Eye on religion: Buddhism and medicine.

For those not familiar with Buddhism and seeing Buddhism as a religion, they might be fascinated by some common threads that inform both medicine and Buddhism. We will explore both the commonality and differences of emphasis or perspective.

Crucial to both Buddhism and medicine is the importance of practice. Practice, the repetition of an act, is crucial in moving toward perfection. As physicians, we practice throughout our professional life to acquire and maintain our skills. Essential to Buddhism, practice is part of learning through quiet, focused concentration and deep awareness.

Medicine and Buddhism share the ultimate goal, nuanced differently, to help relieve the suffering of others. In medicine, there is the famous anonymous saying, "to cure sometimes, to relieve the pain and suffering often, and to comfort always." (1) In Buddhist practice, this refers not only to others but also to oneself. From the Buddhist perspective, we must simultaneously do this for ourselves while we do this for all living beings. In medicine, however, self-care is often overlooked. How often do we as physicians practice self-care, including self-awareness, as it relates to both caring for patients but also in all aspects of life?

Buddhism began because of the insights of a person living in Northern India approximately 2600 years ago. Later known as the Buddha (translated as one who is "awakened"), this individual was a prince whose father was determined to shelter him from all painful aspects of living. It was as a married adult, during journeys outside his royal home, that he first encountered a corpse, an old man, a sick person and an impoverished person. After these experiences, he left his royal home on a journey to uncover a deeper understanding of the life. These encounters resulted in his seeking to fully understand suffering and its ending. After many years of concentrated meditation practice, he vowed to continue meditating until he fully deeply understood the nature of suffering. After the Buddha's awakening--enlightenment--he began to share what have become the basic teachings in Buddhism, namely, the "Four Noble Truths": There is suffering; there are causes of suffering; there is an end to suffering; and there is a path to find the ending of suffering. The Buddha emphasized how devoting oneself to the practice of mindfulness can ultimately lead end of suffering. (2)

Mindfulness can provide deep insight and understanding and move one further along the path which ultimately leads to the end of suffering. Zen Master Thich Nhat Hanh writes, "Mindfulness is the energy that allows us to look deeply at our body, feelings, perceptions, mental formations, and consciousness and see clearly what our real needs are, so we will not drown in the sea of suffering." (3) This insight is one of the fundamental components of basic Buddhist teachings, known as the Eight Fold Path. The Eight Fold Path contains eight practices, each embodying the other and also containing essential practices that will lead to the end of suffering. All involve nonharming. Through mindfulness, one first becomes adept at focusing and concentrating the mind, and then learning how to increase the subtlety of one's awareness. The outcome is increased insight, deep understanding and awareness of inner peace. These insights and the possibility of personal transformation uncovered during both meditation and in bringing the practice of mindfulness into everyday life can lead to a profound, "deep understanding" of life. Deep understanding and personal transformation develops through an experimental process, rather than intellectual analysis. In Buddhism, "deep understanding" refers to self, other human beings and one's total environment.

The process of practicing mindfulness helps us "see" the past and future in the context of the present moment. From teaching and personal experience, I have become convinced that physicians could find significant benefit in learning these tools irrespective of their religious/cultural perspective. The question that is often posed is: If we are not living in the present moment, then are we truly in touch with life? One might consider how this would enrich medical practice.

Buddhist practice fundamentally has to do with intention, attention and awareness, which are key components of this meditation practice. In medicine, we are familiar with cardiopulmonary resuscitation (CPR). A Buddhist mindfulness equivalent could be ABC: Awareness (mindfulness); Breath (concentration focus); Calm (being at peace). These are the basic elements of mindfulness. Kabat-Zinn described this as "a coherent phenomenological description of the nature of mind, emotion, and suffering and its potential release, based on highly refined practices aimed at systematically training and cultivating various aspects of mind and heart via faculty of mindful attention. The contributions of Buddhist traditions have been in part to emphasize simple and effective ways to cultivate and refine this capacity and bring it to all aspects of life." (4) Mindfulness practices have been formalized in medical research and interventions for a wide range of medical (asthma, cancer, etc) and psychiatric diseases (Dialectical Behavioral therapy). (5) This includes the pioneering work of Jon Kabat Zinn, using mindfulness techniques at the University of Massachusetts Medical Center as well as Herbert Benson (The Relaxation Response) (6) and Joan Borysenko's many contributions, including author of Minding the Body, Mending the Mind, (7) initiating using point focus meditation and other skills including cognitive behavioral therapy techniques at Harvard Medical School's Mind Body Medical Institute and in teaching hospitals throughout the US.

