Endure, Adapt, or Overcome? The Concept of Suffering in Buddhist Bioethics“, in: Ronald M. Green, Nathan J. Palpant (ed.), Suffering and Bioethics, New York: Oxford University Press 2014, 309-336

Full text

1
Suffering and Bioethics
Edited by Ronald M.Green
and
Nathan J.Palpant
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1
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Library of Congress Cataloging-in-Publication Data
Suffering and bioethics / edited by Ronald M.Green and Nathan J.Palpant.
p. ; cm.
ISBN 978–0–19–992617–6 (hardcover :alk. paper)
I. Green, Ronald Michael, editor of compilation. II. Palpant, Nathan J., 1979– editor of
compilation.
[DNLM: 1. Bioethical Issues. 2. Pain. 3. Stress, Psychological. WB60]
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Printed in the United States of America
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v
CONTENTS
Foreword ix
DANIEL CALLAHAN
List of Contributors xiii
Suffering and Bioethics:An Introduction to the Volume 1
RONALD M.GREEN AND NATHAN J.PALPANT
PART ONEThe Nature, Meaning, and Experience of Suffering
1. Suffering and Human Dignity 15
ERIC J.CASSELL
2. Understanding Suffering 31
BARRY HOFFMASTER
3. Paying Homage to the Silence of Suffering 54
GORDON D.MARINO AND SUSAN E.MARINO
4. Suffering, and the Promise of a World without Pain 61
JOSEPH A.AMATO
PART TWOSuffering in Biology
5. Social Neuroscience Meets Philosophy: Suffering, Empathy, and
Moral Cognition 89
JEAN DECETY
6. Biology of Suffering 106
DANIEL KRASHIN, NATALIA MURINOVA, CATHERINE Q.HOWE,
AND JANE C.BALLANTYNE
7. What Is Suffering and What Sorts of Beings Can Suffer? 134
DAVID DEGRAZIA
PART THREESuffering in Policy and Law
8. Individual and Social Callousness toward Human Suffering 157
DANIEL B.HINSHAW, PETER D.JACOBSON,
AND MARISA P.WEISEL
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vi Contents
9. Human Rights and the Moral Obligation to Alleviate
Suffering 182
ROBERTO ANDORNO AND CRISTIANA BAFFONE
10. Exploring Interactions between Pain, Suffering,
and the Law 201
MARGARET SOMERVILLE
PART FOURReligious Perspectives on Suffering and Medicine
11. Suffering:ACatholic Theological-Ethical View 231
LISA SOWLE CAHILL
12. The Orthodox Christian View of Suffering 249
H. TRISTRAM ENGELHARDT JR.
13. Redemptive Suffering Redeemed: AProtestant View
of Suffering 262
KAREN LEBACQZ
14. Suffering:Reflections from the Jewish Tradition 275
LAURIE ZOLOTH
15. Human Suffering through Illness in the Context of
Islamic Bioethics 296
ABDULAZIZ SACHEDINA
16. Endure, Adapt, or Overcome? The Concept of “Suffering”
in Buddhist Bioethics 309
JENS SCHLIETER
17. Human Suffering and the Limits of Secular Bioethics 337
MARK J.CHERRY
PART FIVESuffering in the Ethics of Contemporary Medicine
and Biotechnology
18. Reproductive Technology in Suffering’s Shadow 357
PAUL LAURITZEN
19. Genomic Information and Suffering in the Genomic Era 374
ROBERTA M.BERRY
20. Preimplantation Genetic Diagnosis and the Prevention
of Suffering 404
MARY ANDERLIK MAJUMDER
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Contents vii
PART SIXConcluding Thoughts
21. Suffering and Ethics in an Age of Empowerment 431
NATHAN J.PALPANT
22. The Evil of Suffering 451
RONALD M.GREEN
Index 467
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309
16
Endure, Adapt, or Overcome? The Concept of
“Suffering” in Buddhist Bioethics
Jens Schlieter
Most people either dread death as the greatest of suffering
or long for death as a relief from suffering.
One who is wise neither deprecates life, nor fears not living.
Epicurus, Letter to Menoeceus
The central position of “suffering” in its fundamental doctrines is, without doubt,
a characteristic of Buddhism.1 Accordingly, its core teachings, conveyed by the his-
torical Buddha in a succinctly worded formula, the “Four Noble Truths,” are all
related to “suffering.” The rst “Noble Truth” states the existence of “suffering”
(Sanskrit:duḥkha, Pali:dukkha); the second, the “Origin of Suffering”; the third,
the “Cessation of Suffering” (duḥkha-nirodha); and, nally, the fourth discloses the
“Path Leading to the Cessation of Suffering,” which is the “Noble Eightfold Path.”
The latter, a “training guide” to reach the end of suffering, comprises elements of
wisdom, ethical self-cultivation, and mental development (such as concentration
and meditation).
Even though the “negative” diagnosis of unrestricted “suffering” of the rst
“Noble Truth” is obviously put into perspective and “neutralized” by the “positive”
third and fourth “Noble Truths,” which emphatically claim that there is (a way
to) “cessation of suffering,” early Western scholars of Buddhism were nevertheless
repelled by the weight of the allegedly single negative truth of suffering in Buddhist
doctrine. As a result of this centrality of suffering, Buddhism seemed to comprise
for them—in combination with the abstract goal of “Nirvāna” as an end to suf-
fering—a kind of “pessimism,” “nihilism,” or “cult of nothingness.” Recent pub-
lications trace this interpretation to the early apprehension of Buddhism by Jesuit
missionaries and other Christian apologetics,2 but it remains inuential and still
constitutes a popular criticism of Buddhism. Therefore, it is important to discuss
suffering in relation to the overall positive claim that Buddhists make, namely, that
there is a way to overcome suffering. But what constitutes suffering in a Buddhist
context?
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310 Religious Perspectives on Suffering and Medicine
A stock phrase, to be found in discourses of the Buddha transmitted in Pāli,
explains:“And what, monks, is the Noble Truth of Suffering? Birth is suffering,
ageing is suffering, death is suffering; sorrow, lamentation, pain, sadness, and dis-
tress are suffering. Being attached to the unloved is suffering, being separated from
the loved is suffering, not getting what one wants is suffering.”3 Here, the concept of
“suffering” includes a wide spectrum of heterogeneous characteristics ranging from
the fundamental anthropological situation of “being human” (birth, ageing, sick-
ness, morbidity) to physical, emotional, and mental states and attitudes. Other texts
portray the social side of human suffering: loneliness, depression, never-ending
stress.4 Therefore, “the Buddhist concept of duhkha, often translated as ‘suffering,’
is not simply an unpleasant feeling. Rather, it refers most deeply to a basic vulner-
ability to suffering and pain due to misapprehending the nature of reality.”5
The translation of the technical term for “suffering” in early Buddhist texts,
Skt. duḥkha, poses some difculties:No single English term captures the full range
of this crucial concept. Renderings, depending on the context, include “despair,”
“fear,” “pain,” and “vulnerability,” but also “stress,” “frustration,” “aversion,”
“longing,” “uncertainty,” and “boredom.”6 Some scholars of Buddhism have pro-
posed to render it primarily as either “unease,” “uneasiness,” or “unsatisfactori-
ness”—in order to cover the larger range of its meaning.7 Therefore, it seems to
be both necessary and useful to distinguish between different Buddhist concepts
of “suffering”:Suffering as a feeling (e.g., pain), suffering as an emotion, and also
purely “cognitive” suffering as an outcome of “false views” (mental attitudes), such
as suffering as a result of the belief one will undergo unpleasant states in the future.8
According to early texts and later commentaries, suffering has its origin in
“desire,” “thirst,” or “craving” (Skt. tṛṣṇā, P.taṇhā); in the attachment to one’s own
body and clinging to a concept of an “adamantine personhood”; and, nally, in the
cycle of unpleasant rebirths. Already in canonical texts, however, there appears a
distinction of “three kinds of suffering”:“suffering due to pain,” “suffering caused
by conditioning,” and “suffering caused by change.”9
Yet, one might ask whether or not these different kinds of suffering may be sub-
sumed under the category of “suffering” as understood in recent Western psychol-
ogy and academic discourse. By way of clarication, we might take a short look at
some recent Western approaches to dene “suffering”:according to the inuential
view of Eric J.Cassell, suffering “can be dened as the state of severe distress asso-
ciated with events that threaten the intactness of the person.”10 Without question,
the rst criterion of “distress” plays an important role in the Buddhist denition
of suffering. Already, early Buddhist texts offer a “psychological” view on suffer-
ing. There, the Buddha is portrayed to explain that human beings have “contact”
to the world by way of sense perception. With “contact as condition,” he proceeds,
“there is feeling. What one feels, that one perceives. What one perceives, that one
thinks about. What one thinks about, that one mentally proliferates.”11 “Distress”
is, therefore, a conditioned mental reaction triggered by unpleasant sense percep-
tions (e.g., pain, but also hurtful words of others). The second criterion, however,
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Endure, Adapt, or Overcome? The Concept of “Suffering” in Buddhist Bioethics 311
the threat to the “intactness of the person,” seems to be less tting:Although “age-
ing” and “death” gure prominently in the Buddhist concept of suffering, they are
not understood as suffering because the “intactness of the person” is in danger.12
Quite to the contrary:According to the Buddhist concept of personhood, the very
idea of a substantial “self” is a prominent source for suffering:“Whether we use
the term self, or ego, or personal identity, for Buddhists it is precisely the notion of
an enduring entity that is the root cause of suffering. The mutable nature of phe-
nomena comes into conict with the hope that our self will endure.”13 Moreover,
at least in early Buddhist discourse, the concept of human suffering is part of the
general suffering all “sentient beings” (Sanskrit:sattva) share; to tie suffering per
denition to “persons” seems to presuppose a certain Western “speciecism,” which
many Buddhists reject quite emphatically.14
The different apprehension of suffering in Buddhist (as well as other Indian) and
in Western traditions can be shown in a telling example. In the view of Western tradi-
tions, the life of the embryo and fetus in the mother’s womb has been conceptualized
as very pleasant, secure, carefree, and guarded—thus, far from being considered as
suffering. As it seems, this depiction emerged already in the Jewish-Christian tradi-
tion:In Isaiah (44:2), we read of the Lord, “who made you, who formed you in the
womb, and who will help you.” The embryo, in short, is cared for already in the
womb. Sigmund Freud diagnosed some patients as being affected by nothing less
than the desire to return to the mother’s womb. Not coincidentally, for Freud and
other psychoanalysts, the womb is a mythical, archaic, and even “holy” space free
from suffering—an “intrauterine paradise.”15 In contrast, in the Buddhist tradition,
the “embryo/fetus” had, according to the karma-and-rebirth doctrine, already lived
previous lives and is, therefore, not a “blank sheet” (“tabula rasa”) and hence bound
to suffering.16 In Buddhaghosa’s important manual of Buddhist doctrine (fth cen-
tury C.E.), we read:“When this being is born in the mother’s womb, he is . . . born . . .
