Eye on religion: considering the influence of Buddhist and Shinto thought on contemporary Japanese Bioethics.

Abstract: Religious traditions can play a significant role in the shaping of bioethical thought. In Japan, traditional Buddhist and Shinto thought continue to influence contemporary bioethical perspectives. To better define this relationship, this paper examines the correlation between Japanese bioethical perspectives and Buddhist and Shinto thought. An in-depth discussion explores how Buddhist and Shinto scholars have used fundamental concepts with each religious tradition to agree and disagree with the disclosure of an incurable disease to a patient, brain death, and brain-dead organ transplantation.

**********

Religious traditions can play a significant role in the shaping of bioethical thought. In Japan, traditional Buddhist and Shinto thought continue to influence contemporary perspectives on several bioethical issues including patient disclosure of incurable diseases and organ transplantation. Despite this relationship, there persists a scarcity of English literature written on this subject. This paper explores the correlation between Japanese bioethical perspectives and Buddhist and Shinto thought. Our discussion focuses on three issues which have been discussed in depth and are well-documented in Japanese literature: patient disclosure of an incurable disease, the definition of brain death, and brain-dead organ transplantation.

The Buddhist and Shinto Traditions

The Buddhist tradition was originally a school of thought taught by Buddha in India during the 5th century BCE. Later it developed into a religious tradition and arrived in Japan during the 6th century CE, subsequently spreading throughout the Japanese islands as a major religion. According to Buddhist thought, all events and phenomena arise in interdependence of countless causes and conditions, and thus all consequences become nonexistent once conditions and causes are eliminated. Based on this philosophy of interdependence, nirvana--a state in which one is liberated from the wheel-of-life--is pursued as one's attempt to renounce earthly desires. Here, "earthly desires" is a collective term for the mental states which torment and trouble the body and mind, such as anger, envy and greed. The pursuit of nirvana and the actions and ascetic training required in Bodhisattva are called the Bodhisattva way of life. (1) To follow the Bodhisattva way of life ultimately allows one to become free from all earthly desires.

The Shinto tradition is a religion native to Japan that focuses on the worship of deities. Its roots are found in the traditions of Buddhism, Confucianism, Daoism, and Ta Yi Chiao. According to Hansen, the Shinto tradition is characterized by vitalism, priestism, and particularism. (2) Vitalism describes the ancient Japanese belief and worship of the power kami (deity), or sacred energy. Priestism is defined as the reliance on a ritually-selected individual to communicate with kami to solve spiritual and physical illness. Lastly, particularism maintains that each kami bestows a divine blessing on its immediate community in accordance with that community's particular needs. Since the Shinto tradition emphasis purity and considers illness and death to be impure, it is rarely involved in rituals of death and has played a very minor role in the discussion pertaining to the ethics of terminal care.

(I) Informed Consent and the Terminally Ill 

Major reasons that support patient disclosure of an incurable disease in Buddhist thought include: (1) an individual should pursue nirvana by directly facing his or her own death until the end; and (2) an individual approaching death should be aware of his or her prognosis and begin to prepare for his or her transition into nirvana.

(1) To liberate oneself from the endless suffering and wheel-of-life (reincarnation), one ultimately needs to renounce all earthly desires such as anger, envy and greed. Informing a patient of his or her prognosis of death encourages him or her to pursue moksha. (3)

(2) According to the books of Deathbed Manners (4) that describe the ideal manners at the time of death, a dying person should be aware of his or her approaching death, renounce his or her preoccupations with life, and practice the necessary rituals for transitioning into nirvana (eg, reciting Amida Buddha, meditating on Amitabha Buddha, or having faith in nirvana). To do this, the individual needs to be aware of his or her prognosis of death.

Opponents of patient disclosure, on the other hand, maintain that patient disclosure of a terminal illness inflicts psychological suffering and should be avoided. This perspective is illustrated in Ayurveda, a classic system of thought that is highly regarded as fundamental to Buddhist nursing and medical care. According to Ayuvedic medicine, if a patient has been diagnosed with a terminal illness, "the physician should not inform the patient unless asked, even when signs of death are observed. And even if the physician is asked by the patient, he or she should avoid telling the truth. If the truth was told, the patient will despair, or other concerned parties are likely to suffer. A wise physician should not inform a patient with observed signs of death, and also should not wish to treat such a patient." (3)

A third view is that the decision to inform a patient should depend upon the patient's personality and conditions. Some patients, indeed, may be psychologically devastated to learn of their untreatable illness and prognosis of death. However, other patients may be able to accept such a prognosis without the onset of shock and begin their transition into nirvana. Accordingly, given the difference among patient personalities and conditions, disclosure should not be decided uniformly, but rather, requires consideration of the person involved and individual circumstances. (5) This situational position rests on the premise that life and death exist on a continuum, which in turn causes the ultimate meaning of death to become relative.

In terms of Shinto thought, there are very few Shinto scholars who have written on the ethics of patient disclosure. This is largely due to the fact that the Shinto tradition is rarely involved with rituals of death due to its views of death as impure.

