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On Being Human

 | 
Daisaku Ikeda
, 
René Simard
, 
Guy Bourgeault

Chapter three. Bioethics

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1. Religion and Medical Ethics

The values that inspire Western medicine

1ikeda • Buddhism arose from humankinds struggle to overcome the most fundamental problems of human existence—the four sufferings of birth, aging, sickness, and death. The confrontation with these problems is also expressed as Shakyamuni’s “four encounters.” Witnessing the effect on humans of old age, sickness, death and religious faith, Shakyamuni abandoned secular life to seek a way to overcome the four sufferings.

2Shakyamuni’s efforts both to come to terms with these conditions that continue throughout the chains of human existence and to attain happiness are still a fundamental task for humanity. Even after Shakyamuni s death, the teachings of Buddhism centred around its concern with the four sufferings.

3The immense philosophical canon known as the Abhidharma (doctrinal studies and commentaries on the sutras) includes a book called A Treasure of Analyses of the Law that examines the four sufferings from many angles, based largely on contemporary medical knowledge—notably the wisdom of the Sacrifical Prayer Veda. What are your thoughts, Dr. Bourgeault, on the relationship between birth, death, and sickness on the one hand and religion on the other?

4bourgeault • I must first make it clear that I am not a religious man. Although I have studied the Bible and Christian theology, I am certainly not a representative of any Christian church and not even a believer. Still, the Judeo-Greco-Christian origins of ideas about life and death, health and sickness are obviously generally—if vaguely—accepted in North America and Europe.

5Health policies, for example, go back, sometimes explicitly, more often implicitly, to the grand ideas of liberty, equality, and fraternity that were the rallying points of the American Revolution of 1775–83 and the French Revolution of 1789, the declarations of which still inspire democracies in North America and Europe. These secular ideas recognize the dignity of every human being as a right. They dispute both political and religious despotic powers, establishing a social contract that creates among all members of a given society a solidarity expressed in mutual respect for others and responsibility for the weakest members. And they strive to harmonize the rights of the group with the rights of each individual.

6These ideals are clearly rooted in the Christian tradition, especially in the teachings of Jesus and Paul, who were themselves heirs of older traditions. Jesus contested established laws and hierarchies and called for solidarity and compassion for the poor in a utopian society where the liberty of the children of God would create egalitarian relationships of mutual understanding and assistance. In his own way, Paul continued this vision by contesting artificial distinctions and divisions between men and women, free people and slaves, Jews and non-Jews.

7Contemporary health and health services policies come under the banner of individual dignity and the right to freedom, by offering services to satisfy the individual right to health. They come under the sign of equality, by making these services accessible to every individual. Finally, they come under the sign of solidarity—if not fraternity—by making everybody, including the healthy, pay for services dispensed to the sick.

8ikeda • In other words, medical ethics is closely related to the concept of human dignity.

9bourgeault • In Europe and North America, the ethics of health professionals has long been characterized, on the one hand, by fundamental exigencies imposed by the dignity of individuals and the dignity of life—or their right to self-determination, as we would eventually come to say—and, on the other hand, by what is commonly called the principle of charity, which calls for preferential attention to be accorded the poor and the sick. This attention is often cited as a characteristic of Christian solidarity.

10According to the Gospels, Jesus was resolutely on the side of the poor, the sick, the marginalized, and the socially excluded. He took up their cause and made service to neighbours, the poor, and the sick a sign of belonging to a new humanity. The “good news”—or gospel—was the announcement that the poor, the ill, the sick, and the outcasts would occupy primary places in the Christian community. Stories of miraculous cures illustrate this. Medical care and professional support for the sick are included in the compassionate, restorative and miraculous actions of Jesus.

11ikeda • The Judeo-Christian spirit was of course influenced by contacts with the classical spirit.

12bourgeault • Yes. We cannot understand the origins and development of professional medical ethics in Europe, and later in the United States, without taking into account their Greco-Roman roots. Today medical ethics codes are still founded on the Hippocratic Oath, which dates to the fourth century bce.

13The encounter between the Judeo-Christian and Greco-Roman heritages leads us to think of human action as co-creationist and oriented toward remaking the world by filling in the gaps of creation, correcting its “errors,” “curing” people and freeing them from their pain. As I have already said, it is scarcely surprising that Western medicine progressively concentrates more on the battle to conquer illnesses like cancer and aids than on greeting and accepting illness in what Buddhism calls—if I understand correctly—inner harmony or wisdom.

Harmony of body and mind, life and environment: The Buddhist view of health

14ikeda • We could say that Christianity adopts the occidental view of sickness as an external enemy that must be overcome. As you point out, Buddhism, on the other hand, sees illness as a matter of discord between the body and the spirit and between life and its environment. The Buddhist approach promotes health by reinforcing the “dynamic harmony” inherent in life’s internal rhythm. It ceaselessly pursues what is now called quality of life, a central consideration in modern bioethics.

15bourgeault • What kind of quality of life does Buddhism teach?

16ikeda • Buddhism proposes three main ways of improving the quality of life. The first is precepts or, more concretely, autonomy. It concerns the ability to take control of insatiable desires and channel them in the right direction.