like a worm in rotting sh, rotting dough, cesspools, etc., he is born in the belly in a
position that is below the receptacle for undigested food (stomach), above the recep-
tacle for digested food (rectum), between the belly-lining and the backbone, which is
very cramped, quite dark. . . . . And on being reborn there, for ten months he under-
goes excessive suffering, being cooked like a pudding in a bag by the heat produced in
the mother’s womb, and steamed like a dumpling of dough, with no bending, stretch-
ing, and so on. So this, rstly, is the suffering rooted in the descent into the womb.”17
Another text on the “Descent of the Embryo,” the Garbhāvakrāntyavadāna, explains
that a fetus has to suffer—because of its negative karma—from that moment onward,
when it is “equipped with the consciousness of [experiencing] suffering” (Skt.:duḥk
hasaṃjñā-prapanna).18 The assumption of prenatal-fetal stress, in Western medicine a
rather recent discovery,19 has likely inuenced the critical stance of Buddhist scholars
in regard to abortion, too. Again Buddhaghosa:“When the mother has an abortion,
the pain that arises in him through the cutting and rending in the place where the pain
arises that is not t to be seen even by friends and intimates and companions—this is
the suffering rooted in abortion.”20
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312 Religious Perspectives on Suffering and Medicine
To return to the discussion of “Western” concepts of suffering, a denition
that seems to be more in line with Buddhist accounts of suffering is the “intuitive”
denition of Edwards:“The rst is that suffering must involve a phenomenological
element. This may include pain but need not. Second, pain is neither a necessary
nor a sufcient condition of suffering. Third, suffering has to have a signicant
duration. This is in clear contrast to pain. Fourth, for a state to count as suffering,
it must have a fairly central place in the mental life of the subject.”21
This denition converges with the “emic” Buddhist concept of suffering in
several respects:the “centrality” of suffering, the difference to “pain,” the tem-
poral extension, and the “nonpersonalist” approach. These characteristics lend
themselves to the argument that not only other sentient beings, such as animals,
suffer, but also fetuses, babies, and human beings in “nonrational” mental circum-
stances (e.g., individuals with dementia). Nevertheless, applying such a denition,
Buddhists may not necessarily conclude that all these cases of suffering are equal
in regard to quality or intensity. Concerning the animals’ suffering, however, early
texts explicate—which may astonish only at the rst glance—that for them hunger,
thirst, heat, abuse, cruelty, struggle, and so forth, will be even more agonizing than
for human beings.22
But what about those humans that seek to suffer deliberately (as radical ascet-
ics do), or those who will sometimes—if perhaps only in certain situations—nd
“joy” in their suffering? According to textual sources of early Buddhism, it seems to
be clear that there is no religious justication for practices of extreme mortication
for the historical Buddha. His teaching of the “middle way” implies to steer clear
from any indulgence of sense-pleasures on the one hand, and self-mortication on
the other, which is judged as either a nite pleasure or a painful and unprotable
undertaking.23 There is, indeed, no appreciation of self-aficted suffering in early
Buddhist sources. Any religious indulgence in suffering and likewise any pleasure in
suffering (e.g., masochism, unnecessary endurance, or unmet desires) are altogether
counted as suffering to be overcome. Clifford Geertz’s depiction that, as a religious
problem, “the problem of suffering is, paradoxically, not how to avoid suffering
but how to suffer, how to make of physical pain, personal loss . . . something bear-
able, supportable—something, as we say, sufferable,”24 is, therefore, only partly true
with respect to Buddhist attitudes. Most Buddhists distinguish between “pain” and
“suffering,” claiming the former to be unavoidable, while regarding the latter to be
completely overcome by the spiritually advanced practitioner. The anthropologi-
cal—or, probably better, the “theriological”—basis of Buddhist views on suffering
lies in the capacity of sentient beings to recoil if they experience aversion (e.g., pain,
violence) and seek situations in which they are secure, happy, and at ease. This is
already stated in verses of the canonical Dhammapada:“All tremble at violence,
to all life is dear. Comparing (others) with oneself, one should not kill or cause to
kill. When a man considers this, he does not kill or cause to kill. Whoever injures
with violence creatures desiring happiness, seeking his own happiness he does not
gain happiness when he has passed away. Whoever does not injure with violence
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Endure, Adapt, or Overcome? The Concept of “Suffering” in Buddhist Bioethics 313
creatures desiring happiness, seeking his own happiness he gains happiness when
he has passed away.”25 This feature is to be found in later texts of the Mahāyāna
tradition, too, such as Śāntideva’s “Guide to the Buddhist Path to Awakening” (sev-
enth century C.E.), which states that “happiness is liked by me and others equally,”
whereas “fear and suffering are disliked by me and others equally.”26 And the cur-
rent Dalai Lama, Tenzin Gyatso, explained:“In your personal view, is a bacterium
a sentient being? The question is important in the Buddhist context because when
you take the life of a sentient being, that constitutes a wrong deed. So is it wrong
to kill an amoeba? Buddhists would say that if the amoeba feels pleasure and pain,
wishes to be happy and free of suffering, then it is wrong to kill it, and otherwise it
is not wrong.”27
In the Dalai Lama’s denition, it seems to be of ethical relevance if a being
is endowed with the capacity of feeling pleasure or pain. There is, however, to my
knowledge no classical text that explicates how the victim’s capacity to feel pain
should guide ethical decision making in regard to human beings. Again, this may
be illustrated with the Buddhist notion of fetal development:as stated previously,
there are several texts in which the fetus is depicted as being bound to suffering;
she is—at a certain advanced stage of fetal development—equipped with the “con-
sciousness [or:clear knowledge] of suffering” (Skt. duḥkhasaṃjñā).28 In premodern
Buddhist tradition, an exact date (as a “terminus ante quem”) for the initial devel-
opment of the fetus’s capacity to feel pain or pleasurable feelings does not seem to
be of ethical importance.29 Remarkably, though, some Vinaya traditions distinguish
between a “human being” (Skt. manuṣya, Tibetan mi) and a being “that possesses
a humanlike form [or body]” (Skt. manuṣyavigraha, Tib. mir chags pa).30 According
to some texts, the “humanlike,” phase spans over the rst forty-nine days,31 which
would more or less comprise the Western denition of “embryonic development.”
However, even killing an embryo in “humanlike form” is explicitly forbidden—yet,
it might, according to some Vinaya texts relevant to Buddhist traditions in East
Asia, be interpreted as comparably less serious.32 Nonetheless, Tibetan embryologi-
cal texts stress the homogeneous continuity of the development with the fact that
the karmic “consciousness principle” may even “experience” entering the womb.33
To summarize, the acceptance of the fact that human beings suffer is seen as
an essential prerequisite for Buddhist practice—essential, because it is the ultimate
motivation to pursue the goal of overcoming one’s own suffering as well as to help
others who suffer. Suffering has, therefore, also “a positive side. It makes us aware
of the vulnerability of life.”34 The latter is especially emphasized in the Mahāyāna
tradition, that is, those schools that focus on the spiritual ideal of the Bodhisattva.
ABodhisattva generates—out of compassion—the wish to attain Buddhahood for
the benet of all suffering beings. And again, in the words of Sharon Salzberg, “the
rst step in developing true compassion is being able to recognize, to open to, and
to acknowledge that pain and sorrow (suffering) exists.”35
The relevance of these ideas and motivations in concrete bioethical decision
making will be discussed later; here, however, a more general remark may be in
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314 Religious Perspectives on Suffering and Medicine
place:claiming the existence of suffering, Buddhist texts emphasize that the over-
all, long-term goal can be neither to mitigate nor to endure (or adapt to) suffering,
but instead to accept it—in order to enter the path of Buddhist practice, which is
intended to fully overcome suffering. Pursuing strategies to prevent a priori any
kind of anticipated suffering for sentient beings would—assuming that these strate-
gies would work—preclude the motivation to search for efcient ways out of the
“ocean of suffering.”36
The Japanese philosopher Masahiro Morioka has coined a brilliant term for
this enterprise, namely to follow the ideal of a “painless civilization”:such a civi-
lization, he says, “is one in which the mechanism of preventive reduction of pain
spreads throughout its society”;37 a development that, he holds, actually already
takes place in highly industrialized nations with advanced biomedicine. For exam-
ple, he asks “why many people choose to abort when a congenital disability, such
as Down syndrome, is found in the fetus.” For him, “there are various reasons for
that decision. Some would say that a severe disability will bring great suffering to
the child itself in the future. . . . However, Ibelieve that one of the strongest reasons
for choosing selective abortion is . . . that parents tend to think that having a disabled
baby may cause great pain and suffering to the parents themselves, both economi-
cally and psychologically. . . . They try to avoid pain and suffering that may fall upon
them in the future, and usually this avoidance is accomplished in a preventive way.
Ihave called this kind of act . . . ‘preventive elimination of pain.’ ”38
Buddhist ethicists may subscribe to Morioka’s view in a crucial aspect—in
Buddhism, ethics pertain rst and foremost to the rst-person perspective:“Each
person must monitor his or her own life.”39 This attitude, which is substantiated
with the theory of karma, may be called a “perpetrator”-centered view of ethics—
instead of a “victim”-centered approach. Practices of selective abortion and the use
of preimplantation genetic diagnostics are not related to real pain and suffering of
affected individuals—simply because they will not be born. Their expected suffer-
ing remains, therefore, still a sheer possibility. At the time of the decision making,
the emotional stress of the expecting is much more manifest.
Answers on How to Alleviate or Overcome Suffering
Overall, Buddhist texts stress that pain and suffering are central to the mental life of
human beings. Nevertheless, they likewise express the optimistic idea that all people
are—in the long run—able to overcome suffering. Because “craving” is considered
one of the fundamental origins of suffering, strategies that aim to abandon desire
will have to eliminate craving as the root cause. “Craving” (Skt. tṛṣṇā; P.taṇhā), lit-
erally “thirst,” is dened as the intensive desire to experience sensual pleasures and
as longing either for the “eternal existence” of the individual self or the soul or for
“non-existence” or total “annihilation” after death. Another important theoretical
doctrine, which can already be found in early Buddhist sources, the “dependent
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Endure, Adapt, or Overcome? The Concept of “Suffering” in Buddhist Bioethics 315
origination” (Skt. pratītyasamutpāda), explicates the origination and cessation of
suffering by a conditional nexus:“by the cessation of craving clinging ceases; by the
cessation of clinging becoming ceases; by the cessation of becoming birth ceases;
by the cessation of birth ageing and death, sorrow, lamentation, pain, grief and
distress cease. And thus this whole mass of suffering ceases.”40
More generally, “suffering”—with “craving” as its root cause—leads to a pro-
cess called “clinging” or “attachment” (P./Skt. upādāna) to the world and a per-
son’s own self. “Attachment” can become manifest in various ways:attachment to
pleasures, emotions, material possessions, or to the very own identity of the “self.”
The latter seems to be the most crucial yet, at the same time, the most difcult
moment of the Buddhist explanation of the coming into existence of “suffering.”
In later Buddhist thought, such as Buddhaghosa’s Visuddhimagga (and elsewhere),
it is the highest sense (ultimate truth) that there is no “person” that feels, no “experi-
encer”:“For there is suffering, but none who suffers; “doing” exists although there
is no doer.”41
Thus, ultimately, any therapy for “suffering” has to succeed with the aban-
donment of any strong notion of a “substantial” self. This is emphasized in most
schools of Mahāyāna Buddhism, too:“As a result of misapprehending the self as
independent, there arises a strong sense of the absolute separation of self and other.
Then, craving naturally arises for the ‘I’ and for what is mine, and repulsion arises
toward the other. The erroneous belief in the absolute distinction of self and other
thus acts as the basis for the derivative mental afictions of craving, hatred, jeal-
ousy, and arrogance. Such toxins of the mind are regarded, in Buddhism, as the
sources of all mental suffering.”42 In a famous and inuential work of Mahāyāna
Buddhism, the philosopher Śāntideva argues that focusing on one’s own suffering
cannot to be justied if the claim of “selessness” is taken seriously:“Without
exception, no sufferings belong to anyone. They are to be warded off simply because
they are suffering. Why is any limitation put on this?”43 It is therefore the ideal of
the Bodhisattva, his “regulative idea,” if Imay allude to Kant here, to champion
the benet of all sentient beings by directing his compassion to them, and fur-
thermore, to work indirectly toward alleviating their suffering by guiding them in
their Buddhist practice.44 Especially, Mahāyāna Buddhist texts emphasize that the
Bodhisattva is obliged to pursue a greater benet even if it may cause some small
amount of harm:“The Bodhisattva makes an effort . . . with all the forces of body,
word and mind for assuaging all bodily and mental pain, both present and future,
for all beings, and for producing bodily and mental happiness present and to come.
