. This may not bother many Japanese parents, for whom children are indeed "objects." In fact, there are "rehabilitation hospitals" in Japan in which anencephalic infants are cared for and raised for as many years as their parents'. finances and interest dictate; they are propped up and made to "greet" their parents whenever the parents desire to visit.[11]

Such unwillingness to admit the finality of death or the fundamental suffering of the human condition runs counter to the basic tenets of Buddhism. We are reminded of the famous story of the woman who asked the Buddha to revive her baby. In response, the Buddha instructed her to ask for food from any house in which no one had died. In the process of asking around the entire village, the woman came to realize that all humans must die and deal with death. In this way she gained enlightenment, stopped grieving for her

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dead child, and became a follower of the Buddha. The relatives who refuse to pronounce dead a relative as long as he has a "face," or the parents who insist on artificially prolonging the appearance of life of an anencephalic infant, cannot claim to understand Buddhism.

A much larger misunderstanding lurks behind the whole discussion between "brain-death advocates" and "brain-death opposers" in Japan. The real issue is not whether or not every body should immediately be scavenged for spare parts as soon as its brain is isoelectric, as some opponents would purport. Rather, the question is whether it is ever acceptable to desist from treatment after brain death (turning the hospital's valuable and limited resources to other waiting patients). In the absence of brain-death criteria, many otherwise hopeless bodies remain on artificial support systems almost indefinitely. Even if brain-death criteria were accepted, nothing would prevent families from finding hospitals which would preserve the bodies of their beloved on artificial support systems indefinitely, nor would anything require organ donation if the patient and family did not desire it. Thus the issue, like that of suicide and euthanasia, is not "Should everyone be forced to follow these criteria?" but rather "May people who desire it be allowed to follow these criteria?" Groundless fears of widespread organ sales or piracy have made this issue into a much greater hobgoblin than it ever needed to become.

This is not merely to criticize the recently voiced positions of Japanese ethicists. Rather, I introduce this body of evidence to demonstrate the slow growth of Japanese thought in bioethics, and particularly their concerns with bodies of value to others rather than with subjects of value to themselves. This concern finds no support either in Japanese Buddhism nor in samurai teaching, but on the level of popular belief, it may have serious ramifications for Japanese bioethics for many generations to come.

The World Federation of the Right to Die Society held an International Conference in Nice (France) in 1984. Although many Japanese attended this conference, apparently none of them contributed to the West's understanding of Buddhist views of euthanasia. When the President of the Society published a book on world attitudes on euthanasia the following year, only 2 percent (2.5 out of 150 pages) was about Buddhist attitudes, and those ideas were gained from California Buddhists, not from Japanese Buddhists at Nice.[12]

Buddhists have a big contribution to make to the humanization and naturalization of medicine and bioethics. I may not speak for all of Japanese Buddhism, but I shall be happy if this article inspires further dialogue and contributions from the Japanese Buddhist side.

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EARLY BUDDHIST VIEWS OF DEATH, SUICIDE, AND EUTHANASIA

Japan has long been more aware of and sensitive to the dying process than modern Western cultures. Moreover, Japan already has its own good philosophical and experiential background to deal effectively with "new" issues of

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bioethics, such as euthanasia. Japanese Buddhists have long recognized what Westerners are only recently rediscovering: that the manner of dying at the moment of death is very important. This fundamental premise probably predates Buddhism itself, but is made very explicit in the teachings of the buddha.[13] In his meditations, the Buddha noticed that even people with good karma were sometimes born into bad situations, and even those with bad karma sometimes found inordinately pleasant rebirths. Buddha declared that the crucial variable governing rebirth was the nature of the consciousness at the moment of death. Thereafter, Buddhists placed high importance on holding the proper thoughts at the moment of death. Many examples of this idea can be found in two works of the Theravada canon, the Petavatthu and the Vimanavatthu ("Stories of the Departed"). Indeed, in many sutras, monks visit laymen on their deathbeds to ensure that their dying thoughts are wholesome,[14] and the Buddha recommends that lay followers similarly encourage each other on such occasions.[15]