17Second is the constant search for universal truth. This means permanency or regularity in a world where people are continuously contraried and beset with vicissitudes. The search for universal truth describes the unshakeable determination to find and uphold the truth, to always act in accordance with the truth, no matter what obstacles arise.

18Third is practical wisdom founded on that universal truth. This idea expresses the unlimited potential for self-actualization present in all of us. Rooted in the faith in this potential, it recognizes the intrinsically equal dignity of every human being and exhorts us to serious efforts to manifest this personal dignity and strive toward a shared enlightenment. Buddhism urges us to integrate these three concepts—autonomy, permanence and practical wisdom—into our way of life, and in so doing, to raise our quality of life.

19bourgeault • To these key Buddhist concepts of autonomy, permanence and practical wisdom I should like to add dignity, individual rights, solidarity, fraternal support (or “brotherly love,” to use traditional Christian terminology) and action to transform, repair, and even re-create the world.

20ikeda • In Buddhism, too, the practice of autonomy, permanence and practical wisdom assumes the form of compassion, in connection with relationships with others. In this case, compassion means action taken to overcome the sufferings of life, together with other people, based on respect for their human dignity.

What kind of humanity do we want for tomorrow?

21bourgeault • In recent decades, scientific and technological developments have achieved stunningly audacious transformations in all fields of human endeavour, perhaps most strikingly in the field of biomedicine. This is why bioethics had to break new ground to replace outdated professional morals. Professional practices changed much earlier than the ethical framework. This happened principally because of a growing recourse to increasingly complex and precise technologies that paved the way for increasingly daring actions.

22ikeda • Medical ethics reform was unable to keep pace with revolutionary medical developments.

23bourgeault • New fields of treatment opened up—and new areas of questioning. This is exactly the function of bioethics, to intervene at a moment of rupture with the past. As has been observed, the lack or inadequacy of old morals and their inability to take the biomedical achievements of recent decades into consideration led us to break with them for the sake of exploring new paths.

24ikeda • That is why it is urgently necessary to create a new ethics compatible with the medical revolution and capable of guiding medical science.

25bourgeault • Bioethics represents an awareness—a will—to tackle new problems connected with the development and use of technologies in the biomedical field. It is not just an effort to update a code reserved exclusively for doctors or health professionals.

26Bioethics proposes to address new and complex problems in a resolutely multidisciplinary fashion. It suggests dealing with them case by case through discussions in pluralist societies that do not ascribe to a pre-determined vision of the human being—discussions which can serve as a sure benchmark for deciding what should and should not be done.

27ikeda • Contemporary societies with increasingly diverse values all share the same kinds of problems.

28bourgeault • The human being is no longer perceived as a given but as something to shape. And we are constantly reshaping the human being at a steadily accelerating rhythm of ever-bolder actions. This is why we must debate the question that I raised earlier, the question that concerns everybody: now that the consensus of yesterday no longer holds, what kind of humanity do we want for tomorrow?

29ikeda • The nature of the humanity we want for tomorrow is the cardinal point of the new bioethics. We will need dialogue to create a new image of humankind.

30bourgeault • It is the duty and essential, democratic task of bioethics to stimulate public discussion of these fundamental issues, because ultimately they concern the lives of every one of us.

Partnership between patients and caregivers

31ikeda • Human relations at medical-treatment centres are an important bioethics issue. A particularly significant change has come about in the relationship between medical staff and patients, with a move from a tradition model of imposed authority to a more balanced model of shared responsibility. This new kind of relationship aims to make the patient an equal partner with the doctor. The importance of the right to self-determination and informed consent is now recognized. Dr. Bourgeault, what are your thoughts on this relationship from a medical-ethics point of view?

  • 1 L’éthique et le droit face aux nouvelles technolopes biomédicales (Ethics, human rights and new bi (...)

32bourgeault • Relations between doctors and other health professionals and the people who call on their services have evolved over the years. In a work on bioethics published some time ago,1 I pointed out the great landmarks and dates that trace this evolution from the Hippocratic Oath—which I later compared to ancient Indian and Chinese texts—to such great contemporary declarations as those of the International Medical Association made at Helsinki (1964) and later at Tokyo (1975) and the more recent one of the World Health Organization.

33From these texts it is easy to draw up relationship models that define doctors as “fathers,” as experts, or as partners in a course of action they do not entirely and exclusively control.

34Let me explain further.

35the paternalist model. In societies where culture and all life depend on superior forces that dictate how things evolve, at times of crises people give precedence to the intervention of priests or sorcerers believed to be in contact with those superior forces. In the collective mind, doctors were long perceived to be the heirs to the secret, mysterious powers of priests and sorcerers. This paternalistic relationship prolonged the sacerdotal model in a secularized form. In this type of relationship, one party knows and the other doesn’t, which leads the second party—the patient, in this instance—to recognize and submit to the undisputed and indisputable authority of the first—the doctor.

36the engineer or expert model. With the development of science and technology, all professionals—including health professionals—became in a sense “engineers.” In recent years, denunciations have been made of medical practitioners who revert to a mechanistic, reductionist anthropology. Instead of regarding their patients as the primary agents in actions supported by others on the basis of their individual competencies, the doctor-engineer treats the patient as an object of isolated interventions, commanded from without.