But if he does not search for the complicated causes leading to all this, nor strive for
the remedy of obstacles in its way; if he does not engender a little pain and grief in
himself which becomes the remedy of much grief in others; nor relinquishes a little
wealth for the sake of great prosperity, yea, if he overlook[s] these duties for even a
moment, then he is guilty of sin.”45
As is well known, the Buddhist tradition developed techniques of concen-
tration and meditation, which are instrumental in the alleviation of suffering.
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316 Religious Perspectives on Suffering and Medicine
Notwithstanding that other philosophical traditions—such as the Greek-Roman
Stoa, namely Epictetus or Marcus Aurelius—have developed certain techniques
for dealing with suffering, it is a quite remarkable, if not distinct, feature of the
Buddhist tradition that these techniques have been elaborated into some kind of
systematic training. The Stoics, for example, developed some basic exercises how
one should refrain from hasty judgments. One should observe one’s own state of
mind in a neutral and disengaged manner—the famous stoic “mental unpertur-
bedness”—and should, moreover, enjoy this passionless state of mind as the most
happy to achieve.46 Likewise, one should “premeditate” (Latin:praemeditatio) pos-
sible painful experiences to come and one’s own process of dying and death in order
to stay calm and peaceful when the time has come. Someone who is trained in pre-
cise observation of negative feelings, such as aggression, self-hate, or jealousy, will
henceforth be probably less governed by these.
This is exactly what the core of Buddhist training (in a more systematic man-
ner) seems to consist of:to gain knowledge of these feelings and emotions in their
most sublime initial stage. Buddhist practitioners who are able to rene their sen-
sitivity in this respect are hoped to cut off conditioned modes of reactions (e.g.,
certain automatized, aversive responses to pain). Paramount in this context is the
“mindfulness” meditation. Already, early Buddhist texts declare that there is “one
path” (or, a “unied path”) “which puries beings, surmounts grief and fear, elim-
inates suffering and distress, abandons crying and weeping . . .—namely the four
establishments of mindfulness.”47 Directing attention to the process of breathing
marks the beginning of mindfulness meditation. Subsequently, the mind is trained
to concentrate on body postures, movements, and the impermanence of the body;
feelings and emotions; thoughts and cognitive states; and nally, central Buddhist
teachings, such as the “four truths.” The overall goal of mindfulness training, which
has in modern Theravāda Buddhism been systematized as “[realization through]
direct insight” (P. vipassanā-bhāvanā), is equanimity, peace of mind, and liberation
from craving and attachment. Buddhist teachers explain that a systematic train-
ing in attention, concentration, and equanimity will lead to their mutual reinforce-
ment:one who is able to strengthen his concentration will be able to deepen his
equanimity; and one who is tranquil will be able to raise his level of concentration
and attention.
A more concrete case of Buddhist views and attitudes with regard to the alle-
viation of suffering can be drawn from the popularization of meditation techniques
as a means to understand—and deal with—stress and chronic pain. The still grow-
ing clinical application of “mindfulness-based stress reduction” (MBSR) may serve
as an example here. This technique, developed by Jon Kabat-Zin as a clinical or
therapeutic group program for alleviating pain and dealing with depression, stress,
and anxiety,48 is devoted to the training of mindfulness in nonreligious settings.
“Mindfulness,” as understood in this technique, “is characterized by dispassion-
ate, non-evaluative and sustained moment-to-moment awareness of perceptible
mental states and processes.”49 While designed for individual self-practice, MBSR
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Endure, Adapt, or Overcome? The Concept of “Suffering” in Buddhist Bioethics 317
presupposes participation in weekly group sessions for eight to ten weeks, where
patients not only learn a basic form of mindfulness meditation but also are intro-
duced to yoga and current scientic knowledge of the psychophysiology of stress
and pain. Over the course of four decades, MBSR has developed into a widely
used program.50 Whereas some of its teachers claim the Buddhist background of
the technique to be of minor importance, the founder, Kabat-Zin, has reinforced
a Buddhist foundation of the therapy in several important aspects, such as in his
implementation of Buddhist “loving-kindness” as a means to foster self-acceptance51
and his conviction that suffering is essentially a reaction to expected pain, which
can be overcome.52
Restricted space precludes me from discussing the MBSR approach in detail
here. It may sufce for our purpose to employ it as an example how traditional
Buddhist meditation techniques are regarded as relevant for the treatment of pain
and suffering in therapeutic settings. Compared with traditional formulas of mind-
fulness meditation, practices such as MBSR53 represent in certain respects the
approach of “Buddhist modernism.” They focus essentially on those elements of
Buddhist teachings and practices that seem to provide helpful action-guides for
coping with the predominant ways of suffering in modern society, whereas other
strands of Buddhist explanations of suffering, such as the karmic roots of suf-
fering, are no longer appealing.54 Moreover, modern mindfulness meditation
contains insights from humanistic psychotherapy, namely, “strong” concepts of
self-acceptance, “self-efcacy,”55 and self-esteem, whereas in early Indian Buddhism
(and sometimes in monastic Buddhism even today), an important exercise of mind-
fulness meditation was to disassociate with the embodied self by rather drastic
means (e.g., contemplation of one’s future fate as a corpse in various stages of
decay).56 This practice is meant to reveal “the repulsive nature of the body . . . during
the stages of its decay, and the fact that death is the inescapable destiny of all living
beings.”57 These practices, intimately tied to a certain negative image of the body in
early Buddhist India, seem to be less tting to modern Western representations of a
generally neutral, if not positive, image of embodiment and hence one’s own body.
Exploring the possibility of whether the Buddhist understanding of suffering
might serve as a public notion of suffering within a modern pluralistic society, it
seems that modernized Buddhist conceptions of suffering share a common ground
with other major therapeutic approaches in two respects. First, suffering is dened
on an “empirical,” “phenomenological,” and “psychological” basis. Second, both
share the conviction that a successful treatment of suffering can be achieved by
“innerworldly” means:through forms of cognitive training, which are in principle
thought to be open to every human being, provided they are endowed with a cer-
tain level of cognitive abilities. Nevertheless, these similarities do not pertain to
Buddhism in general but rather to Buddhist modernism only. Most important, it
is the nonempirical doctrine of karma that has to be discounted, if not suspended,
which has been done in some Western philosophical reconstructions of Buddhist
ethics58 or in a straightforward “Buddhism without beliefs.”59
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318 Religious Perspectives on Suffering and Medicine
To summarize, from early on, Buddhist texts and teachers have suggested
meditation as a technique to overcome suffering. This kind of training should
enable an experienced meditator to sustain a tranquil but attentive state of mind,
which allows the practitioner to realize the ephemeral and transient quality of any
intense feeling (such as pain). It follows that persistent states of suffering may not
arise—for those who are able to unmask a certain interpretation of pain, namely,
to identify with a “strong” notion of “one’s own self bound to suffer.” Moreover,
this kind of “self-help” attitude averts those “unwholesome” thoughts that con-
sist of attempts to blame others to be accountable for one’s own suffering. From
this perspective, any effective therapy of suffering is, therefore, mainly a cognitive
undertaking, which aims not to enhance capacities to endure or adapt to suffering
but to eliminate suffering.
This being said, Buddhist perspectives seem to converge largely with the
(neo-Buddhist) Schopenhauerian “cognitive” denition that “all happiness rests
solely upon the relation between our demands and that which we receive . . . and
likewise, that all suffering actually emerges from the discrepancy between what we
demand and expect and what happens to us—a discrepancy that apparently lies only
in knowledge and could, through better insight, be fully dissolved” (Schopenhauer
1818 [my translation]).60
Suffering:Implications for Buddhist Bioethical Decision Making
Considering recent Buddhist discourse on suffering in bioethical decision making,
it is important to acknowledge the diversity of opinions voiced in the eld. As my
own empirical research on Buddhist bioethics suggests,61 Buddhist discourse on
bioethics seems in fact to be as complex as the respective discourses in the Jewish,
Christian, or Muslim traditions.
Before discussing concrete examples, an overall question must be addressed,
namely the relationship between Buddhist ethics and suffering. It is a remarkable
fact that there are no direct equivalents that correspond with Western “ethics” in
the various premodern Buddhist traditions—neither as a term nor as a discipline.
In a way, ethical reasoning on Buddhist grounds was initiated and systematized by
Western scholars—for example, in the eld of bioethics, by Damien Keown.
Nevertheless, from early on, ethical reasoning and morality have formed
an essential part of Buddhist discipline and philosophy. Of utmost impor-
tance is the goal to refrain from intentionally harming sentient beings (“non-
violence,” Skt. ahiṃsā). Ethical reasoning, furthermore, implies the analysis of
an intended action with regard to whether it is “skillful” or “unskillful” for all
parties involved. This ethical reasoning—illustrated with the mirror metaphor
for ethical “reection”—has been portrayed by the Buddha with the following
words:“What do you think, Rāhula? What is the purpose of a mirror?” “For the
purpose of reection, venerable sir.” “So too, Rāhula, an action with the body
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Endure, Adapt, or Overcome? The Concept of “Suffering” in Buddhist Bioethics 319
should be done after repeated reection; an action by speech should be done
after repeated reection; an action by mind should be done after repeated reec-
tion. Rāhula, when you wish to do an action with the body, you should reect
upon that same bodily action thus:‘would this action that Iwish to do with the
body lead to my own afiction, or to the afiction of others, or to the afiction
of both? Is it an unwholesome bodily action with painful consequences, with
painful results?’ When you reect, if you know:‘This action that Iwish to do
with the body would lead to my own afiction, or to the afiction of others,
or to the afiction of both; it is an unwholesome bodily action with painful
consequences, with painful results,’ then you denitely should not do such an
action with the body.”62 The Buddha advises Rāhula and his other followers to
reect in the same manner on verbal and mental actions—and not only to do so
before any bodily, verbal, or mental action but also to continue to reect while
acting, and even after the deed is done. For some Western scholars but also some
Theravāda Buddhist scholars, this and other similar passages provide “powerful
evidence” for a “consequentialist interpretation of early Buddhist ethics.”63
There is, however, also a strong emphasis on the intention behind an action.64
With an intention to kill or harm a living being, any action is thereby rendered
unwholesome because motives, greed, fanaticism, and delusions all have the same
unwholesome effect. In this respect, Buddhist ethics have thus been called “inten-
tionalist” ethics. Yet, this is not to be confused with a pure evaluation of the mind’s
intentions only. Already, classical commentarial texts of the Vinaya (regulation
of moral conduct of monks and nuns) dene explicitly that an intention (Skt.,
P.:cetanā) can only be an intention if the intended action is executed. Interestingly,
however, there are only few Buddhist texts of the Mahāyāna tradition that argue
ethically by balancing and weighing harms and benets for all parties concerned.
This obvious lack of casuistry (leaving casuistry concerning the application on
Vinaya rules aside, which is in most cases ethically not relevant) makes a strong
case for Buddhist ethical reasoning having an intentionalist core.