Buddhism sees death as not the end of life, but simply a transition; suicide is therefore no escape from anything. Thus, in the early sangha (community of followers of the Buddha), suicide was in principle condemned as an inappropriate action.[16] But the early Buddhist texts include many cases of suicide which the Buddha himself accepted or condoned. For example, the suicides of Vakkali[17] and of Channa[18] were committed in the face of painful and irreversible sickness. It is significant, however, that the Buddha's praise of the suicides is not based on the fact that they were in terminal states, but rather that their minds were selfless, desireless, and enlightened at the moments of their passing.

This theme is more dramatically visible in the example of Godhika. This disciple repeatedly achieved an advanced level of samadhi, bordering on parinirvana, and then slipped out of the state of enlightenment into normal consciousness again. After this happened six times, Godhika at last vowed to pass on to the next realm while enlightened, and quietly committed suicide during his next period of enlightenment. While cautioning his other disciples against suicide, the Buddha nonetheless blessed and praised Godhika's steadiness of mind and purpose, and declared that he had passed on to nirvana. In short, the acceptability of suicide, even in the early Buddhist community, depended not on terminal illness alone, but upon the state of selfless equanimity with which one was able to pass away. It is interesting in passing that all these suicides were committed by the subject knifing himself, a technique which came to be standardized in later Japanese ritual suicide.

When asked about the morality of committing suicide to move on to the next world, the Buddha did not criticize it.[19] He emphasized that only the uncraving mind would be able to move on towards nirvana, and that, conversely, minds desiring to get free of or flee something by their death might achieve nothing. Similarly, there are stories in the Jataka tales of the Buddha

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giving his own body (in former lives) to save other beings, both animals and humans. Thus death out of compassion for others is also lauded in the scriptures.[20] It is also well known that in the Jain tradition, saints were expected to fast until their deaths,[21] and thereafter there have been those in both China and Japan who have followed this tradition.[22]

In China, it is believed that a disciple of Zendo's[h] jumped out of a tree in order to kill himself and reach the Pure Land. Zendo's response was not that the action of suicide was right or wrong in and of itself, but that the disciple who wanted so strongly to see the Pure Land was doubtless ready to reach it.[23] Other more recent examples may be found in the Buddhist suicides of the Vietnamese monks protesting against the Vietnam government.[24] Whether or not these stories are all historical fact is not at issue here. The point is that they demonstrate the consistent Buddhist position toward suicide: there is nothing intrinsically wrong with taking one's own life, if it is not done in hate, anger, or fear. Equanimity or preparedness of mind is the main issue. In summary, Buddhism realizes that death is not the end of anything, but a transition. Buddhism has long recognized persons' rights to determine when they should move on from this existence to the next. The important consideration here is not whether the body lives or dies, but whether the mind can remain at peace and in harmony with itself. The Jodo (Pure Land)([i] tradition tends to stress the continuity of life, while the Zen tradition tends to stress the importance of the time and manner of dying. Both of these ideas are deeply rooted in the Japanese consciousness.

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RELIGIOUS SUICIDE AND DEATH WITH DIGNITY IN JAPAN

Japanese Buddhists demonstrated an unconcern with death even more than their neighbors. Japanese valued peace of mind and honor of life over length of life. While the samurai often committed suicide on the battlefield or in court to preserve their dignity in death, countless commoners chose to commit suicide in order to obtain a better future life in the Pure Land. On some occasions, whole masses of people committed suicide at the same time. In others, as in the situation depicted in Kurosawa's famous film "Red Beard," a poverty-stricken family would commit suicide in order to escape unbearable suffering in this life and find a better life in the world to come. Often parents would kill their children first, and then kill themselves; this kind of shinju can still be seen in Japan today. The issue for us today is: how does Buddhism appraise such suicide in order to gain heavenly rebirth?