37ikeda • The first two models are hierarchical relationships, whereas the third suggests equality.

38bourgeault • Yes, I call it the partnership model. The first two models I described are like photographic negatives of another model sometimes called a contractual relationship, though I prefer to call it a partnership. This model is part contract and part friendliness. The contract sets down the equality of the two parties; the friendliness expresses their close association in a fundamentally collaborative act—a human commonality, the responsibilities of which will be jointly accepted. This approaches the compassion of which you spoke, but without the religious dimension explicit in Buddhist tradition.

39This model places the professional and the professional’s actions in the dynamic of a conscious, deliberate partnership that orchestrates diverse, complementary efforts. Each party remains the primary agent of his or her own life. Each party determines his or her own orientation and makes the necessary choices. Each party takes appropriate action. Most important, each party defines “well-being” and “quality of life” on his or her own. Although this is done with the help of others, notably specialists or professionals, the patient maintains control of the whole process from beginning to end—from examination and situation analysis to reparative or curative action by way of diagnosis and therapy selection.

40ikeda • I also believe that the doctor and patient should face their tasks as partners, united in the effort to defeat disease. The idea reminds me of the Three Admonitions of Buddhist medicine—one to doctors, one to nurses, and one to patients—exhorting them to co-operate and learn together to battle against illness. In this way all can find fulfilment. Ethical demands are made of all three.

41Nagarjuna’s Treatise on the Sutra of the Perfection of Wisdom says the ideal doctor or “Grand Healer” should be skilled in the healing arts, full of compassion, and indifferent to the patients financial condition. The Great Canon of Monastic Rules admonishes nurses to care for patients gently and compassionately, without thinking of compensation. It warns that thinking of personal gain destroys compassion. It also encourages patients to endure pain, live regular, disciplined lives, and acquire enough knowledge to understand their own conditions.

42In general, these Buddhist medical ethics suggest approaching treatment and patient care as a shared and reciprocal effort to which doctor, nurse and patient all contribute, creating harmony between the three parties.

2. Definition of Death

From God’s will to human life and death

43ikeda • The first organ transplant in Japan took place in 1968, but it wasn’t until 31 years later, in March 1999, two years after the enactment of the Organ Transplant Law, that the first surgery involving vital organs from a brain-dead donor took place. The first Japanese transplant operation—performed three decades earlier—was questionable from various viewpoints and aroused vehement criticism in the medical community and among the general public. The 1968 case was an obstacle to the development of organ donation involving brain-dead donors in Japan.

44The recent revival of transplants, however, has aroused great interest in brain death and death with dignity. To get to the basic premise of bioethics, I would like to discuss the nature of human life and the various ways people define death.

45bourgeault • For the past twenty years, pragmatic, decision-oriented bioethics as practised in the United States and Canada has managed to achieve common consensus by avoiding all meaningful discussion of the most basic question: what is human life? I think it is about time to tackle this issue squarely and to simultaneously ask another question: what is human death?

46ikeda • What you have just said has very profound repercussions. In a lecture I gave in 1993 at Harvard University, I expressed my conviction that modern civilization has failed in its attempt to overlook death. To avoid death is to ignore the meaning of life.

47As you also said, we hedge so as not to tackle the most important human issue: life and death. If we try to ignore death, we are courting disaster: death will insinuate itself into us in the form of anger—we have only to look at the numerous instances of genocide in the twentieth century to see it. When we ignore the meaning of life, we end up undervaluing life. We see so many acts of unspeakable and unpardonable violence today, each of which deals a terrible blow to human life.

48bourgeault • My own interest in ethical order has made me particularly mindful of widespread and constant violence against life and our astonishingly widespread irresponsibility toward it.

49ikeda • In a lecture you delivered in Japan, entitled “Science and Technology and the Responsibility of Humankind,” you said that modern technoscientific progress has engendered an age in which both the global environment and human life itself are being disrupted by new kinds of change. As you point out, in the past the boundary between life and death was taken for granted. Modern ways of manipulating life, however, blur that boundary.

50bourgeault • Definitely. Even before birth, prenatal tests—pre-implantation tests in the case of in-vitro fertilization—can determine the “quality” of life in store for the gestating embryo if it is allowed to develop. The emergence of new choices poses new questions. And this situation continues until the end of life. In the last moments, we can separate life from agonizing sufferings. We can hasten or delay death itself, whose ancient power, if not yet abolished, can be held temporarily in check. One cannot, however, avoid raising the question of the meaning of life, which becomes especially acute just before death.

51ikeda • Indeed, progress in modern medicine has reintroduced questions about the nature of life and death.

52bourgeault • I was born and raised in a society steeped in Christian tradition. All cultural traditions—often religious in nature—abound with ideas, images, myths, and metaphors that provide guideposts for our conduct in life. I am happy that we have been given a chance to set two great traditions—the Buddhist and the Christian—in parallel and perhaps in communion. I should like to take this chance to say that I read your article on brain death with great interest. I learned much about the Buddhist conception of death from it.

53ikeda • We will get to the subject of brain death later on. Right now I would like to ask you about the Christian idea of death. I believe Christianity teaches that death is the result of the will of God.