At the heart of Buddhist practice is its ethical foundation. This includes the practice of nonharming, nonstealing, sexual responsibility, mindful speech (which includes not saying things that one is not certain to be true), and avoiding toxic ingestion, including alcohol, drugs, and has been interpreted as extending to TV programs and the like.

Fundamental to Buddhism is the practice of what is translated as the four Immeasurable minds. They are love, compassion, joy and equanimity. These are considered in Buddhism as the four elements of true love: "Happiness is only possible through true love ... they are called immeasurable because if you practice them, they will grow in you every day until they embrace the whole world. You will become happier and then everyone around you will become happier, also." (3) The practice of true love is the very nature of an enlightened person. The four aspects of true love exist within ourselves and within everyone and everything. (8)

To develop these immeasurables, one has to listen deeply so that we know what to do and what not to do to make others happy and thereby help them transform suffering. "If you offer your beloved something she does not need, that is not true love. You have to see her real situation or what you do might bring her unhappiness. To live in peace we have to be aware of our tendencies--our habit energies--so we can exercise some self-control. This is the practice of preventive care." Thich Nhat Hanh, Zen Buddhist Master, writes about how initially he did not understand how the Buddha could not be disturbed by all the suffering and came to understand that the Buddha had enough understanding, calm, clarity and strength to not be overwhelmed by it. "He is able to smile to suffering because he knows how to take care of it and to help transform it." (3)

By exploring the fourth element of true love--equanimity--we can see how this could positively influence our practice of medicine. Equanimity is translated from the Sanskrit by Thich Nhat Hanh as letting go, nonattachment, nondiscrimination, and evenmindedness. (3) If, as physicians, we would cultivate these practices of true love and could truly be in the present with our patients, they could experience this deep caring from our speech and our actions. In equanimity (nondiscrimination), we don't experience the patient (or anything) as other. But rather we learn to see/experience the common humanity that is shared by all. We shed all discrimination and see before us an individual who is seeking our deep understanding of the science of disease and our art of care for mind and body.

In Buddhism, three other perspectives are essential to articulate. One, learning to be free from our anxiety, fear and anger, and other negative states of mind requires us to be open to ultimately acceptance of everything as it is. It is a way of living and being that leads to a deeper sense of love of self, clarity, joy, meaning in life and inner peace. Second, suffering ultimately comes from our mind (In Eastern psychology, this includes the heart). How one interprets and then responds to what one encounters in life--its pain, joy and happiness--is responsible for our experience of suffering. Mindfulness practice enables one to begin to transform, ie, let go of our attachments (possessions), anxiety, aversions (fear, anger) and delusions and "deeply understand" them for what they are. If we do not acknowledge what is real in the present, how can one begin to transform suffering? One needs to be truly present to enjoy the sunshine, our beloved, the rain ... if not now, when? Buddhist practice encourages one to accept reality as it is to begin to liberate oneself from suffering. One can begin to appreciate this by being more mindful in each moment, of our breathing, walking, smiling, our food ... the flowers wherever they are found. Several colleagues and I have noted that practicing mindfulness have noted that practicing mindfulness contributes much to the quality and joy of medical practice and scientific inquiry.

In practicing medicine, when we begin to "see" with deep awareness, openness of heart, clarity of vision, with love, joy and nondiscrimination, we can then practice care and compassion that our patients and we need as part of our common humanity.

References

1. Anonymous, France 15th century.

2. Dharma Cakka Pavattana Sutta. Samyutta Nikaya V, 420.

3. Hanh TN. Teachings on Love. Berkeley, Parallax Press, 1997.

4. Kabat-Zinn J. Mindfulness-Based Interventions in Context: Past, Present, and Future Clinical Psychology: Science and Practice 2003;10:144-156.

5. Linehan MM. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, Guiford Press, 1993.

6. Benson H. The Relaxation Response. New York, William Marrow, 1975.

7. Borysenko J. Minding the Body, Mending the Mind. New York, Bantam Books, 1988.

8. Sutra 744, Tsa A Han (Samyuktagama) Taisho 99.

David E. Arond, MD MPH

From Division of Public Health Practice, Harvard School of Public Health, Boston, MA.

Reprint requests to David E. Arond, MD, MPH, Harvard School of Public Health, Division of Public Health Practice, 841 Parker Street (Ground Floor), Boston, MA 02120. Email: [e-mail]