On a popular level, the desire to "leave this dirty world and approach the Pure Land" (Enri edo, gongu jodo[j]) was fostered by wandering itinerant monks such as Kuya[k] in the Heian period, and Ippen[l] in the Kamakura period. The tradition of committing suicide by entering a river or west-facing seashore apparently began in the Kumano[m] area, but rapidly spread throughout the nation along with the Pure Land faith upon which it was based. The

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common tradition was to enter the water with a rope tied around one's waist, held by one's retainers or horse.[25] If one's nerve and single-minded resolution failed, then one would not achieve rebirth in the Pure Land as desired. In such an instance, either the suicide himself, or his retainers (judging from his countenance), might pull him out of the water and save him from dying with inappropriate thoughts. However, if the suicide retained a peaceful and unperturbed mind and countenance throughout the drowning, the retainers were to let him die in peace, and simply retain the body for funeral purposes. Such situations clearly demonstrate that what is at stake here is not the individual's right to die, but rather his ability to die with peace of mind. If death with a calm mind is possible, then it is not condemned.

A paradigmatic example of this situation can be found in the records of Saint Ippen.[26] Ajisaka Nyudo[n], a Pure Land aspirant possibly of noble descent, gave up his home and family to follow the teachings of Saint Ippen. For unclear reasons, Ippen refused him admission to his band of itinerant mendicants, but advised him that the only way to enter the Pure Land was to die holding the Nembutsu[o] (name and figure of Amida) in mind. Nyudo then committed suicide by drowning himself in the Fuji River.

The scene is vividly depicted in the scroll paintings.[27] Here, Ajisaka is seen with a rope around his waist. His attendants on the shore hold one end of the rope. As he bobs above the current, he is seen perfectly preserving the gassho position, at peace and in prayer. Music is heard from the purple clouds above him, a common sign of Ojo, or rebirth in the Pure Land.

When Ippen heard of this suicide, he praised Ajisaka's faith, interpreting the purple clouds and Ajisaka's unruffled demeanor as proof of his attainment of rebirth in the Pure Land. At the same time, he warned his other disciples, repeating Ajisaka's last words (nagori o oshimuna), not to grieve over their master's passing.[28] When Ippen himself died, six of his disciples also committed suicide in sympathy, hoping to accompany their master to the Pure Land. This occasioned some debate about the propriety of "sympathy suicide." Shinkyo[p], Ippen's disciple and second patriarch of the Ji School[q], declared that the disciples had failed to obtain rebirth in the Pure Land, for their action was seen as "self-willed,"[r] and Pure Land faith relies entirely on the power and will of Amida Buddha[s]. Assertion of self-will is seen as running counter to the reliance on other power demanded by the Amida faith.[29]

Several important points can be learned from these examples. First, suicide is never condemned per se. Rather it is the state of mind which determines the rightness or wrongness of the suicide situation. The dividing line between choosing one's own time and place of death with perfectly assured peace of mind, and self-willing one's own death at the time of one's master's death is perhaps a thin grey one, but this should not obscure the criteria involved: death with desire leads not to rebirth in the Pure Land, but death with calm

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assurance does. Even the method of water suicide, using a rope as a preventive backup, stresses the importance of the state of mind in this action.

Secondly, Ajisaka's famous phrase, "Nagori o oshimuna," means that Buddhists are not to kill themselves in "sympathy" when others die. A literal translation would be that we are not to cling to what remains of the name or person, but to let the deceased go freely on to the next world. In other words, when someone dies with an assured state of mind, it is not for those who remain either to criticize or to wish that he had not died in this situation. Those who are left behind are to respect and not resent death which might seem to them untimely.