54bourgeault • Back when no one could change the course of life, or more specifically, the course of sickness, a priest would come quickly to take over from the doctor. A Christian prayer recited at the approach of death goes something like this, “The Lord giveth, and the Lord taketh away. Praise be to God.”

55ikeda • But today medical science is deeply involved in prolonging human life and postponing death. Artificial respirators and intensive care units are used to prolong at death’s door lives that, in the past, would already have ended. Since modern medicine is able to prolong life in these ways, we cannot deny its merits. But we must try to use its powers wisely. And this brings us back to the issue of the nature of death.

Three functional levels of life and the principle of nine consciousnesses

56bourgeault • It seems to me that in recent years we have been more concerned with defining the moment of death pragmatically than with discussing its meaning. The goal is to set guidelines, to help us decide whether to discontinue treatment and whether to proceed to harvesting and transplanting organs.

57People are generally unaware of what has brought us to this juncture. I might refer back to ancient Greek anthropology, which distinguished between the body and the feelings, the psyche and the sentiments, the soul or the spirit and reason. In the Middle Ages, people fiercely debated the moment at which the human embryo is animated. They drew distinctions between the vegetable and animal kingdoms—both separate from human beings. In direct line with this tradition, people have recently distinguished various functional levels in human beings. First, biological functions like circulation and respiration, which keep the organism alive. Second, sensual functions and motion, which permit the living being to react to exterior stimuli. Third, functions of conscience and communication, which are specific to human beings. As the ravages of a sickness grow worse, it becomes doubtful whether human life persists when awareness seems extinguished, although the vital—that is, biological—functions continue.

58If I am not mistaken, the Buddhist tradition posits a scale of levels of life comparable to the one I have just outlined.

59ikeda • To answer that, I would like to cite the Buddhist teaching that I think is most relevant to this three-stage concept. It is called the principle of the nine consciousnesses and it presents the Buddhist epistemological vision of the essence of life.

60The first five levels of consciousness correspond to the five senses: sight, hearing, smell, taste, and touch. The sixth level, known as the thinking spirit or “mental consciousness,” integrates these five and passes judgment on the exterior world. This could be compared to what is called consciousness in Western psychological terminology.

61The seventh level represents the internal, spiritual world. This is the source of identity of the self, operating in the name of self-preservation and expansion. It seems to correspond to the Western idea of the ego.

62There is another level called the alaya consciousness or “storehouse.” On a deeper level, this eighth consciousness stores the energy that supports all the other consciousnesses. Jung’s “collective subconscious” is a component of the alaya consciousness.

63Some schools of Buddhism posit the existence of a ninth consciousness which is the true entity of life and the basis of all the other functions. Your three functional levels seem to correspond to the first seven Buddhist consciousnesses.

64bourgeault • Could you explain more specifically how they correspond?

65ikeda • In your first stage, there is neither sensitivity nor awareness. In Buddhist terms, this means that life activities are confined to the seventh consciousness or below. In your second level, the person reacts to pain and other stimuli, but is unable to communicate. Here the self-preservation aspects of the seventh consciousness are active, allowing the first five and sixth consciousnesses to perform according to their natures, but the activity is passive. In your third level, the person is able to interact with the exterior world in a positive and independent fashion. At this level, the five sensory consciousnesses and the sixth consciousness are fully functional.

66bourgeault • In the West, people tend to think that the capacities to know, judge, and communicate distinguish the human state from all others.

67ikeda • In other words, beings living in your third level are recognized as human while, if I understand you correctly, those living in levels one and two are something less.

68bourgeault • The distinctions are more nuanced and the problems more complex. Loss of conscience does not entail loss of the right to life. Since uncertainty persists about the moment at which death occurs, people have tried to establish guidelines to control removal of organs for transplantation. This led us to resort to the notion of brain death.

A continuing process

69ikeda • Earlier in my explanation of the nine consciousnesses, I made no distinction between human and non-human life. This is because Buddhism interprets life as a continuum. According to this line of thinking, at death, life moves progressively from the third level of full consciousness to the second level of unconsciousness, with its residual sensitivity to external stimuli, and then on to the first level or comatose state in which no response is made to the external world. Moving from level three to level two is not considered a loss of humanity. Perhaps it is in this that the Buddhist view differs most noticeably from Western ideas.

70bourgeault • The West, too—especially in the face of the great ecological challenges of our times—is becoming aware of a continuity of life that motivates us to protect life in all its forms.

71ikeda • That view coincides with the Buddhist way of thinking. A person who has attained the seventh consciousness (deep subconscious) is still considered living, even though outside observers may be unaware of it. Such a person can still receive external information and stimuli and experience emotional reactions.

72Nurses have told me some touching tales on the subject. One told me she had spoken softly to a comatose patient and played his favourite music. Upon regaining consciousness, he expressed his gratitude for her kind words and attentions. She was thrilled, of course, but also frankly astonished that he not only knew what was happening around him while he was in the coma, but that he was able to remember afterward.

73The members of a medical team who treat presumably dying comatose patients mechanically or coldly would no doubt be mortified to hear recriminations from those patients should they regain consciousness. I would hate to be in their shoes!

74Buddhist teachings assume continuity rather than segmentation of the stages of life.

