Eye on religion: Buddhism.

The relevance of Buddhism in healthcare and patient management in the U.S. is dependent on 1) the healthcare system and its personnel's appreciation of the tradition and culture, and more specifically, its notions of health, medicine, and therapies; and 2) the varying degrees of enculturation and acculturation of Buddhist devotees, many of whom are recent immigrants, and their American-born and raised descendants. This sketch of Buddhist medical theory and caregiving and the spiritual efficacy of the tradition in the American context are preceded by a survey of its origins.

Origin and Spread

Siddhartha Gautama (563 to 483 B.C.E.), the founder of the Buddhist faith and community, began his spiritual journey with the question of human suffering that accompanies aging, sickness, and death. After six years of spiritual exercises, Gautama realized the Dharma, the truth of pratityasamutpada (dependent coarising or interdependence) and became the Buddha, "the Enlightened One." Pratityasamutpada, the ideological content of the Enlightenment, articulates the belief that all things, all beings, and all events are mutually related and interdependent; it is also the conceptual paradigm that guides Buddhist thought and practice, including the healing arts. In addition, all Buddhist traditions agree that change is the nature of reality, that suffering is endemic to the human condition, and that nirvana is the goal of their spiritual project. These presuppositions, together with the confidence that compassion toward and gratitude for all things and beings are profound virtues, and that practice and devotion based on wisdom and/or sincere faith can overcome suffering, are instilled by the tradition's Dharma masters, the material culture, and rituals.

Buddhism is the single common experience for most of Central, South, Southeast, and East Asia. Theravada, one of its two traditions, is dominant in Sri Lanka and the Southeast Asian countries of Myanmar, Thailand, Kampuchea, and Laos. The other, Mahayana, is a vital force in China (including Tibet), Japan, and South Korea. Both traditions are active in Vietnam. Except for a few isolated pockets, Buddhism disappeared from India in the late 13th century until the social reformer Bhimrao Ramji Ambedkar's (1891-1956) conversion in 1936 sparked a revival.

The US Census Bureau, Statistical Abstract of the United States: 2006 estimates that there are 1,082,000 Buddhists in the US. (1) This figure is extrapolated from 50,281 random digit-dialed telephone surveys by the American Religious Identification Survey conducted in 2001. Somewhat earlier in 1994, Peter Jennings (1938-2005) on ABC Nightly News reported an estimate of the American Buddhist population to be between four and six million individuals. (2) Whatever the numbers, roughly 75 to 80% are of Asian descent who inherited Buddhism as a family tradition; the remaining 20 to 25% are American converts. (3) East Asian migrants, who began arriving in the middle of the 19th century, and their descendents make up most of the Buddhist population. Since the latter half of the last century, refugees from Tibet and Southeast Asia have been added to the mix. The Hart-Celler Act of 1965 allowed large numbers of Asian Buddhists to enter the country. Currently, virtually every form of Buddhism can be found in the US.

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Medical Theory

Reflecting the belief of an interdependent world, ancient Buddhist medical theory understands mind and body to be a single unit. Illness of the body impacts the mental health; similarly, mental illness directly affects physical well-being. Health is evidence of the balance among all of the four elements (mahabhuta): earth (solid), water (wet), fire (hot), and wind (mobile) that constitute the corporeal body. Illness arises when one or more of these elements undergo radical change(s) that disturbs this fourfold equilibrium. Medical and pharmacological therapies aim to maintain and restore physical and mental well being that may be upset by diet, seasonal changes, and physical and emotional stressors. While disease is traced to empirical causes, the residual effects of karma (past action), is also a category of medical etiology. Unwholesome thoughts and deeds impact present and future health.

Buddha traced many physical and mental illnesses to poverty. Adequate nutrition, clothing, shelter, and healthcare optimizes the possibility for education and spiritual development. The government has the responsibility to ensure wholesome living conditions by safeguarding the natural environment, responsibly managing and distributing economic and other resources, instituting effective public health policies, and protecting the poor and dispossessed from exploitation. In keeping with the belief that prevention is the best guarantee against illness and disease, the Buddha urged moderation in all life activities, including spiritual exercises.