It is not coincidental that the word for euthanasia in Japanese is anrakushi,[t] a term with Buddhist meanings. In Buddhist terminology, aurakukoku[u] is another name for the Pure Land, the next world of Amida Bodhisattva, to which each Japanese expects to go after death. German-educated doctor and historical novelist Mori Ogai's[v] famous book Takasebune[w] specifically deals with anrakushi; it is the story of Yoshisuke killing his sickly young brother who wants to die but lacks the strength to kill himself.[30] Many famous twentieth-century Japanese authors wrote of suicide, and some, such as Akutagawa, Dazai, Kawabata, and Mishima, actually committed suicide. Following the deaths of each emperor (Meiji, Taisho, and, last year, Showa), faithful retainers have also committed suicide in sympathy with their departed leaders. While some of these suicides are not Buddhistic (they show anger, pessimism, nihilism, and so forth), they are still reminders that the Japanese Buddhist world view does not condemn suicide.

Japanese law does not criminalize suicide, and European law is slowly beginning to follow the Japanese model in this regard. However, Japanese law does hold it to be a crime to assist or encourage a suicide. In normal situations, this is only wise and prudent, for healthy people should be encouraged to live and make the most of their lives. But in the situations where songenshi (death with dignity) is requested, it is precisely because the person is facing imminent death that it is morally acceptable to assist his suicide, particularly if the motive is mercy.

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SAMURAI, SEPPUKU AND EUTHANASIA

Among the warrior elite, who usually followed Zen Buddhism, suicide was considered an honorable alternative to being killed by others or continuing a life in shame or misery. Beginning with the famous seppaku of Minamoto no Tametomo[x] and Minamoto no Yorimasa[y] in 1170, seppuku[z] became known as the way that a vanquished but proud Buddhist warrior would end his life.[31] Soon thereafter, headed by Taira Noritsune[aa] and Tomomori[ab], hundreds of Taira warriors and their families committed suicide in the battle of Dannoura[ac] of 1185. Famous suicides included that of Kusunoki Masashige[ad] in 1336, in the battle between Nitta and Hosokawa[ae], and that of Hideyori

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Toyotomi[af], under siege by Tokugawa Ieyasu[ag] in 1615. In the Tokugawa period, love suicides were dramatized in a dozen plays by Chikamatsu Monzaemon[ah], including Sonezaki shinju, Shinju ten no Amijimo[ai], and Shinju mannenso.[32] The forty-seven Ako ronin, who committed suicide after avenging their master's death, was another famous true story, dramatized in the Chushinguru[aj] plays and films.[33] The samurai's creed, to be willing to die at any moment, was dramatically spelled out by the Hagakure.[34] According to the Hagakure[ak], the important concern was not whether one lived or died, but (1) being pure, simple, single-minded, (2) taking full responsibility for doing one's duty, and (3) unconditionally serving one's master, without concern for oneself.

Although seppaku may seem like a violent death to the observer, it was designed to enable the samurai to die with the greatest dignity and peace.

It is particularly noteworthy that the samurai's code of suicide included a provision for euthanasia: the kaishakunin[al] (attendant). Cutting of the hara alone was very painful, and would not lead to a swift death. After cutting their hara, few samurai had enough strength to cut their own necks or spines. Yet without cutting their necks, the pain of the opened hara would continue for minutes or even hours prior to death. Therefore, the samurai would make arrangements with one or more kaishakunin to assist his suicide. While the samurai steadied his mind and prepared to die in peace, the kaishakunin would wait by his side. If the samurai spoke to the kaishakunin before or during the seppuku ceremony, the standard response was "go anshin" (set your mind at peace). All of the interactions and conversations surrounding an officially ordered seppaku were also fixed by tradition, so that the suicide might die with the least tension and greatest peace of mind. After the samurai had finished cutting to the prearranged point, or gave some other signal, it was the duty of the kaishakunin to cut the neck of the samurai to terminate his pain by administering the coup de grace.[35]

Many samurai suicides were in fact the moral equivalent of euthanasia. The reasons for a samurai's suicide were either (1) to avoid an inevitable death at the hands of others, or (2) to escape a longer period of unbearable pain or psychological misery, without being an active, fruitful member of society. These are exactly the sorts of situations when euthanasia is desired today: (1) to avoid an inevitable death at the hands of others (including disease, cancer, or bacteria), (2) to escape a longer period of pain or misery without being a fruitful, active member of society.