75bourgeault • Perceiving life stages as a continuum might give us a new perspective on points of convergence between traditional Eastern and Western thought.

76ikeda • You are suggesting an interpretation of life deeper and more inclusive than traditional ones. In the Buddhist view, death is regarded as a passage through the three levels you described, with life eventually passing to the eighth or alaya consciousness, the most secret stratum of individual existence, and finally melding with the life of the cosmos itself. At some point in this process, brain death occurs.

3. Brain Death

Responsibility and solidarity

77bourgeault • For a long time, human beings—as individuals and as a collective—have perceived themselves to belong to a universe far larger than themselves. They depend on its order and are subject to the natural laws and rules governing it. Scientific and technological developments of the last decades have been oriented toward the transformation of the world and its natural order and toward the modification of human life itself. They have introduced us to a new cultural universe. After a frenzy of grand projects to deconstruct and reconstruct the world—to transform life—growing unrest now calls urgently for a sense of responsibility.

78ikeda • Are you referring to each persons responsibility for his or her own life?

  • 2 The Path of the Law Sutra (Dhammapada), Volume XII.

79Shakyamuni explained the fundamental spirit of Buddhism as a sense of individual responsibility. “You are your only master. Who else? Subdue yourself and discover your master.”2 In other words, we must each take responsibility for our own self-discipline and for cultivating meaningful lives.

80He goes on to say that we must each save ourselves. No child, no parent, no family member can face death for us. This means that, in clinical instances, each of us has the free will to determine whether to terminate or prolong our lives, to live as we judge best. Of course, agreement among family members and the co-operation of friends and doctors are essential. Nonetheless, the individual makes the final decision. This has been the Buddhist philosophy since the time of Shakyamuni.

81bourgeault • We envision the ethical issues at stake differently depending on whether we regard human life as a gift, a project, or an individual and collective responsibility. If life is a gift—moreover a divine gift—we regard it as intangible and afford it absolute respect from the beginning of embryonic existence to the last breath. We attempt neither to create it artificially nor to shorten its course when it seems to become meaningless. The meaning of life as a gift, with its unforeseen potentialities, is itself given. If we regard life as a personal project, on the other hand, it ceases to be apparent that we must not terminate it when the meaning we seek to impart to it proves unattainable. Finally, if we see life as part responsibility and part solidarity, we must take the social and political dimensions of our decisions into consideration, above and beyond our individual desires.

82ikeda • Technoscientific developments have made your first approach—leaving life and death entirely up to the will of God—no longer practical. The second approach—the personal project—consists largely of following the caprices of earthly desires. This may give an illusion of freedom, but it can degenerate into selfishness and self-indulgence and can bring on the ruin of the self and of others as well. That only leaves the third, the individual responsibility approach, the only way that honours the dignity of life.

83bourgeault • But the transition from a morality of duties or rights and liberties to an ethic of interdependent responsibility will not occur by itself.

84ikeda • Responsibility and solidarity are indeed the ethical model human beings must strive for. A passage in the Buddhist scriptures says, “Those who protect themselves protect others as well. Protect yourself and you will be wise and come to no harm.” In other words, self-responsibility requires a sense of solidarity.

85Buddhism further teaches that the self and the other are so closely related as to be inseparable. All beings exist solely in their relationship to each other. They are bound together by the law of dependent origination. They must therefore co-operate and seek happiness together. Seeking happiness only for one’s self is doomed to failure. The only reasonable alternative is to join forces with each other for the good of all. This means that the person with a sense of self-responsibility also feels responsible for the lives of others and considers solidarity a duty.

86bourgeault • I think that an ethics of responsibility requires us not to reject innovation but to circumscribe its risks and to restrain its harmful effects as much as possible.

87ikeda • A most appropriate definition. The idea of brain death may require a new definition of mortality. Nonetheless, maximum consideration must be taken of any possible negative consequences. Everyone engaged in the debate has a responsibility to minutely examine all possible ramifications.

More precise criteria for the declaration of brain death

88bourgeault • According to medical practices authorized in Canada, the United States, and Europe, irreversible coma is considered a sign of brain death—thus the end of human life—and suffices for permission not only to terminate treatment, but also to remove organs for transplantation.

89ikeda • That seems to coincide with the current medical point of view.

90bourgeault • But can we legitimately and logically associate—or equate—an indication of death with a reality that escapes our perception and control? Can we in this way determine the moment when a human life—a life with human qualities—ceases, even though it continues to perform so-called vital functions? The problem, if I can put it this way, is that people no longer die naturally in hospitals. Pretty soon, people will only die because they were “unplugged.” Hospitals cannot serve as storehouses for people under deferred death sentence!

91At what moment can we unplug a patient, or stop providing treatment deemed no longer useful? Who should make this decision? When, exactly, is a person dead and when should he or she be declared dead? Based on what criteria and what indications? And with what degree of certainty? What percentage of error is tolerable? Because there will no doubt be errors—which of course we won’t even be aware of!

92ikeda • That is exactly the aspect of brain death that worries many people.