Buddhist ethics include a reection of the consequences that actions have for
others, but still the main focus is on the consequences for the offender or perpetra-
tor:“Ultimately decision-making power rests with the agent of the action, since it is
that person who will reap the fruits of the action.”65 Every ethically relevant action
is believed to have an effect on the perpetrator’s next life; unwholesome actions
will lead to bad karma and will therefore imply an increase of personal suffering
in the next rebirth. Ihave proposed to denote this kind of perspective on ethics as
“offender centered”—in contrast to “victim centered” ethics, which focus on the
dignity and inviolability of other affected individuals.66
However, Buddhist ethics have also been conceptualized as contextual (“situa-
tion ethics”), or “virtue ethics” (e.g., by Damien Keown). Finally, another important
facet of Buddhist ethics is the notion of a self-transformative enterprise, which looks
at individual moral practice from a salvic point of view (in line with the “offender
centrism” mentioned previously). ASri Lankan professor of Buddhist philosophy,
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320 Religious Perspectives on Suffering and Medicine
P. Don Premasiri, has acknowledged this transformative quality of “morality”
(sīla) with the following words:“If the entire spiritual training is understood as an
attempt to transform the moral nature of man, sīla can be considered as the begin-
ning of this conscious and deliberate process of self-transformation.”67 To conclude,
the best (Western) way to describe the different aspects of Buddhist ethics seem to be
some kind of “polythetic” approach:Buddhist ethics combine certain elements of
utilitarian consequentialism, intentionalist ethics, situation ethics, and virtue ethics.
To provide some insights into current Buddhist discourse with regard to the
alleviation of suffering in bioethical decision making, Iwill now examine concrete
cases of Buddhist evaluations within three ethical domains:(1) prenatal genetic
diagnostics and abortion; (2)end-of-life issues—palliative care and euthanasia; and
(3)alleviation of suffering through psychotropic drugs.
Prenatal Genetic Diagnostics and Abortion
To evaluate suffering in bioethical decision making with respect to the beginning
of individual human life, Iwill start with some general remarks concerning tradi-
tional Buddhist notions of conception and prenatal life. According to early Buddhist
texts of various traditions, life is inaugurated by the convergence of three factors:the
fertile substances of father and mother, the fertile period of the mother, and a
“consciousness-principle” (Skt. vijñāna, P.viññāṇa).68 The “consciousness-principle,”
which is said to descend into the mother’s womb at the time of sexual intercourse, is
propelled by karmic forces and destined to take rebirth in a new worldly existence.
The traditional attitude might therefore be called “conceptionalism” because it iden-
ties the appearance of a new being with conception. This new life, addressed as
“embryo” (Skt. garbha) or “being” (Skt. sattva), is further qualied by terms such
as “mind” (Skt./P. citta), or, again, “consciousness.” In texts on monastic discipline
(Vinaya), we read the denition:“Human being means:from the mind’s rst arising,
from (the time of) consciousness becoming manifest in a mother’s womb until the
time of death, here meanwhile he is called a human being.”69 An important aspect of
this being is its possession of (or, sometimes, identication with) a “vital force” or
“life-faculty” (P./Skt. jivitīndriya). The ethical relevance of these denitions becomes
visible in the evaluation of abortion:for monks and nuns, it is clearly forbidden to
engage in practices of abortion70—abortion is regarded as taking the life of a human
being. Whereas this quite strict position is most clearly expressed for monks and
nuns, it should pertain to lay Buddhists as well. They should likewise practice the
training rule to abstain from “killing.”71 For L.P. N.Perera, it is “the Buddhist view
that the right to life commences at the very rst embryonic stage of a being, since
maitrī or love, according to the Mettasutta (Sn vv. 143–152) should be extended even
to the embryo or ‘one seeking birth’– sambhavesī (Sn v.147).”72 For some Buddhists,
even the embryo is entitled to a “right to self-determination,” equated with the idea
of karma, “which puts total responsibility on the individual for his life.”73
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Endure, Adapt, or Overcome? The Concept of “Suffering” in Buddhist Bioethics 321
Moving to the recent Buddhist discussion on prenatal diagnostics, Iwill not
be able to present the ethical discussion (e.g., on abortion of a defective embryo or
fetus) thoroughly. Instead, Iwill try to highlight some aspects related to the question
of suffering. Prenatal (in vivo) diagnostics of severe genetic diseases (e.g., Down syn-
drome, cystic brosis, Duchenne muscle dystrophy, beta-thalassemia) raise the prob-
ing question of whether—and if so, in which cases—abortion might be justiable.
Buddhists may approach this issue from various angles.
First, there is the question of whether prenatal diagnosis of such defects can
establish any secure knowledge about the amount of suffering the “nasciturus,” or
human-to-be, will be confronted with. Are there—for Buddhists—any criteria to
estimate the suffering of challenged individuals? Would the situation improve if the
respective life were terminated? Nevertheless, such a judgment should be based on
criteria that allow for a conclusive deliberation over whether no longer being alive
would be better than living an impaired life.
Intricate questions already arise with the interpretation of prenatal test
results:What does it mean, for example, to be confronted with a probability of 1in
280 that the child-to-be will be affected with trisomy 21? Far from being able to
predict the grade of the individual occurrence of every single genetic disease, even
for medical specialists, it is sometimes difcult not to confuse population statistics
with the prediction of the individual’s medical fate.74
Furthermore, it will not count as evidence here to rely on the testimony of indi-
viduals who judge from their life that for them it was not worth living. This kind
of circular reasoning is splendidly portrayed in the paradoxical words of a Yiddish
joke:Two rabbis are musing about life. One of them sighs and says to the other, “How
hard is life. So much suffering! In fact, sometimes Ithink it’s better not to have been
born at all.” “True,” says his friend. “But how many are that lucky? Not one in a mil-
lion!”75 For Buddhists, however, karma is the force that propels the cycle of rebirths.
Therefore, “[not] to be born” is not perceived as an act of divine creation, which trans-
forms into pure contingence, if there is no longer (knowledge of) a divine will. For
Buddhists, “to be born” as a human is, nevertheless, a very valuable achievement,
regulated by the “natural law” of karma (P. kammaniyama).76 There are, to my knowl-
edge, no classical Buddhist sources arguing that termination of a living being may be a
justiable means to prevent further suffering of the affected victim. “The fact that we
are suffering now does not make us immune from future harm if we do harm to some-
one else. We cannot, in the long run, get out of suffering by causing more suffering.”77
Again—in classical texts, and for those Buddhist scholars who adhere to the
traditional “conceptionalist view”78—the focus on the doer of deeds will be of
importance here. To terminate a form of life implies suffering not only for the life
that gets terminated (and will likely be reborn) but also for the decision-making
perpetrators because it is they who will suffer from the negative karma they took as
burden through their action.79 Furthermore, some more traditional Buddhists may
argue that the diagnosed genetic disease of the embryo or fetus is a karmic force
that will only be reduced by exhausting itself.80 By any third-party interruption of
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322 Religious Perspectives on Suffering and Medicine
this process, negative karma will still be there, inuencing the next life to come.
Altogether, the expected suffering of a being not yet born seems for many Buddhists
in itself no argument for aborting a positively tested embryo—even if with high
probability it will be hindered to live a normal life (in terms of the amount of suf-
fering to be expected, even a normal life is merely an abstract statistical illusion).
Although classical texts do not discuss these aspects because modern diagnos-
tic technologies were not within their reach, one might nevertheless argue that for
Buddhists, these new diagnostic-prognostic technologies open up a new dilemmatic
situation, too. In this situation, which in certain aspects is similar to the ethical
reection on the legitimacy of euthanasia (discussed later), the expected amount of
suffering could indeed matter. Let us assume as a premise (1)the conviction of many
intellectual Buddhists that in principle every practitioner is capable of generating
potent mental strategies for alleviating her suffering. Assuming, moreover, (2)that
many Buddhists hold the opinion that practitioners will need, for an efcient use of
these potentials, some basic cognitive capacities at their free disposal. If, now, (3)a
certain person has been born with such a genetic disease that typically includes a
severe degree of intellectual disability, such as Down or Tay-Sachs-syndrome, she
will most likely not be able to learn the Buddhist cognitive strategies (such as medi-
tation) in order to alleviate her suffering. So, in other words, she will not be able to
develop sufcient means to ward off pain and suffering. Some Buddhist ethicists
fell into a pondering silence or admitted the intricacy of the problem when ques-
tioned regarding this matter.81 But again, the main criterion is the question of the
status of the embryo. Obviously, it is less problematic for Buddhist bioethicists to
divert from a conceptionalist view and argue instead that the descent of the “con-
sciousness principle” takes place later—for example, when the primitive streak and
the nervous system develop82—than to declare that “killing” might be justied with
the hypothetical prevention of the affected individual’s future suffering.83
Second, there is the pressing question of whether the suffering of other par-
ties, such as the parents-to-be, or effects to society at large84 should also be taken
into consideration. Especially in poor countries and circumstances, considerable
economic and social costs accompany parents with disabled children. According
to the Buddha’s advice for Rāhula, the doer should reect not only if harm is
done to others but also if harm is done to himself (e.g., by generating unwhole-
some thoughts)—and this reection should take place before, during, and after his
action. Actually, reformulating Morioka’s argument given previously, the embryo’s
suffering in the future is usually the decision maker’s own suffering—the latter
being troubled by scenarios of the affected embryo’s as well as his own future.
Thereby, the decision maker dismisses not only the embryo’s actual situation but
also his own because the anticipated negative scenario may not actually come to
pass. With regard to the intentionalist vein of Buddhist ethics, a Buddhist evalua-
tion could therefore also begin with the motives of parents who decide that having
a child with a severe inherited disease means an unbearable burden to them. Apart
from a critical evaluation of the motives (compassion, convenience, or egoism?),
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Endure, Adapt, or Overcome? The Concept of “Suffering” in Buddhist Bioethics 323
Buddhist ethicists might also consider the long-term effects on society:“The par-
ents’ desire for their offspring to have the most desirable genetic makeup is every-
one’s dream. But should science develop to meet this desire? The concern with
the welfare of the yet-to-be-born is good intention. However, it could lead to an
eugenic movement. . . . If this happens, genes will become the determining factor
for discrimination,”85 resulting, in an extreme scenario, in a society in which peo-
ple with undesirable genes will—in one way or other—be forced not to have off-
spring (an extreme case of what Michel Foucault called “biopolitics”).86 Buddhists
stress here, again, the perpetrator’s intention:whether or not the doer believes or
could notice the embryo to be a living being (or, inversely, just an agglomeration
of cells) is decisive because the action will—in terms of negative karma—be even
more harmful if the intention is a conscious act of killing.
End-of-Life Issues:Palliative Care and Euthanasia
With regard to suffering in the nal stage of dying, a critical aspect for Buddhists
is in which state of mind the person actually dies. If this state is “wholesome” (Skt.
kuśala), it is expected to have positive effects on the next rebirth; if it is unwhole-
some, the effect will be accordingly.87 Thus, scholars of Theravāda and Mahāyāna
Buddhist traditions declare unanimously that retaining a clear and “present” state
of mind when dying is of utmost importance. The dying person should be able to
develop skillful, wholesome mental attitudes—such as being content, tranquil, and
focused, and not being angry, jealous, regretful, or aggressive.
The aim to retain a clear consciousness and a focused mind is an essential
part of several meditation techniques, which focus on the “recollection of death”
(P. maraṇasati). The importance of the very last moment of consciousness (P.
cuti viññāṇa) has been already stressed in early texts; Sugunasiri could bring the
Buddha’s advice to the point by speaking of an “exit mind.”88 Of special impor-
tance, too, is the dying person’s state of mind in most schools of the Tibetan tradi-
tion, in which a comprehensive teaching and ritual, the reading of the Tibetan Book
of the Dead89 (and other texts) has been developed for escorting the dying person or,
more precisely, the departing consciousness.