In regard to (1), most Japanese are now cut down in their seventies by the enemies of cancer and other diseases, rather than in their youth on a battlefield. Regardless of whether the person is hopelessly surrounded by enemies on a battlefield, or hopelessly defeated by enemy organisms within his body, the morality of the situation is the same. In regard to (2), it might be argued that there is a difference between the pain or misery of the per-

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manent incapacitation of a samurai, and the pain or misery of the permanent incapacitation of a hospital patient. But if anything, the hospital patient is in even less of a position to contribute to society or feel valued than is the samurai, so he has even more reason to be granted the option of leaving this arena (world) when he chooses. The samurai tradition shows that the important issue is not the level of physical pain, but the prospect for meaningful and productive interaction with other members of society. If there are no prospects for such interactions, then samurai society claimed no right to prevent the person from seeking more meaningful experiences in another world.

Now in both cases, there may be relatives or retainers in the area who do not wish to see their friend die. The issue in these cases is not whether or not the besieged person will die; it is only a question of how soon, and in what manner. From ancient times, Japanese have respected the right of the individual to choose the moment and manner of dying. This Buddhist principle ought to apply equally well to the modern medical battles against the enemies of the body. The argument that if a body still has a face, it is still a person to those around him, is a basically un-Buddhist failure to understand (a) the difference between body and life, (b) the importance of each person's determination of his own mental states, and (c) the importance of placing mercy over desire in Buddhism.

Of course there need to be safeguards in such situations, and those safeguards have already been spelled out by the decision of the Nagoya High Court. In a case of euthanasia, the Nagoya High Court (22 December 1962) defined certain conditions under which euthanasia could be considered acceptable:

(1) The disease is considered terminal and incurable by present medicine.

(2) The pain is unbearable--both for the patient and those around him.

(3) The death is for the purpose of his peaceful passing.

(4) The person himself has requested the death, while conscious and sane.

(5) The killing is done by a doctor.

(6) The method of killing is humane.

If these safeguards are followed, it seems there is no moral reason that Buddhists should oppose euthanasia.

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CONCLUSIONS

There are Japanese who hold that the Japanese lack the independent decision-making abilities of Western people, and that therefore doctors should make the decisions for their patients. This logic is backwards. The reason patients cannot make good independent judgements is because the doctors refuse them the information and freedom to do so, not because they lack the mental abilities or personal characteristics to make judgements.[36] Buddhism has always recognized the importance of individual choice,

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despite social pressures; examples range from the Buddha himself, through Kukai[am], Honen[an), Shinran[ao), and Nagamatsu Nissen[ap). The ability of Japanese to take personal responsibility for important decisions in times of stress, danger, or anguish has been repeatedly shown in the historical examples of these bold Buddhist reformers.

In order for the patient to make an intelligent decision about when and how he wants to die, he needs to know the facts about the nature of his disease, not only its real name, but the realistic prospects and alternative outcomes of all available forms of treatment. This means renouncing the paternalistic model held by present Japanese medicine, and granting substantial freedom to the patient in deciding his own case. Some Japanese doctors have argued that (1) patients do not really want to know the bad news about themselves, that (2) knowing the truth may harm their conditions, and that (3) the phys-

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ician can judge more intelligently than the patient. However, studies in the West show that none of these claims is true. As Bok points out, "The attitude that what [the patient] doesn't know won't hurt him is proving unrealistic--it is rather what patients do not know but vaguely suspect that causes them corrosive (destructive) worry."[37] People recover faster from surgery and tolerate pain with less medication when they understand their own medical problems and what can and cannot be done about them.[38] In any case, doctors' withholding of information from patients is based not on statistical proof or ethical principles, but on the physicians' desires to retain control over patients.[39] This is a situation that clear-thinking Buddhists naturally oppose. There is no reason to believe that these findings, long known and supported in Western medicine, should prove any different for the Japanese.