93bourgeault • We must propose an acceptable general framework and establish rules. Though it may seem cynical, we are compelled to talk in terms of risks and tolerable errors. We must realize that risks exist and determine under what conditions they are morally acceptable. In this connection, I will limit myself to the notion of moral certitude commonly in use first by European and then by American philosophers since the sixteenth century. Moral certitude is defined as the degree of certitude required and sufficient to ensure that the decision taken and its subsequent actions are themselves moral. This appears tautological, but the basic idea behind it seems just and important. We must know that the required and sufficient certitude has been reached after a faithful effort to understand and take into consideration all known elements in the problem or situation, even though we realize that we cannot know and master them all. In other words, we must recognize the possibility of a persisting incertitude.

94The question of defining death and determining the moment of its occurrence is all the more pressing because every day people are making the decision to terminate the battle against death or to remove organs from what is considered a cadaver. Unable to give a totally certain answer to the first question—which refers back to the vexatious issue of defining life—we have nevertheless established parameters useful in medical practice in relation to the second question.

95ikeda • As we said earlier, the party involved must take the initiative beforehand for accepting medical judgment on brain death and state willingness to donate organs. In Japan, people often carry donor cards indicating agreement to these conditions. The nature of family participation in the decision is still being debated.

96I agree that “moral certitude” is of the essence in this issue. A similar certitude is necessary for the patient and his or her family to accept the medical verdict of brain death and consent to organ donation. This is one way to minimize the negative effects of the decision.

97bourgeault • In Canada, the medically and legally recognized definition of brain death presupposes the total arrest of all cerebral functions, including those of the brain stem, which controls things like spontaneous respiration. Once brain death has been confirmed, it is permissible, with the consent of the relatives, to terminate treatment and proceed to remove organs.

98Basing their approach on the thought of American and European philosophers, some people suggest we consider dead anyone whose superior cerebral functions—which enable consciousness and communication—have ceased. This would make greater supplies of organs available for transplantation. So far, their request has been unfavourably received.

99ikeda • Although the criteria may differ slightly, in Japan, too, we consider the cessation of all brain functions, including the brain stem, as the basis for determining brain death.

100bourgeault • Some people contest the validity of defining human death on the basis of brain death, denouncing a legal flaw in its objective. They argue that the purpose of the definition is to terminate treatment and more specifically to obtain organs for transplanting and that the definition of brain death has been “invented” or adjusted to authorize those practices. Personally, I cannot accept this. Although I recognize the ambiguity of the definition and the element of uncertainty it entails, I nonetheless consider the definition legitimate and useful for reasons already advanced: the need to act and the absence of certainty in spite of that need.

101ikeda • My article on brain death calls for more precise criteria and argues that society will accept brain death as a basis for judgment if it is proven that the functions of the entire brain are irretrievably lost, that is, if the damage is irreparable.

102If we refer back to the three levels of life, this would mean people on the first level who have reached a point where medical science as we know it can no longer improve their condition. In terms of the nine consciousnesses, it means a state in which the five senses and the sixth and seventh consciousnesses have been irretrievably lost.

103That said, however, I am sure that repeated debate from many vantage points will enable us to formulate a convincing moral certitude. We must found our decisions on ethical models that entail individual responsibility and a sense of solidarity with our fellow humans. The same mature consideration is needed to deal with the issue of transplanting organs from the brain dead.

Are organ transplants frequent in Canada today?

104bourgeault • Organ transplants are fairly widespread in Canada. According to statistics compiled in 1991, more than 800 kidney transplants, 5 kidney-pancreas transplants, 144 heart transplants, 58 lung transplants, 10 heart-lung transplants, and 174 liver transplants were performed. For a transplant to take place, the donor must have clearly stated willingness. This may be done in written form—on a card that citizens are encouraged to carry with them for the sake of rapid action in case of accident—or it may be verbal, in which case, relatives, too, must give their consent.

105ikeda • With more than twenty years of history behind it, organ transplantation in Europe and North America is technically advanced. Rejection of the transplanted organ was once a great obstacle, but new drugs have solved this problem. Today many transplant recipients recover their health and lead normal lives.

106In Japan, by contrast, no organ transplants were carried out for almost a year and a half after the law permitting them went into effect. This is partly because social consensus on brain death has yet to be achieved and partly because of a traditional Japanese belief that the body, living or dead, is the permanent seat of the soul. There have even been cases in which family objections have resulted in cancellations of planned transplants in spite of prior donor consent.

107bourgeault • In general, religious authorities approve transplants in the belief that they respect the dignity of the individual and—from the standpoint of the donor—are in line with the Christian dynamic of fraternity or solidarity—what you would no doubt call compassion. I would add that relatives often feel comforted in their mourning by the idea that the death of a beloved person has benefited someone else and that life thus triumphs over death.

108ikeda • We must all consider brain death and organ transplantation as personal issues. Families should discuss honouring each other’s wishes in this connection.

109Even in the West, where organ transplants are now routine, it took years to achieve social consensus. In Japan, we have a long way to go before discussions of the issue reach this level.

110bourgeault • The system is not, however, without risk of such abuses as commerce in organs at the expense of the poor—individuals and whole peoples. There is no reason to think, however, that such abuses have been or are current in Canada, where standing laws clearly forbid commerce in human organs or tissues and all infringements of bodily integrity.

111Still, organ removal and transplantation are complex, requiring the orchestrated co-operation of many performers. Of necessity, they are institutionalized and therefore subject to the play of exchanges, confrontations, and controls.