Many Buddhists explain that even the intention or wish to commit suicide is
usually90 governed by the intention to kill. For them, the suicidal person may likely
be motivated by some kind of hidden self-hate—which is, of course, an unwhole-
some mindset. Generally, there is a more depreciative attitude toward suicide as a
means to end physical pain or suffering in this life:“Because a human lifetime is
an ideal opportunity for achieving liberation, the practice of euthanasia or assisted
suicide is antithetical to Buddhist thinking. Even a life of suffering and hardship is
counted as a valuable opportunity for realization and spiritual evolution.”91 Hence,
for those Buddhists, who believe in the negative quality of the intention to kill,
direct euthanasia or assisted suicide will be no plausible way to end pain, suffering,
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324 Religious Perspectives on Suffering and Medicine
and despair because they will fear the negative karmic effect on future lives:instead
of ending or reducing suffering, suffering is actually expanded.
Moreover, a palliative therapy, which uses strong analgesics, might likewise not
be adequate if, as a side effect, the consciousness and mental presence of the patient
become blurred or disturbed. Some Buddhist scholars argue, however, that a person’s
fear of the pain becoming unbearable may also disturb the process of focusing the
mind—and, accordingly, vote for a more permissive attitude with respect to medi-
cal pain treatment.92 The majority of Buddhist ethicists regard any form of active
euthanasia as intended killing and consequently recommend abstaining from it. With
respect to passive or indirect euthanasia, however, there are a signicant number of
Buddhist scholars opting for more permissive options on a case-by-case basis (e.g., in
regard to the withdrawal of life support).93 As a matter of fact, even the current XIV
Dalai Lama offers liberal opinions. In an interview regarding human beings in “hope-
less” irreversible states (being, as we may say, beyond “the point of no return”94),
he took not only into consideration the amount of suffering these futile treatments
might cause to the family but also nancial aspects:“From the point of view of a
Buddhist, any pain has to be faced, if not in this lifetime, then some other lifetime.
One can use this chance to eliminate the pain by meditating or thinking about com-
passion. . . . This is a very complicated issue and has to be individually assessed on
a case-to-case basis. If the person cannot think because of too much pain, or is in
a coma with no hope of recovery, then the family will also eventually suffer. In the
meantime, this is costly in resources, so then euthanasia may be considered.”95
If dying persons proclaim their wish that their pain shall be eased by strong
analgesics, doctors and relatives will presumably decide in their favor—even if
Buddhist specialists would argue that doing so poses a greater challenge to realize
the “exit mind” for the dying person.
As noted previously, Buddhist ethics are, especially for lay persons, a matter
of training precepts, which should be cultivated as persistently as personal abilities
allow. More difcult are those cases in which someone is no longer able to articu-
late her preferences. In many Asian countries with a signicant Buddhist popu-
lation (Japan being an exception here), a more pragmatic attitude with regard to
irreversible states such as brain death seems to prevail. Accordingly, also nancial
constraints of the family, and the quite often limited resources in intensive care
facilities are taken into consideration.
Pharmacological Mood-Lifting:Alleviation of Suffering through
Psychotropic Drugs
Western biomedicine established over time a distinction between clinical forms of
depression, mood disorders, and so forth, and milder, nonclinical forms of depres-
sive moods and episodes (e.g., as a reaction to loss). It would be interesting, how-
ever, to discuss how this psychiatric differentiation of clinical from nonclinical forms
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Endure, Adapt, or Overcome? The Concept of “Suffering” in Buddhist Bioethics 325
might converge with traditional Buddhist perspectives on suffering. An intriguing
aspect here is the—in comparison with the United States—hesitant use of uoxetine
(Prozac) and other antidepressants in Japan, a fact that has been connected to cul-
tural differences in labeling depression—that is, to more “positive” evaluations of
moods of melancholy, sadness, and grief, as well as of impermanence and loss, in
Japan.96 In the following discussion, Iexamine some Buddhist positions regarding
pharmaceutical treatment of the latter, of healthy persons. As is well known, anti-
depressants such as uoxetine have been extensively used in nonmedical contexts,
bringing the topic of “pharmacological” alleviation of suffering to the forefront.
The example of emotional and cognitive enhancement may provide an inter-
esting test case for Buddhist ethicists. On the one hand, it might be construed as a
competing “therapy” for suffering. On the other hand, it is not tied to the decisive
ethical question of how to evaluate certain states of human life, such as embryonic
life or aphasic, persistent vegetative, or brain-dead states, in which the affected are
not yet—or are no longer—able to articulate how much they actually suffer.
First, I will summarize some arguments that were put forth by Buddhist
ethicists relating to pharmaceutical emotional enhancement. For Karma Lekshe
Tsomo, the use of these new generations of pharmaceuticals “may alleviate suffer-
ing temporarily, but may also result in a loss of perspective and/or personal agency,
create unhealthy dependencies, and lead to even greater suffering.”97 Accordingly,
her central argument revolves around whether these pharmacological treatments
will lower or better the appreciation of one’s own personal agency. For her, the
Buddhist model of mental cultivation is indeed an efcient method to alter one’s
own consciousness (the latter not being just an epiphenomenon of brain functions).
Therefore, meditation is held to be a superior method for the alleviation of non-
clinical forms of depression because for Tibetan Mahāyāna Buddhists, there is “a
subtle form of mental consciousness” that “is not fully dependent on the brain.”98
Let us assume as a thought experiment, that, for a certain practitioner, the result
of Buddhist mental cultivation and pharmaceutical enhancement is experienced as
absence of suffering, as happiness, or even as bliss. But because pharmaceuticals
do not reach to the origins of suffering according to a Buddhist framework (e.g.,
impermanence, ego-centeredness, clinging), they will be efcient as a treatment only
of symptoms and not of causes. Enjoying some kind of transient relief of suffer-
ing—something that is, in Buddhist cosmology, a characteristic of gods in their
respective realms—the practitioner may simply delay the pursuit for a permanent
way out of suffering.99
Even though, for Buddhists, ultimate reality is beyond suffering, there is an intri-
cate, if not dialectical, relation between suffering as experience and the motivation to
practice the Buddhist way to get out of suffering. Not to acknowledge the reality of
suffering—mythologically speaking, the failure of gods absorbed in pleasure, power,
and longevity—will prolong suffering because no efforts are made to end transmigra-
tion.100 Seen from this perspective, the permanent use of mood-lifting pharmaceuti-
cals as the only means of therapy in nonclinical circumstances might for some work as
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326 Religious Perspectives on Suffering and Medicine
a “clutch” for decoupling certain aspects of reality. The undesirability of enthusiastic
feelings that do not correspond to sufcient cause has been demonstrated by Robert
Nozick’s philosophical thought experiment of an “experience machine.”101
Leaving the topic of antidepressants behind, Iwill move to the recent discus-
sion of whether a more general pharmaceutical cognitive enhancement of humans,
which might enable a more efcient cognitive handling of suffering, should be con-
sidered administrable.
Presenting Buddhist thoughts on neuroethics, philosopher Andrew Fenton
takes a quite permissive stand, focusing, however, on pharmaceutical enhancement
of cognitive abilities. If a consequence of pharmaceuticals is to achieve “further
insight into our self-nature or the reduction or alleviation of duḥkha,”102 they should,
according to Fenton, not be opposed from a Buddhist point of view. Arguing that
the supposed ends of pharmaceutical enhancements—“greater skill in concentra-
tion or a more exact perception of events or changes of processes in one’s environ-
ment”103—are quite similar to the ends meditation and self-cultivation aim for, there
should be no principle objections in regard to the overall goals. Using these sub-
stances as “helpers” for cognitive or affective enhancement will equally contribute
to boosting the ability to focus on compassion, thereby accumulating good karma,
which in turn may help to alleviate suffering. If objections arise, Fenton argues,
they must therefore address obviously unwholesome effects of the pharmaceutical
means used. Such effects might include a certain false conception of “self ” (e.g.,
self-aggrandizement, attachment to social reputation, or engagement in social com-
petition) or adherence to a dualist framework of upper and inferior mental quali-
ties. Yet, all these possible dangers, Fenton concludes, are not causally connected
to these pharmaceutics; they are, therefore, not intrinsic arguments for a rejection.
Assessing this position with traditional Buddhist descriptions of suffering
in mind, one might be skeptical with regard to Fenton’s claim that the “ends” of
enhancement—pharmaceutical enhancement and self-cultivated cognitive enhance-
ment—are really the same. Should a “pharmaceutically enhanced mind” be regarded
as an end in itself, or a means for the reduction of suffering—a means that neverthe-
less might be claimed applicable by Buddhist modernists in the future?104 The most
important difference between nonmedical use of antidepressants and pharmaceu-
ticals for cognitive enhancement seems to be the possible effects on the motivation
to start with, and maintain, Buddhist practices:namely, if they will prevent practice
through avoidance of a certain psychological strain (which is denitely more present
in the application of antidepressants). In consequence, it may discourage personal
efforts necessary for coming to terms with suffering in the long run.
Summary and Discussion
Do Buddhist scholars of ethics advise individuals mainly to endure, or to mitigate, or
to adapt, or to (try to) overcome suffering regarding bioethical decisions? Apivotal
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Endure, Adapt, or Overcome? The Concept of “Suffering” in Buddhist Bioethics 327
aspect of the Buddhist discourse on suffering seems to be—as we could see regard-
ing the end of life—that there is no “higher” justication for suffering that people
“have to endure” in these situations. Suffering, albeit an important aspect of human
life, has no “natural quality” of “fate,” “retribution,” or the like. In Buddhism, there
is no blueprint of “good” suffering. Instead, the nal goal is to cultivate capacities
in order to overcome—and not to endure, nor to mitigate—suffering. This has to be
done individually, motivated by one’s own conscious intentions, and as persistently as
the individual abilities permit. This “rst-person view” on suffering implies that, for
Buddhist ethicists, it is important to stress the individual’s capacity to overcome suffer-
ing through mental strategies such as meditation. Accordingly, for Buddhist specialists,
these long-term strategies of overcoming attachment, craving, and so forth are more
valuable than any method of transient relief of suffering. Moreover, Buddhists schol-
ars emphasize that it is “never too late to exercise”—for example, in their recommenda-
tion that dying persons should try to retain a clear consciousness and mental presence.
An important regulative idea of Buddhism in regard to one’s own suffering
appears in the form of certain self-critical questions. Tackling, for example, the prob-
lem of genetic enhancement, Yao characterizes the “the Buddhist approach” quite
aptly:“we are required to think rst about why we want to do genetic enhancement
since all forms of genetic enhancement are our cravings.”105 This “rst-person,”
or “offender-centered” approach is also of inuence for decisions in regard to the
suffering of others. Asubstantial criterion is the ideal of not harming or killing
sentient life (including oneself); if taken literally, it implies some connements in
regard to Prenatal-Diagnosis-cum-abortion (see note 79)or “mercy killing.” On the
other hand, Buddhist texts do not offer criteria to estimate (future) suffering of oth-
ers. The amount of suffering to be expected is, for that reason, no important ethical
action-guide—notwithstanding, that to generate “compassion” for all beings that
suffer is a very important Buddhist virtue.