Health and healthcare are common metaphors. Buddha, as the great physician, and his devotees attended to their spiritual ills through self-cultivation, and administered medical and nursing care to the sick. Caregiving is a cooperative endeavor between the caregiver and the patient. The Anguttara Nikaya lists the five desirable qualities of the competent caregiver: 1) knowledge of medicaments and their uses; 2) tending to the sick with amity of mind and without thought of personal nourishment and profit; 3) not being lazy; 4) not being prone to frustration, nor loathing the removal of excrement, urine, sweat, or vomit; and, 5) taking delight in conversing with the sick by cultivating the art of listening and by sharing the Buddha's Dharma--a quality which emerged from a belief among early Buddhists linking illness to mental states gone awry. (4) The patient in turn must be actively involved in his or her care. The Anguttara Nikaya lists the five faults of a patient that impede recovery. These are: 1) indiscriminate eating and drinking, 2) irregular eating habits, 3) refusal to take medicaments, 4) surrendering to depression and irritation, and 5) being abusive toward the caregiver. (4)

Symbols and Rituals

Mortuary and memorial rituals perhaps best crystallize the popular understanding of the faith. In addition to highlighting the fragileness and capriciousness of the human existence, these ritual observances underscore the importance of family during times of crisis and reciprocity between generations. In China, Buddhism seamlessly incorporates Confucian notions of filial piety, family lineage and cohesion, and the reciprocity between the living and dead with its teachings of impermanence, suffering, and interdependence. The adult child sponsors these rituals as an expression of filial gratitude for a debt that can never be fully repaid. His or her children and grandchildren learn filiality by observing their elders and participating in these services. The Japanese, heirs of Chinese Buddhist culture, append Shinto ideas of ancesterhood and regular observances to facilitate the transformation of the deceased from a physical to a spiritual being (kami). Mortuary and memorial rites are preceded by a series of late life rituals, beginning with the 60th birthday that marks the completion of one full life cycle according to the Chinese Zodiac. These rituals serve to reassure the elderly that they will be cared for as they age and remembered in death. Popular Buddhism in Southeast Asia also reflects the importance of family and has incorporated animistic beliefs. The sick, too, are appreciative of strong family ties.

During my tenure as a temple priest, I observed the therapeutic value of material objects that remind the sick and dying of their faith. An image of the Buddha that is readily visible from the sick bed is a source of great comfort; it is a reminder of the Buddha's great compassion and the community. I would often leave a nenju (prayer beads) with the sick to clutch. An elder woman dying with liver cancer and under hospice care was able to rest peacefully for six hours after I delivered a Buddhist chant. Her daughter asked that I return regularly, because morphine was increasingly unable to suppress the pain.

The practical efficacy of Buddhist spirituality in the American healthcare setting requires an appreciation of the varieties of Buddhist culture and the varying degrees of cultural diffusion among their respective devotees. A spiritual toolbox of universally recognizable Buddhist paraphernalia, including fact sheets of different Buddhist cultures, would be useful. Finally, there are American converts to Buddhism. Fluent in English and American medical practices, with the exception of their preference for vegetarian meals, these Buddhists do not experience the same difficulties as ethnic Buddhists.

References

1. Table 69: Self-described Religious Identification of Adult Population: 1990 and 2001. U.S. Census Bureau, Statistical Abstract of the United States: 2006. Available at: http://www.census.gov/compendia/statab/population/pop.pdf. Accessed on December 4, 2006.

2. Prebish C, Tanaka KK eds. The Faces of Buddhism in America. Berkeley, University of California Press, 1998, p 1.

3. Buddhism in America. Available at: http://en.wikipedia.org/wiki. Accessed on December 4, 2006.

4. Takakusu J ed. Taisho Shinshu Daizokyo hangyokai. Tokyo, Japan, 1925-1931, pp 680c.

Ronald Y. Nakasone, PhD

From the Graduate Theological Union, Berkley, CA.

Reprint requests to Ronald Y. Nakasone, PhD, Graduate Theological Union, 2400 Ridge Road, Berkley, CA 94709. Email: [e-mail]