(II) Brain Death

Next, we will consider how Buddhist and Shinto thought have influenced Japanese perspectives on the definition of death. According to the Buddhist perspective, an individual is considered dead when they lack (1) alaya consciousness, and/or (2) vitality, heat, and consciousness.

(1) Alaya consciousness (alaya-vinana) is a transcendent reality that exists in all living beings, the "consciousness beneath consciousness" that unites the mind and body. The alaya is said to be located in the central nervous system, and its departure is equivalent to death. According to this view, alaya no longer exists in a brain-dead individual who has irreversibly lost the integrated functioning of the mind and the body. (6)

(2) According to Samyutta-Nikaya, death is the departure of vitality (ayus), heat (usman), and consciousness (vinana) from the body: "The exit of all three from the body makes the flesh forsaken and inanimate, a thing for others to feed on." Vitality is regarded as the same as prana, that which regulates respiration, heartbeat, swallowing, digestion, elimination, menstruation, and other bodily functions. The essential function of prana is to coordinate and integrate the basic organic processes that sustain life. Vitality/heat are inseparable, a mutuality considered equivalent to flame/light. According to this view, vitality and its inseparable other, heat, do not exist in a brain-dead individual who has irreversibly lost the integration of organic processes. (7)

However, brain death can be negated by Buddhist thought on the basis (1) that brain death is impossible given the concepts of Karama, dependent coarising, and becoming (pratitya samutpada; Japanese: engi); and (2) that the brain-dead body remains warm with a heartbeat and therefore is not dead. Specifically, these positions maintain the following:

(1) Pratitya samutpada: Life exists only when all material and nonmaterial conditions (form, consciousness and sensation) are present. (6)

(2) Abhidharma-kosa: Vitality maintains life by sustaining heat and consciousness. According to one interpretation, heat is body temperature, and consciousness includes neurologic function (spinal reflex). A brain-dead body that maintains vital warmth and spinal reflexes is thus considered to have consciousness. (8)

On the other hand, according to Shinto thought, an individual is considered temporarily dead when his or her soul leaves the body, and is only considered dead when the permanent departure of the soul has been religiously confirmed. For example, from the 2nd to 5th century CE, the ancient court of Japan placed the body of a deceased emperor in a temporal palace called mogari, in hope for resurrection. On this same accord, some regions in Japan practice a ritual called tamayobai and hitoyobi, in which survivors shout the name of the deceased immediately after his or her death, in hope of their revival. In summary, a human is not considered permanently dead immediately after his or her heart stops beating since it is believed that the person may be revived through spiritual methods. (9)

Although the ancient books and practices of the Buddhist and Shinto traditions address the topic of brain death, it must be recognized that different interpretations have the ability to change religious practice and perspective and contradicting interpretations indeed exist.

(III) Organ Transplantation From Brain-dead Donors

Buddhist and Shinto scholars in Japan have expressed both approval and opposition to organ transplantation from brain-dead donors. The Buddhist proponents of organ transplantation from brain-dead donors, including the contemporary scholar Umehara, hold: (1) that organ donation constitutes an offering and the Bodhisattva way of life, and for that reason is acceptable (10); and (2) that organ donation can be ethically acceptable based on situational Buddhist ethic. The Bodhisattva way of life can be exemplified in the actions of Buddha when he was Mahasattva in a previous life, the son of King Maharatha (ie, Mahasattva offered his own flesh to a hungry tigress that was unable to feed her seven young cubs).

Other Buddhist scholars have argued for organ transplantation based on situational ethical arguments. As exemplified in the phrase, "Beware of to whom and of what you speak," the Buddhist tradition emphasizes one to consider what is most appropriate in each given situation, depending on concerned parties, time, and place. (11,12) Nevertheless, this argument allows for a relative stance to be reasoned both for and against organ transplantation.

Conversely, Buddhist opponents of organ transplantation maintain a variety of positions ranging from rituals of dying to risks of impurities in offering and receiving an organ. Some opposition is based on the assumption that souls still temporarily remain in the bodies of persons who have just departed, and therefore still maintain some kind of consciousness and emotions. At Buddhist funerals as well, families and friends often recite speeches on the same basis that the immediate dead still maintain some kind of consciousness and emotions. (11) Another perspective emphasizes that people should live the length of their life, predetermined by cause and effect, and that they should receive treatments for curable diseases only, not for incurable diseases (a decline of all excessive treatments). (13) Still others support their argument with the Buddhist commandment of ahimsa: to refrain from inflicting injury to any other living creature in order to preserve one's own life. According to this view, accepting an organ from a donor would constitute taking a part of the donor's "life." (13) Another argument against organ transplantation is based the premise that one should encourage dying persons to accept death and not to save another life by organ donation. (14) A final argument is that the mind and the body are one and that organs should not be treated as parts of a mere machine. (13)