One important question for Buddhists today remains: what, if any, are the differences between suicide and euthanasia? Obviously one important difference is in the case where the person receiving euthanasia is unconscious. In this case, we have no way of knowing whether the patient genuinely desires euthanasia, unless he or she has previously made a declaration of wishes in a living will. On the other hand, once the consciousness has permanently dissociated itself from the body, there is no reason in Buddhism to continue to nourish or stimulate the body, for the body deprived of its skandhas is not a person. The Japan Songenshi Kyokai[aq] (Association for Death with Dignity) has done much to improve the ability of the individual Japanese to choose his time and manner of death.

Another issue is the relation of pain-killing to prolonging life and hastening death itself. The Japan Songenshi Kyokai proposes the administering of painkilling drugs even if they hasten the death of the patient. Buddhists would agree that relief of pain is desirable, and whether the death is hastened or not is not the primary issue. However, consider a case where the pain is extreme and only very strong drugs will stop the pain. Here there may be a choice between: (a) no treatment at all, (b) pain-killing which only blurs or confuses the mind of the patient, and (c) treatment which hastens the end while keeping the mind clear. In such a situation, the Buddhist would first prefer the most natural way of (a) no treatment at all. But if his mind were unable to focus or be at peace because of the great pain, the Buddhist would choose (c) over (b), because clarity of consciousness at the moment of death is so important in Buddhism.

Doctors who do not like the idea of shortening a person's life would prefer to prolong the material life-processes, regardless of the mental quality of that life. This is where Buddhists disagree with materialistic Western medicine. But there need be no conflict between Buddhism and medicine. There is no reason to assign the doctor the "responsibility" for the death of the patient. Following the guidelines of the Nagoya court, patients potentially eligible for euthanasia are going to die soon anyway, so that is not the fault of the doctor. And the patient has the right to determine his own death. The fact that he is too weak to hold a sword or to cut short his own life is not morally significant. If his mind is clear, calm, and ready for death, then the one who understands and compassionately assists that person is also following Buddhist morality. In summary, the important issue for Buddhists here is whether or not the person will be allowed responsibility for his own life and fate. The entire Buddhist tradition, and particularly that of suicide within Japan, argues that personal choice in time and manner of death is of extreme importance, and anything done by others to dim the mind or deprive the dying person of such choice is a violation of Buddhist principles. Japanese Buddhists may respect this decision more than Western cultures, and lead humanitarian bioethics in a different perspective towards dignified death.

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NOTES

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1    Morioka Masahiro, "Nosh) to wa nan de atta ka" (What was brain death?), in Nihon Rinri Gakkai kenkyu happyo yoshi (Japan Ethics Association outline of presentations) (Japan Ethics Association 39th Annual Conference, Waseda University, October 14-15, 1988), p. 7.

2    Anzai Kazuhiro, "No to sono ishiki" (Brain and its consciousness), in Nihon Rinri Gakkai, p. 6.

3    Kawasaki Shinjo, "Toyo kodai no seimei juyo" (The accepted understanding of life in the ancient Orient), in Nihon Rinri Gakkai, p. 26.

4    Visuddhimagga, pp. 299ff.

5    Kawasaki, "Toyo kodai no seimei juyo," p. 27.

6    Iida Tsunesuke, "Bioethics wa nani o nasu no ka" (What does bioethics accomplish?), in Nihon Rinri Gakkai, pp. 40ff.

7    Mary Anne Warren, "Do Potential People Have Moral Rights?" Canadian Journal of Philosophy 7, no. 2 (1978): 275-289.

8    Carl Becker, "Old and New: Japan's Mechanisms for Crime Control and Social Justice," Howard Journal of Criminal Justice 27, no. 4 (November 1988): 284-285.

9    Ohara Nobuo, "Sei to shi no rinrigaku" (The ethics of life and death), in Nihon Rinri Gakkai, pp. 54-55.

10    Carl Becker, "Religion and Politics in Japan." chap. 13 of Movements and Issues in World Religions, ed. C. W-H. Fu and G. S. Spiegler (New York: Greenwood Press, 1987), p. 278.