Interestingly, there is in regard to the central place of the actor’s “no injury”
maxim in Buddhist ethics some similarity with Karl Popper’s proposal to replace the
traditional utilitarian principle of “maximizing pleasure” with “minimizing pain”:“I
believe that there is, from the ethical point of view, no symmetry between suffering
and happiness, or between pain and pleasure. . . . In my opinion . . . human suffering
makes a direct moral appeal, namely, the appeal for help, while there is no similar call
to increase the happiness of a man who is doing well anyway. . . . Instead of the great-
est happiness for the greatest number, one should demand, more modestly, the least
amount of avoidable suffering for all.”106 Yet, the Bodhisattva should also work for the
happiness of others (as Śāntideva declared previously). Another difference between
Popper’s “negative utilitarianism” (Ninian Smart) and Buddhist attitudes toward suf-
fering is, however, that the latter do not conceptualize ethics primarily from the vic-
tim’s point of view but rather, as Ipointed out earlier, from the perpetrator’ point of
view. Even though the Buddhist idea of “compassion” is intimately tied to the aim
of alleviating suffering, it has traditionally not been dened by certain “therapeutic”
obligations in a practical manner. The Bodhisattva’s “compassion” may, for example,
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328 Religious Perspectives on Suffering and Medicine
consist of his “energetic empathy” directed toward the sufferer; or the Bodhisattva
may offer, motivated by compassion, instructions on how to cope with suffering. With
other words, “compassion” in Buddhism is—in contrast to the Christian conception
of active “charity” (caritas)—much less dened in terms of concrete actions of heal-
ing, curing, or other ways of restoring a former “good condition” of others.
Going through the different cases presented, one might nally ask if there are,
in regard to the suffering of others, any clear-cut Buddhist ethical imperatives for
medical professionals. Are there any rst principles that rule Buddhist Bioethical
decision making? For modern Buddhists, the ideal of “compassion” should also
be an action-guide for medical professionals. For Pinit Ratanakul, “compassion”
gures as a “prima facie duty” of Buddhist medical ethics—along with veracity,
noninjury to life, and justice.107 Other scholars of ethics, however, came to the con-
clusion that Buddhist ethics—in the form it has been presented so far—are not very
helpful for pressing ethical dilemmas. Approaches of Western ethics (and bioethics,
respectively), it has been remarked, possess a considerable strength in supplying a
hierarchy of ethical principles, in offering hermeneutics of concrete cases and so
forth, whereas, in contrast, Buddhist ethics sometimes lack clear guidelines “besides
‘caution,’ which is too vague to be of any practical value.”108 Indeed, Buddhist eth-
ics do not seem to offer—at least in their premodern types—in-depth studies of
ethical dilemmas in regard to the suffering of others. Instead, Buddhist ethics offer
rather unwieldy (and sometimes uncomfortable) instructions for “not killing” and
“not harming,” and for the primacy on the actor’s motivation and self-cultivation,
which is for others exactly the strength of Buddhist ethics. Quite tellingly, only very
few early or classical Buddhist texts discuss situations in which an actor is forced
to sacrice a precept (e.g., the abstention of killing) in order to mitigate a greater
mass of suffering. It seems that Buddhist specialists are largely agreeing that “not
to act at all” (or even to act intuitively) is in most dilemmatic situations a legitimate
option. Here, credit may again be given to the theory of karma, which regulates the
nal outcome of deeds for the perpetrator, while the victim’s perspective is left aside.
Already, early texts (such as the Dhammapada verses 130–132 quoted earlier) had
explained that generally everybody seeks to be happy. This seems not to be meant
as a moral obligation—nevertheless, being without greed, hate, or fear is, without
doubt, held to be an important precondition for acting morally wholesome.
Notes
1. Here, Buddhism is used generically and should be understood as a cover term,
despite the diversity of different traditions, both past and present. Abbreviations for Pāli
texts follow the editions and translations of the Pali Text Society.
2. Cf. Urs App, The Cult of Emptiness:The Western Discovery of Buddhist Thought
and the Invention of Oriental Philosophy (Tokyo:University Media, 2012); Roger-Pol Droit,
The Cult of Nothingness: The Philosophers and the Buddha (Chapel Hill:University of
North Carolina Press, 2003).
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Endure, Adapt, or Overcome? The Concept of “Suffering” in Buddhist Bioethics 329
3. Mahāsatipaṭṭhāna Sutta, D II.306–307, in The Long Discourses of the
Buddha: A Translation of the Digha Nikāya, trans. Maurice Walshe (Boston: Wisdom,
1995), 344.
4. Asanga Tilakaratne, “Suffering and Liberation in Theravāda Buddhism,”
International Journal of Buddhist Thought and Culture 10 (2008):87–103, 101–102.
5. Paul Ekman, Richard J. Davidson, Matthieu Ricard, and B. Alan Wallace,
“Buddhist and Psychological Perspectives on Emotions and Well-Being,” Current Directions
in Psychological Science 14, no. 2 (2005):59–63, 60.
6. Cp. Narendra Kumar Dash, ed., Concept of Suffering in Buddhism (New Delhi,
Kaveri Books, 2005).
7. Cf. Damien Keown, Buddhism and Bioethics, 2nd ed. (London, New York: St.
Martin’s Press, 2001), 2; Bhikkhu Ñāṇamoli, The Path of Purication (Visuddhimagga),
by Bhadantācariya Buddhaghosa (Kandy, Sri Lanka:Buddhist Publication Society, 2010),
XVI.34, note 8.
8. The latter concept of suffering might be termed the “metaphysical” understanding
of suffering:because it has its roots in the individual’s production of “negative karma,” the
strategy of overcoming this kind of suffering is connected to moral behavior, i.e., ethical
training. Asian Buddhist cultures, however, admittedly still use some more traditional means
of coping with suffering:safeguarding amulets and formulas, sacrices, healing rituals, etc.
9. P.dukkha-dukkhatā, saṅkhāra-dukkhatā, vipariṇāma-dukkhatā (D III. 216); trans.
Walshe, supra note 3, 484; in the later Mahāyāna tradition, e.g. in Asaṅga’s compendium of
“philosophical systematization” (Skt. abhidharma), the threefold scheme is explained by an
eightfold typology:the sufferings of birth (1), aging (2), disease (3), and death (4)and suffering
associated with what is unpleasant (5)are “sufferings due to pain” (Skt. duḥkha-duḥkhatā).
The ve aggregates of attachment (8)are “suffering caused by conditioning”; whereas the
suffering of separation from what is pleasant (6)and the suffering caused by not obtain-
ing what one desires (7)are “suffering caused by change” (cf. Abhidharmasamuccaya:The
Compendium of the Higher Teaching (Philosophy), by Asaṅga, trans. Walpola Rahula and
Sara Boin-Webb (Freemont, CA:Asian Humanities Press, 2001), 84-85.
10. Eric J.Cassell, The Nature of Suffering (Oxford:Oxford University Press, 1991),
33. Here, Idiscuss Cassell’s classical denition of the 1990s; for Cassell’s current thoughts
on “suffering,” the reader is advised to consult his contribution in this book (see chapter1).
Additionally, the reader may consult David DeGrazia’s contribution (see chapter7) for a
discussion on the relationship of distress and suffering.
11. M I.111–112; The Middle Length Discourses of the Buddha:ATranslation of the
Majjhima Nikaya, trans. Bhikkhu Bodhi with Bhikkhu Nanamoli (Boston:Wisdom, 1995),
203.
12. “Death is the greatest suffering of all, because it is the ultimate threat to our
self-identity and self-interest. As long as we cling to ourselves or our loved ones, death
brings great suffering. But when we analyze the notion of self and try to identify an inde-
pendently existing self, we cannot nd one. The notion that dying is a tragedy is therefore
based on a false premise,” as Karma Lekshe Tsomo, Into the Jaws of Yama:Buddhism,
Bioethics, and Death (Albany, NY:State University of NewYork Press, 2006), 34, explains.
13. Ibid., 34. The concept of “selessness” is, moreover, closely tied to the “compas-
sion”—Pinit Ratanakul, “Buddhism and Human Genome Research,” in GenEthics and
Religion, ed. Georg Peiderer, Gabriella Brahier, Klaus Lindpaintner (Basel:Karger, 2010),
138–150, 140:“Compassion in Buddhism is the quality of the heart and is not an ephemeral
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330 Religious Perspectives on Suffering and Medicine
sentiment. It is a sublime emotion arising from the knowledge of suffering inherent in all
sentient beings, and also from the realization of their unsubstantial nature (anattā) and
inter-relatedness (paticcasamuppada).”
14. Cf. Lambert Schmithausen and Mudagamuwe Maithrimurthi, “Tier und Mensch
im Buddhismus,” in Tiere und Menschen:Geschichte eines prekären Verhältnisses, ed. Paul
Münch, Rainer Walz (Paderborn:Ferdinand Schönigh, 1998), 179–223.
15. Cf. Carola Bindt, A. Huber, and K. Hecher, “Vorgeburtliche Entwicklung,” in Entwi
cklungspsychiatrie:Biopsychologische Grundlagen und die Entwicklung psychischer Störungen,
ed. Herpertz-Dahlmann, Beate, Franz Resch, etal. (Stuttgart:Schattauer, 2007), 89–117, 95.
16. Because of this existence of prenatal suffering, some embryological texts of the
Tibetan tradition argue that the fetus may in fact be able to “practice Buddhism,” e.g., to
meditate—cf. Frances Garrett, Embryology in the History of Tibetan Medicine:Becoming
Human (NewYork and London:Routledge, 2008), 103-105.
17. Vism 500; Ñāṇamoli, supra note 7, 512.
18. Michael Hahn, “Kṣemendras Garbhāvakrāntyavadāna (Sanskrittexte aus dem
tibetischen Tanjur II),” Journal of the European Ayurvedic Society 5 (1997):82–112, 89.
19. Cf. K. O’Donnell and V. Glover, “New Insights into Prenatal Stress:Immediate
and Long-Term Effects on the Fetus and Their Timing,” in Neonatal Pain:Suffering, Pain
and Risk of Brain Damage in the Fetus and Newborn, ed. G. Buonocore and C. V.Bellieni
(Milan:Springer, 2008), 57–64.
20. Vism 500; Ñāṇamoli, supra note 7, 512; cf. Garrett, supra note 16, 108.
21. Steven Edwards, “Three Concepts of Suffering,” Medicine, Health Care and
Philosophy 6 (2003):59–66, 65.
22. Cf. Schmithausen and Maithrimurthi, supra note 14, 208–211.
23. E.g. in S V.420; trans. in Bhikkhu Bodhi, The Connected Discourses of the
Buddha:ATranslation of the Saṃyutta Nikāya (Somerville, MA:Wisdom, 2000), 1843–1844.
24. Clifford Geertz, The Interpretation of Cultures:Selected Essays (London:Fontana
Press, 1993), 103.
25. Dhp 130–132; Kenneth Roy Norman, The Word of the Doctrine. Dhammapada,
translated with an introduction and notes (Oxford:Pali Text Society, 2000), 20.
26. Bca VIII.95–96; trans. in Kate Crosby and Andrew Skilton, Śāntideva. The
Bodhicaryāvatāra: A Guide to the Buddhist Path to Awakening, 2nd ed. (Birmingham,
UK:Windhorse, 2002), 128.
27. XIV Dalai Lama, in Jeremy L Hayward and Francisco Varela, ed., Gentle
Bridges:Conversations with the Dalai Lama (London, Boston:Random House, 1992), 67;
cf. Dalai Lama XIV (His Holiness Tenzin Gyatso), Kindness, Clarity, and Insight, Jeffrey
Hopkins, trans. and ed.; Elizabeth Napper, co-ed. (Ithaca, NY:Snow Lion, 2006 [1984]), 75.
XIV Dalai Lama explained his basic approach like this:“My approach—and you can call it
a leap of faith—is based on two premises. One is that life is precious. The second is that at
the core of human nature there is a need to seek happiness. . . . These are the rst principles.