4. Death with Dignity: Overcoming the Suffering of Death

Buddhism condemns active and voluntary euthanasia

112ikeda • What are your thoughts on euthanasia and death with dignity?

113bourgeault • The news media frequently reopen the debate on euthanasia. As people say, “They shoot horses, don’t they?” If that is so, why should we condemn human beings to suffer prolonged agony?

114ikeda • The meaning of the word euthanasia differs from one historic period and one nation to another. Here I refer to its most commonly accepted meaning: that is, the shortening of an incurably ill patient’s life, on the basis of that patient’s own will and the wishes of his or her family. I’m speaking of what can be called “compassionate murder,” a deliberate intervention, in keeping with the wishes of the person involved, to hasten death in order to eliminate intolerable suffering.

115bourgeault • We sometimes still make a distinction between direct and indirect, or passive and active euthanasia. But the development of a techno-medical arsenal has rendered null and void such traditional distinctions and the ethical guidelines that controlled them. Are we therefore delivered up—bound hand and foot—to the supposedly therapeutic determination of a constantly expanding techno-medical power? Demands for the right to die and to die with dignity oppose that power.

116And this brings us back to the question of the meaning and mastery of life. Who is master of my life? Who, if not I, can determine its meaning? What determines for me—for others and ultimately for all humankind—the quality of life and of the death that terminates it?

117ikeda • In 1991, a Japanese doctor administered a fatal injection of potassium chloride to a terminally ill patient and was accused of murder. Failing to ascertain the patient’s wishes, he acted on the basis of a request from family members. What he did cannot exactly be called euthanasia, but it is likely that in the future, as an increasing number of patients request euthanasia, his actions will be repeated.

118bourgeault • The debate on euthanasia is coloured by a plurality of views and opinions on life and its human quality. Some people advocate complete and absolute respect for human life out of belief in its sanctity. Others demand that individual personal decisions and judgments about the quality of life be taken into consideration. Some of the latter feel life is no longer worth living when we can no longer maintain and improve its quality—that at this point, it is not worth or no longer worth living. Though one cannot take the life of another (against that person’s will or without that persons stated volition), it should at least be possible to terminate life for oneself. Respect for life can thus legitimate deliberate action for its termination. This is where euthanasia comes in.

119If the principle of the sanctity of life is contested, can we define rules of conduct that, if not eliminating all risk, at least prevent abuse? Ethical guidelines on respect for life and its human quality in the relativist, pluralist context I have already mentioned have been put forth. I am thinking, for instance, of advances made over the past decade by the Canadian Law Reform Commission that define the appropriate legal framework for cessation of treatment and euthanasia. The guidelines favour life, respect for personal autonomy, and the individual right to self-determination. They specifically take quality of life and protection of the weakest members of society into consideration.

120ikeda • In the court ruling on the 1991 murder case I mentioned earlier, active euthanasia was deemed permissible in Japan under the following conditions: unbearable physical pain; inevitability and imminence of death; exhaustion of known methods for eliminating or alleviating physical pain and lack of alternatives; and clear indication of the patient's consent to having life shortened.

121In the West, the lower house of the Dutch parliament recently adopted guidelines on euthanasia after years of debate.

122bourgeault • The adoption of euthanasia legislation by the Netherlands Parliament has certainly not closed the discussion. But the polemics leading up to it were highly educational. They serve as a kind of summation of the developments of the last decade. What is sometimes called the Dutch model is not without interest. The code of conduct governing medical practice in the matter of euthanasia in Holland is summarized in the following three general requirements. (1) After obligatory consultation with other physicians, the doctor in charge must establish that the seriousness of the patient’s condition precludes hope and submit this conclusion to the hospital administration. (2) The doctor must inform the patient of the gravity of the condition and of foreseeable developments, which will determine the orientation of subsequent care. (3) The doctor must receive formal, express, and repeated requests from the patient in question for euthanasia. To keep both patient and colleague-consultants well informed, the doctor must keep a logbook recording details of the treatment and the consecutive reactions of the patient.

123These rules generally satisfy the demands of prudence and vigilance. They call for circumspection on the part of the doctor, and for supervision of the medical treatment by the patient, colleagues, and the administration of the institution. They demand vigilance from everyone. The requirement of a log or medical file and of disclosure and consultation forbids all precipitate action. The patient must make a “current” explicit request (expressing a decision taken in the currently experienced situation) and repeat it. Since a “living will” drawn up beforehand is considered invalid, this would seem to exclude recourse to euthanasia on the request of another person when the patient cannot express his or her will.

124As debates surrounding the adoption of the law in November 2000 indicated, however, things are not actually that clear. While many Dutch citizens now carry what is called a “euthanasia passport,” we are witnessing an upsurge of anti-euthanasia sentiment. On principle or out of conviction, and sometimes out of fear of abuse, more than 20,000 people carry what they call “life passports.” Nor does their fear seem irrational. Results of studies made before and after the adoption of these new practices show that, in spite of regulations, in the past few years, more than a thousand cases of non-voluntary euthanasia were performed annually.

125ikeda • Recent discussions on active euthanasia in Europe and North America emphasize the patient’s right to self-determination and seem to be moving in the direction of allowing euthanasia when the will of the patient can be ascertained.