11    Among the author's students are nurses at such hospitals.

12    Gerald A. Larue, Euthanasia and Religion: A Survey of the Attitudes of World Religions to the Right-to-Die (Los Angeles: The Hemlock Society, 1985).

13    Cf. Hastings Encyclopedia of Religion, vol. 4. p. 448.

14    Majhima Nikaya II, 91; III, 258.

15    Samyutta Nikaya V, 408.

16    Tamaki Koshiro, "Shi no oboegaki" (Memoranda on death), in Bukkyo shiso, vol. 10, ed. Bukkyo Shiso Kenkyukai, Tokyo (September 1988), pp. 465-475.

17    Sutta Vibhanga, Vinaya III, 74; cf. Samyatta Nikaya III, 119-124.

18    Majhima Nikaya III, 263-266 (Channovada-sutta); Samyatta Nikaya IV, 55-60 (Channavaga).

19    Samyutta Nikaya I, 121.

20    Jataka Suvarna Prabhasa 206ff.

21    Acaranga Sutra 1, 7, 6.

22    A mummified body of one such monk is preserved in the Myorenji temple, close to Tsukuba University.

23    Ogasawara Senshu, Chugaku Jodokyo no kenkyu (Researches in Chinese Pure Land Buddhism) (Kyoto: Heirakuji, 1951), pp. 60ff.

24    Thich Nhat Hanh, The Lotus in the Sea of Fire (London, 1967).

25    Kurita Isamu, Ippen Shonin, tabi no shisakusha (Saint Ippen, the meditative wayfarer) (Tokyo: Shinchosha, 1977), pp. 165-169.

26    Ohashi Shunno, Ippen (Tokyo: Yoshikawa Kobunkan, 1983), pp. 105ff.

27    Ippen goroku, scroll 6, stage 2 (maki 6, dan 2).

28    Kurita, Ippen Shonin.

29    Ohashi, Ippen, pp. 107ff.

30    Mori Ogai, Takasebune (Tokyo: Iwanami Bunko, 1978).

31    Jack Seward, Hara-Kiri: Japanese Ritual Suicide (Tokyo: Charles E. Tuttle, 1968). Seward describes these and many other significant suicides in detail.

32    Donald Keene, trans., Major Plays of Chikamatsu (New York: Columbia University Press, 1961).

33    Fujino Yoshio, ea., Kanatehon Chushingura: Kaishaku to kenkyu (Chushingura) (Tokyo: Ofusha, 1975).

34    Watsuji Tetsuro, ea., Hagakure (Tokyo: Iwanami Bunko, 1970).

35    All condensed from Seward, Hara-Kiri.

36    Kimura Rihito, "In Japan, Parents Participate but Doctors Decide," Hastings Center Report 16, no. 4 (1986): 22-23.

37    Sisela Bok, "Lies to the Sick and Dying," in Lying: Moral Choice in Public and Private Life (New York: Pantheon Books, 1978).

38    Lawrence Egbert, George Batitt, et al., "Reduction of Post-operative Pain by Encouragement and Instruction of Patients," New England Journal of Medicine 270 (1964): 825-827; and Howard Waitzskin and John Stoeckle, "The Communication of Information About Illness," Advances in Psychosomatic Medicine 8 (1972): 185-215.

39    Cf. Bernard Gert and Charles Culver, "Paternalistic Behavior," Philosophy and Public Affairs 6 (Summer 1976); and Allen Buchanan, "Medical Paternalism," ibid., vol. 7 (Summer 1978).

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Carl B.Becker is currently a Visiting Professor of Philosophy at Tsukuba University.

AUTHOR'S NOTE: This article was first presented as a paper at "Japanese Morality: An East/West Dialogue," at California State University, Fullerton, March 1-3, 1989.

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Revised on 2000.08.11 (Source: EBSCOhost FullText Database)