Lastly, in terms of Shinto thought, a fraction of scholars continue to support organ transplantation from brain-dead donors based on the following reasons: (1): to offer one's organ to a recipient whose life would not be saved otherwise fulfills the service of community, which is encouraged by the Shinto tradition (15); and (2) to receive an organ from a brain-dead donor is acceptable as long as the ritual of transferring the soul to the spiritual world (the ritual of spiritual transfer) is performed beforehand. (16)

In all, however, the majority of Shinto scholars do not accept the concept of brain death and thus oppose all organ transplantation from brain-dead donors. Further positions include the following: (1) Shinto thought maintains that being natural is good and thus organ transplant, which is unnatural, is unacceptable (17); (2) a would-be recipient waits for the unfortunate death of a donor, and thus exists with the desire that another face death (18); and (3) transplantation interrupts the inheritance of a soul from the body of an ancestor to a descendant. (15)

References

1. Nakamura H, (ed). Bukkyogo daijiten [A dictionary of Buddhist terms]. Tokyo, Tokyo Xhoseki, 1981.

2. Hansen W. Shinto and the Japanese attitude toward healing. South Med J 2007;100:118-119.

3. Maeda E. Seimeirinri iinkai houkoku [Bioethics committee report]. In-dogaku-bukkyogaku kenkyu 1995;41:320-369.

4. Shinmura T. Kokuti no rekisi [A history of patient disclosure]. In: Zaitaku-si No Jidai [The Era of Home Death]. Tokyo, Hosei University Press, 2001, pp 151-177.

5. Takamura T. Vihara katudo ni okeru taminaru kea [Terminal care in Vihara movement]. In: Jodoshu Honganji-ha Study Group of Vihara Movement (ed). Vihara Undo [Vihara Movement]. Kyoto, Honaganji Shuppansha, 1993, pp 157-206.

6. Hardacre H. Response of Buddhism and Shinto to the issue of brain death and organ transplant. Camb Q Healthc Ethics 1994;3:585-601.

7. Keown D. Buddhism and Death. Buddhism and Bioethics. New York, Palgrave, 1995, pp 144-158.

8. Ashikawa H. Noushi, zoukiishoku mondai to bukkyo rinri [Issues of brain death and organ transplant, and Buddhist ethics]. In: Ikeda H, Kiba M, (eds). Shisei-kan To Bukkyo [View of Life and Death, and Buddhism]. Tokyo, Heibonsha, 2000, pp 53-76.

9. Senke T. Mada ikasaret iru. [They are still made alive]. In: Yoshida K, (ed). Noushi: Watashi Ha Kou Omou [Brain Death: My Opinion]. Tokyo, Hokuso Shuppansha, 1991, pp 366-372.

10. Umehara T. Noushi: Sokuratesu no to ha hantaisuru [Brain death: So-cratics are against it]. In: Watashi Ha Zouki Wo Teikyoshinai [I Will Not Be a Donor]. Tokyo, Yousensha, 1992, pp 207-236.

11. Fujii M. Zoukiishoku to nihonjin no igaikan [Organ transplant and Japanese view of dead body]. Indogaku Bukkyougaku Kenkyu 1990;39:316-323.

12. Slingsby BT. The nature of relative subjectivity: a reflexive mode of thought. J Med Philos 2005;30:9-25.

13. Nabeshima N. Vihara katudo ni okeru taminaru kea [Terminal care in Vihara movement]. In: Jodoshu Honganji-ha Study Group of Vihara Movement (ed). Vihara Undo [Vihara Movement]. Kyoto, Honaganji Shuppansha, 1993, pp 365-366.

14. Ogawa I. Noushi zoukiishoku ni tuiteno ichi bukkyouto no shiten [A Buddhist view of brain death and organ transplant]. Indogaku Bukkyougaku Kenkyu 1991;39:338-344.

15. Jinja-honcho Kyogaku Kenkyujo [The Association of Shinto Shrines, Research Center], Shinto no Shiseikan: Noushi Mondai To Shinso-sai [Shinto's View of Life and Death: Issue of Brain Death, and Funerals in Shinto]. Tokyo, Jinja Honcho, 1994.

16. Ueda K. Noushishita jiten de reikon ha hataraki wo ushinau [A soul loses its function at the time of brain death]. Jinja-shinpo 1992:2174.

17. Tsushiro H. Shinto no shiseikan kara [From the Shinto's view of life and death]. Komatsu Y, Doi K, (eds). Shukyo To Seimeirinri [Religion and Bioethics]. Kyoto, Nakanishiya, 2006, pp 181-208.

18. Morita Y. Takai kannen kara mita zoukiishoku mondai [Issue of organ transplant in terms of the idea of next other world]. Yasukuni May 1, 1992.

Toshinari Mizuno, MD, MSc, and Brian Taylor Slingsby, MPH

From the Center for Biomedical Ethics and Law and the Graduate School of Medicine, University of Tokyo, Tokyo, Japan.

Reprint requests to Dr. Toshinari Mizuno, Center for Biomedical Ethics and Law, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan. Email: [e-mail]