Everything else is based on them” (Richard J.Davidson, Anne Harrington, ed., Visions of
Compassion:Western Scientists and Tibetan Buddhists Examine Human Nature [Oxford,
NewYork:Oxford University Press, 2002], 216).
28. Cf. Hahn, supra note 18, 89.
29. Relevant embryological texts of the Mahāyāna tradition usually adhere to descrip-
tions found in the most prominent texts of Indian Āyurveda medicine, which assume
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Endure, Adapt, or Overcome? The Concept of “Suffering” in Buddhist Bioethics 331
that consciousness of feelings or mental activity will spring forth between the third and
fth month of fetal development. According to Vāgbhaṭa’s medical compendium, the
Aṣṭāṅgahṛdayasaṃhitā (ca. seventh century C.E.), “conscious knowledge of pleasure
and pain” (Skt. jñānaṃ ca sukhaduḥkhayoḥ; Ah Śā II.55) starts in the third month. In
the Suśrutasaṃhitā (second or seventh century C.E.) “mental activity” (cetanā) starts in
the fourth month (SuS Śā III.18); according to Vāgbhaṭa in the fth (Ah Śā II.57b; cf.
Rahul Peter Das and R.E. Emmerick, ed. “A Machine-Readable Transcription of the
Aṣṭāṅgahṛdaya by Vāgbhaṭa,” accessed March 15, 2014, http://gretil.sub.uni-goettingen.de/
gretil/1_sanskr/6_sastra/7_ayur/vagaah_u.htm.
30. Prātimokṣa-Sūtra (Tib. so sor thar pa’i mdo) of the Mūlasarvāstivādin (Derge Kanjur,
‘dul ba, ca, 1b1–20b7); quoted according to Mahāmahopādhyāya S. C. Vidyabhusana,
“Sor-sor-thar-pa; or, a Code of Buddhist Monastic Laws. Being the Tibetan Version of
Prātimokṣa of the Mūla-sarvāstivāda School,” Journal and Proceedings of the Asiatic
Society of Bengal, New Series, XI (1915):29–139, 79.
31. Cf. Huimin Bhikkhu, “Buddhist Bioethics:The Case of Human Cloning and
Embryo Stem Cell Research,” Chung-Hwa Buddhist Journal 15 (2002):457–470.
32. Cf. Giulio Agostini, “Buddhist Sources on Feticide as Distinct from Homicide,”
Journal of the International Association of Buddhist Studies 27, no. 1 (2004):63–95, p.73.
33. Cf. Garrett, supra note 16.
34. Ratanakul, supra note 13, 146.
35. Sharon Salzberg, Loving Kindness: The Revolutionary Art of Happiness
(Boston:Shambhala, 1995), p.104.
36. In Buddhist mythology, this is the fate of the gods (devas), who, although virtually
free from pain and sorrow, are not able to experience full liberation and are still subject to
migration after their good karma is consumed.
37. Masahiro Morioka, “Painless Civilization and Fundamental Sense of
Security:APhilosophical Challenge in the Age of Human Biotechnology,” polylog:Forum
for Intercultural Philosophy 6 (2005):17, accessed March 15, 2014, http://them.polylog.
org/6/fmm-en.htm.
38. Ibid.
39. Somparn Promta, “Buddhism and Human Genetic Research,” in Genomics
and Bioethics: Interdisciplinary Perspectives, Technologies, and Advancements, ed. Soraj
Hongladarom (Hershey, NY:IGI Global/Medical Information Science Reference, 2011),
1–14, 11.
40. D II.35; trans. Walshe, supra note 3, 212. The Thai Buddhist bioethicist Pinit
Ratanakul holds that the “Buddhist perspective on life, suffering and death can never
be truly understood apart from the Buddhist law of conditionality (paṭiccasamuppāda),”
which he, as many other Theravāda Buddhists, regards as a “natural law” (Pinit Ratanakul,
Bioethics and Buddhism [Bangkok:Mahidol University,2004], 299; cf. Promta, supra note
39, 6.
41. Vism 513; Ñāṇamoli, supra note 7, 529.
42. Ekman etal., supra note 5, 61.
43. Bca VIII.102; trans. Crosby and Skilton, supra note 26, 129.
44. Buddhist bioethicists emphasize that generating compassion is not merely a reli-
gious goal—it is of concrete help in decision making:“Compassion . . . involves both bene-
cence and non-malecence. With compassion as motivation, science and technology will
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332 Religious Perspectives on Suffering and Medicine
be steered towards the optimum relief of human suffering. . . . This needed compassion
and conscience are already inherent in our hearts and minds, but in a slumber-like state
because of our egoism” (Ratanakul, supra note 13, 149). The importance of “compas-
sion” in Buddhist bioethics—as the Bodhisattva’s guiding therapeutic attitude toward the
suffering of others, e.g., as a justication of genetic intervention—is stressed by Fuchuan
Yao, An Ethical Study of Genetic Intervention based on Rawlsian Justice and on Buddhism,
dissertation thesis (Norman, OK:University of Oklahoma, 2006).
45. Śikṣā Samuccaya: A Compendium of Buddhist Doctrine. Compiled by Śāntideva
Chiey form Earlier Mahāyāna Sūtras, trans. Cecil Bendall and W. H. D. Rouse
(Delhi:Motilal Banarsidass, 1999 [1922]), 16.
46. Cf. Martha C.Nussbaum, The Therapy of Desire:Theory and Practice in Hellenistic
Ethics (Princeton, NJ:Princeton University Press, 1996), 316–318; Dougal Blyth, “Suffering
and Ancient Therapy:Plato to Cicero,” in Perspectives on Human Suffering, ed. Jeff Malpas
and Norelle Nickiss (Dordrecht, Heidelberg, etc.:Springer, 2012):131–154, 144–146.
47. T 1, 582b, trans. Tse-Fu Kuan, Mindfulness in Early Buddhism:New Approaches
through Psychology and Textual Analysis of Pali, Chinese and Sanskrit Sources (Abington,
Oxon/NewYork:Routledge, 2008), 146; cf. M I.55, trans. Ven. Anālayo, Satipaṭṭhāna:The
Direct Path to Realization (Birmingham, UK:Windhorse, 2007), 3.
48. Cf. Jon Kabat-Zinn, Full Catastrophe Living:Using the Wisdom of Your Body and
Mind to Face Stress, Pain and Illness, 15th ed. (NewYork:Bantam Dell, 2005 [1990]).
49. Paul Grossman, Ludger Niemann, Stefan Schmidt, and Harald Walach,
“Mindfulness-Based Stress Reduction and Health Benets:AMeta-Analysis,” Journal of
Psychosomatic Research 57 (2004):35–43, 36.
50. For the historical background of this approach, see W. Dryden and A. Still,
“Historical Aspects of Mindfulness and Self-Acceptance in Psychotherapy,” Journal of
Rational-Emotive & Cognitive-Behavior Therapy 24 (2006):3–28.
51. Kabat-Zin (supra note 48, 185) advised this Buddhist practice in its literal
form:“ ‘May Ibe free from anger, may Ibe free from hatred; may Ibe lled with compas-
sion, may Ifeel kindness toward myself.’ Then we can go on to invoke someone else, per-
haps a particular person we care about. We can visualize that person in our mind’s eye or
hold the feeling of the person in our heart as we wish that person well:‘May he or she be
happy, may he (she) be free from pain and suffering, may he (she) experience love and joy’.”
52. “Aversion to pain is really a misplaced aversion to suffering. Ordinarily, we do not
make a distinction between pain and suffering, but there are very important differences
between them. Pain is a natural part of the experience of life. Suffering is one of many
possible responses to pain. . . . It involves our thoughts and emotions and how they frame
the meaning of our experiences. Suffering, too, is perfectly natural. . . . But it is important to
remember that suffering is only one response to the experience of pain. Even a small pain
can produce great suffering in us if we fear that it means we have a tumor or some other
frightening condition. . . . So it is not always the pain but the way we see it and react to it that
determines the degree of suffering we will experience. And it is the suffering that we fear
most, not the pain” (ibid., 285–286).
53. For a critical review of studies claiming evidence for the effectiveness of MBSR,
see S. R.Bishop, “What Do We Really Know about Mindfulness-Based Stress Reduction?”
Psychosomatic Medicine 64, no. 1 (2002):71–83 (e.g., the problem of operationalizing con-
structs of “mindfulness”; dismantling the core effects of mindfulness in regard to other aspects
of MBSR, such as psychosocial group expectations; or other methodological problems).
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Endure, Adapt, or Overcome? The Concept of “Suffering” in Buddhist Bioethics 333
54. The role of karma as an explanation of suffering has been a disputed topic in
Buddhist traditions. Some Theravāda Buddhist texts convey the Buddha’s statement that
karma is only one cause among several others, whereas some Buddhists, especially of Tibetan
Mahāyāna, argue that karma is the origin of all forms of “suffering.” Patrul Rinpoche
(1808–1887), an inuential teacher of the Tibetan Nyingmapa school, explains:“In all their
inconceivable variety, the pleasures and miseries that each individual experiences—from the
summit of existence down to the very lowest depth of hell—arise from the positive and nega-
tive actions [i.e., wholesome and unwholesome karma, J. S.] that each has amassed in the
past” (Patrul Rinpoche [O rgyan ʼjigs med chos kyi dbang po Dpal sprul], The Words of My
Perfect Teacher: Kunzang lama’i shelung. AComplete Translation of a Classic Introduction
to Tibetan Buddhism, trans. the Padmakara Translation Group [New Delhi:HarperCollins
India, 1998], 118). The same argument can be found in Karma Lekshe Tsomo’s work on bio-
ethics from a Tibetan Buddhist view:“Coming face-to-face with death and impermanence,
suffering, and the immanent dissolution of the illusory self are all opportunities for gaining
insight into these basic Buddhist truths. Sufferings can be understood as the result of one’s
own actions in the past, rather than some inexplicable injustice. Through the experience of
suffering of illness and approaching death, this negative karma is expiated, and it is possible
to achieve profound realizations” (Tsomo, supra note 11, 188).
55. Kabat-Zin, supra note 31, 201–203.
56. Cf. M I.58, trans. Anālayo, supra note 47, 6, 152–155.
57. Ibid., 153.
58. Cf. Mark Siderits, Buddhism as Philosophy (Cambridge, UK:Hackett, 2007); ibid.,
“Buddhist Reductionism and the Structure of Buddhist Ethics,” in Indian Ethics:Classical
Traditions and Contemporary Challenges, Vol. 1, ed. P. Bilimoria, J. Prabhu, and R. Sharma
(Burlington, VT:Ashgate, 2007), 283–296.
59. E.g., Stephen Batchelor, Buddhism without Beliefs (NewYork:Riverhead Books,
1998); ibid., Confession of a Buddhist Atheist (NewYork, Spiegel & Grau/Random House,
2010).
60. In Schopenhauer’s own words:“[dass] alles Glück nur auf dem Verhältniß beruht
zwischen unsern Ansprüchen und dem, was wir erhalten . . . :und eben so, daß alles Leiden
eigentlich hervorgeht aus dem Misverhältniss dessen, was wir fordern und erwarten, mit
dem, was uns wird, welches Misverhältniss aber offenbar nur in der Erkenntniss liegt, und
durch bessere Einsicht völlig gehoben werden könnte.” Arthur Schopenhauer, Die Welt als
Wille und Vorstellung, Vol. I., 1:§ 16 (Zurich:Haffmans, 1999 [1818]), 137–138.
61. Interviews on matters of bioethics were conducted with Buddhist scholars,
monastics, and decision makers (e.g., members of bioethics committees) in Sri Lanka and
Thailand (Theravāda), and with Tibetan Buddhists in India (Mahāyāna), as well as with
members of both traditions in Western countries. The results are due to be published soon
(Bioethics in Buddhist Traditions:Doctrinal Background and Global Discourse [habilitation
thesis]).
62. M I.416; trans. Bhikkhu Bodhi with Bhikkhu Nanamoli, supra note 11, 524.
63. Charles Goodman, Consequences of Compassion:An Interpretation and Defense of
Buddhist Ethics (Oxford:Oxford University Press, 2009), 48; cf. P. D.Premasiri, “Place of
Ethics in Buddhism,” in Encyclopedia of Buddhism, Vol. 5., ed. G.P. Malasekera and W.G.
Weeraratne (Colombo:Government of Sri Lanka, 1990), 144–165.
64. For Karma Lekshe Tsomo, “Compassion, Ethics, and Neuroscience:Neuroethics
through Buddhist Eyes,” Science and Engineering Ethics 18, 3 (2012): 529–537, 532,
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334 Religious Perspectives on Suffering and Medicine
Buddhist ethical decision making “is guided by three general considerations:the law of
cause and effect (karma), the intention that motivates an action, and compassion.”
65. Tsomo, supra note 12, 207.
66. Cf. Jens Schlieter, “Some Observations on Buddhist Thoughts on Human Cloning,”
in Cross-Cultural Issues in Bioethics—The Example of Human Cloning, ed. Heiner Roetz
(Amsterdam:Rodopi, 2005):179–202.
67. Premasiri, supra note 63, 150.
68. E.g., in M I.265–266; cf. Peter Harvey, An Introduction to Buddhist
Ethics: Foundations, Values and Issues (Cambridge, UK: Cambridge University Press,
2000), 312.
69. Vin III.73; quoted in ibid., 313.
70. cf. Keown, supra note 7, 93–96.
71. cf. Suwanda H.J. Sugunasiri, Embryo as Person. Buddhism, Bioethics and Society
(Toronto:Nalanda College of Buddhist Studies, 2005), 7–9, 24–27; and generally Damien
Keown, ed., Buddhism and Abortion (Honolulu:University of Hawaii Press, 1998).
72. L. P. N. Perera, Buddhism and Human Rights:A Buddhist Commentary on the
Universal Declaration of Human Rights (Colombo:Karunaratne & Sons, 1991), 30.
73. Ratanakul, supra note 13, 144.
74. Cf. the contributions in Georg Peiderer, Edouard M. Battegay, and Klaus
Lindpaintner, ed., Knowing One’s Medical Fate in Advance:Challenges for Diagnosis and
Treatment, Philosophy, Ethics and Religion (Basel:Karger, 2012). Simpson points out that
in some respect the “genetic forecast” and its notions of predeterminism and susceptibil-
ity correspond with traditional astrology and its schema of causality and fate (cf. Bob
Simpson, “Negotiating the Therapeutic Gap:Prenatal Diagnostics and Termination of
Pregnancy in Sri Lanka,” Journal of Bioethical Inquiry 4, no. 3 [2007]:207–215, 213).
75. Cf. Robert Nozick, Anarchy, State, and Utopia (Oxford, UK, and Cambridge,
MA:Blackwell, 1999 [1974]), 38–39, 338.
76. Cf. Ratanakul, supra note 13, 144.
77. Nyanasobhano, A Buddhist View of Abortion, Bodhi Leaf Booklet no.117 (Kandy,
Sri Lanka:Buddhist Publication Society, 1989), 19; cf. Ratanakul, supra note 13, 147. In
the words of Karma Lekshe Tsomo (supra note 11, 188):“To cut short a life prematurely
merely perpetuates the suffering; it simply postpones the suffering to another time, when
it might be even more unbearable, and it sows the seeds of further, even greater sufferings
through the non-virtue of taking life.”
78. Those Buddhist ethicists that argue for a more permissive attitude toward a termina-
tion of pregnancy in case of positively tested embryos usually do not argue with the amount
of expected suffering but instead argue that if the intention of lay Buddhists is not governed
by greed, hate, or delusion, they may opt for a termination—taking, however, into consider-
ation the karmic consequences their actions may have. Rather liberal attitudes with regard
to selective abortion in cases of detected genetic defects have been reported from coun-
tries with a signicant Buddhist population such as Sri Lanka (cf. Bob Simpson, V. H.W.
Dissanayake, and R. W.Jayasekera, “Contemplating Choice:Attitudes towards Intervening
in Reproduction in Sri Lanka,” New Genetics and Society 24, no. 1 [2005]:99–118; Simpson,
supra note 74, 210–212) and Thailand (cf. Robert Florida, “Abortion in Buddhist Thailand,”
in Buddhism and Abortion. ed. Damien Keown [Basingstoke, UK:Macmillan, 1998], 11–30).
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Endure, Adapt, or Overcome? The Concept of “Suffering” in Buddhist Bioethics 335
79. In general, the same holds true for embryo research and preimplantation diagnos-
tics, cf. Keown, supra note 7, 119–121; Harvey, supra note 68, 319; Ratanakul, supra note
13, 143–144; yet, Buddhist ethicists voiced generally much more “permissive” positions in
regard to the justication of research on superuous and “orphaned” extracorporal embryos
than on Prenatal-Diagnosis/Preimplantation-Diagnosis-cum-subsequent-abortion, cf.
Schlieter, supra note 66; Keown, supra note 7, 97–100, 118–122.
80. Cf. Pinit Ratanakul, “Socio-Medical Aspects of Abortion in Thailand,” in Buddhism
and Abortion, ed. Damien Keown (Basingstoke, UK:Macmillan, 1998), 53–65, 59.
81. E.g., an interview with P. D. Premasiri on October 4, 2012 (conducted with
Dr.E. Guhe, Fudan University, Shanghai). Contrarily, one may pose the question of
whether a truly severe intellectual impairment will prevent the affected person to experi-
ence all forms of “suffering” (as per Buddhist denition).
82. Cf. Simpson, Dissanayake, and Jayasekera, supra note 78; Simpson, supra note 78.
83. These observations could be made in interviews conducted with Buddhist ethicists
Somparn Promta, Mano Laohavanich (Bhikkhu Mettānando), P.D. Premasiri, Sumana
Ratnayake, and others.
84. Promta, supra note 39, 11–14.
85. Ratanakul, supra note 13, 145.
86. Foucault is mainly interested in practices of power and neoliberal governmental-
ity—the transition of a classical system in which a sovereign executes power over life and
death to a modern nation state with the power to install eugenics and other forms of man-
aging “life” itself (cf. Michel Foucault, The Birth of Biopolitics:Lectures at the Collège de
France, 1978–1979, trans. Graham Burchell (NewYork:Palgrave MacMillan, 2008).
87. Ratanakul, supra note 40, 319–322.
88. Sugunasiri, supra note 71, 78, 80.
89. The best translation of these Tibetan teachings, which became increasingly popu-
lar in Western hospice care, can be found in The Tibetan Book of the Dead: The Great
Liberation of Hearing in the Intermediate States, trans. Gyurme Dorje (London:Penguin
Books, 2005).
90. It is necessary to note here that some Buddhist texts portray examples of ethi-
cally justied self-induced death:some spiritually advanced practitioners (“arhats”) were
able to develop wholesome thoughts even in such moments (cf. Bhikkhu Dhammavihari,
“Euthanasia: A Study in Relation to Original Theravada Buddhist Thinking” (1996),
accessed March 15, 2014. http://www.metta.lk/english/euthanasia.htm; Padmasiri de
Silva, Buddhism, Ethics, and Society:The Conicts and Dilemmas of Our Times (Clayton,
Victoria, Australia:Monash Asia Institute, 2002), 81–96; Martin Delhey, “Views on Suicide
in Buddhism: Some Remarks,” in Buddhism and Violence, ed. Michael Zimmermann
(Lumbini, Nepal:Liri, 2006), 25–63.
91. Tsomo, supra note 12, 177.
92. Cf. Dhammavihari, supra note 90; Keown, supra note 7, 184–185.
93. Cf. Ratanakul, supra note 40, 322–325.
94. Cf. Jens Schlieter, “Karma, Contingency, and the ‘Point of No Return’:Predictive
Medicine and Buddhist Perspectives,” in Knowing One’s Medical Fate in Advance:Challenges
for Diagnosis and Treatment, Philosophy, Ethics and Religion, ed. Georg Peiderer etal.
(Basel:Karger, 2012), 106–120.
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336 Religious Perspectives on Suffering and Medicine
95. XIV Dalai Lama, in Wendy Bainbridge and Elizabeth Baines, “Insight into
Palliative Care:An Audience with the Dalai Lama,” European Journal of Palliative Care 8,
no. 2 (2001):66–69, 67.
96. Laurence J.Kirmayer, “The Sound of One Hand Clapping:Listening to Prozac in
Japan,” in Prozac as a Way of Life, ed. Carl Elliott, Tod Chambers (Chapel Hill:University
of North Carolina Press, 2004), 164–193, 174.
97. Tsomo, supra note 64, 533.
98. Ibid. This argument, however, should not be confused with the argument of
authenticity, which uses concepts of a normatively loaded “naturalness” and “enduring
personal identity,” which are both problematic for Buddhists (cf. James J.Hughes, “Using
Neurotechnologies to Develop Virtues:ABuddhist Approach to Cognitive Enhancement”
(three parts, 2012), accessed March 15, 2014. http://ieet.org/index.php/IEET/more/
hughes20121016.
99. Cf. ibid.
100. Cf. Susanne Mrozik, Virtuous Bodies: The Physical Dimensions of Morality in
Buddhist Ethics (Oxford:Oxford University Press, 2007), 67.
101. Nozick, supra note 75, 42–43. In the summary of Thomas Metzinger, The
Ego-Tunnel (NewYork:Basic Books, 2009), 198, the relevance of Nozick’s thought experi-
ment for the question of treating suffering through pharmaceutical means (or other exter-
nal stimulants) becomes immediately clear:“You have the option of being hooked up to
an ‘Experience Machine’ that keeps you in a state of permanent happiness. Would you do
it? Interestingly, Nozick found that most people would not opt to spend the rest of their
lives hooked up to such a machine. The reason is that most of us do not value bliss as such,
but want it grounded in truth, virtue, artistic achievement, or some sort of higher good.”
Actually, we do not want to be “deluded Bliss Machines but conscious subjects who are
happy for a reason. . . . We want an extraordinary insight into reality, into moral value or
beauty as objective facts. Nozick took this reaction to be a defeat of hedonism.”
102. Andrew Fenton, “Buddhism and Neuroethics: The Ethics of Pharmaceutical
Cognitive Enhancement,” Developing World Bioethics 9, no. 2 (2009):47–56, 47.
103. Ibid., 51.
104. Surprisingly, Fenton himself argues with the cognitive enhanced mind as a
means—as it shall be used, like meditation, for “deepening the insight into the nature of
the self and world and the gradual elimination of duḥkha” (ibid., 53).
105. Yao, supra note 44, 214.
106. Karl Popper, The Open Society and Its Enemies. Volume 1:The Spell of Plato
(London:Routledge, 2002), 284–285.
107. Pinit Ratanakul, “Bioethics in Thailand:The Struggle for Buddhist Solutions,”
Journal of Medicine and Philosophy 13 (1988):301–312, 301–302; this approach of four prin-
ciples has been modeled in reaction to Tom L.Beauchamp; James F.Childress, Principles
of Biomedical Ethics,5th ed. (Oxford:Oxford University Press, 2001), 12–13:“autonomy,
benecence, non-malecence, justice.”
108. Yao, supra note 44, 214.
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