126Nonetheless, Buddhists are fundamentally against any form of assisted death. The progress of medical treatment—including methods used in palliative care units—offers hope, even though treatment cannot totally eliminate suffering. Still, instead of taking this as a reason to affirm active euthanasia, we should seek to improve methods of alleviating unbearable pain through medical advances and the co-operation of family, friends and the medical team.

127Buddhism teaches that human life is invaluable, because Buddha nature is inherent in every person. Assisted death may deprive someone of the possibility of manifesting Buddha nature. This is why we must oppose euthanasia.

128bourgeault • I can understand the Buddhist way of thinking quite well.

Ethical guidelines and rules for euthanasia

129ikeda • Since the 1970s, developments in euthanasia-related discussions in the United States have led to a radical change in direction. Former emphasis on easing suffering has recently shifted to “death with dignity.” In cases of incurable illness, as the end draws near, people wish to maintain their pride, self-respect, and some control over their faculties and personal dignity. One of the reasons for the change in emphasis is certainly growing awareness of patients’ rights, including the right to die. Without the possibilities offered to us today by medical science, this right would be purely theoretical.

130Medical science has made great progress in the development of treatments that relieve pain and eliminate the agony of illness. Sophisticated technology has developed support equipment to greatly prolong life. The down side of these advances, however, is that they at times maintain patients in vegetative states, uselessly prolonging their lives. From whence the moral question: Does a comatose or nearly comatose patient with no hope of recovery, plugged into an artificial respirator and attached to feeding tubes and various other machines, possess true human dignity?

131bourgeault • Doctors in Quebec—as in France, Switzerland, and surely elsewhere—insist on a distinction between euthanasia and what we call “total sedation” to relieve patient suffering. According to some, this distinction sets up a tenuous, practically imperceptible, even nonexistent border because both total sedation and euthanasia entail irreversible loss of consciousness.

132Sedation or euthanasia? In either case, ethical guidelines must be proposed and rules of conduct enforced to counter possible abuses of people who may be kept almost indefinitely in a degenerative state.

133ikeda • I agree. Dying with dignity is an integral part of the responsibility of each individual as a human being. Human life is dignified in and of itself, as is every patient and every family, not to mention the doctor-patient relationship, which is based on mutual respect. Today, however, it is extremely difficult to define that dignity in relationships dominated by therapeutic technologies that far outstrip advances in medical ethics. It is of vital importance to carefully examine all the issues surrounding the dignified death of people in a vegetative condition.

Maintaining the creative capacity to serve others

134ikeda • That brings to mind the last hours of Shakyamuni, who announced his own death three months before it happened. Just before the end, a monk by the name of Subhadda came to see him, but a disciple named Ananda intercepted him, saying that Shakyamuni was too tired to be disturbed. Subhadda came three times. On the last occasion, hearing of his arrival, Shakyamuni received him and earnestly related how, ever since abandoning the secular world, he had always walked in the way of justice and the Law. Subhadda became Shakyamuni’s last disciple. He later said, “The Revered One revealed the truth in many ways as if he were lighting lamps in the dark.” As this episode reveals, by expounding the Law for the sake of saving humanity until the final days of his life, Shakyamuni showed his disciples how to die with human dignity.

135My mentor, Josei Toda, died with dignity. From his sickbed, he encouraged others and answered questions about Buddhism. Until his last breath, he gave advice to people in distress. All his life, he radiated health in the true sense of the word, even after he became ill. True health does not mean the absence of illness. Rather, it is a life-state characterized by openness to the hearts and minds of others and to the environment. It is constant readiness to exercise the creative ability to serve society.

5. Confronting Death

Quality instead of quantity

136ikeda • Advances in modern medicine greatly prolong the pre-death period, giving patients in the terminal phase of their illness much more time to live in the face of death. Consequently, one of the main concerns of contemporary medicine is to find ways to support the dying so they can overcome fear and anxiety. This is why terminal care has become a focus of great attention.

137bourgeault • During the past twenty years, a number of hospices have been established in Canada. I am familiar only with those in Montreal and Quebec. They give good service but are too few in number, which makes their patients seem privileged. Some people, however, reject reliance on such specialized institutions, preferring to keep patients at home as long as possible, sometimes right up until death, providing all the medical and paramedical support needed—especially pain relief.

138ikeda • Of course, hospices are not the only solution for terminal care. Palliative home care is also very important. We expect palliative care to encourage a religious or spiritual attitude in the face of death, to help patients deal with the end of their lives and to go beyond the attitudes of modern civilization, which present death in a very negative light. Indeed, determining existential issues such as how a person should live out the final chapter of life is exactly the kind of question religion has always sought to answer.

139bourgeault • I consider it necessary to encourage and sustain in practical terms all efforts to make life worthwhile and dignified to the end. I think I have already mentioned Trémolières’s words to the effect that it is better to add life to years than to add years to life. Life expectancy today is increasing. We must interpret the increase more qualitatively than quantitatively.

140ikeda • Precisely. Spiritual considerations have incited people to look much more closely at institutionalized care. Institutions are designed to provide the necessary personnel: doctors, nurses, social workers, aids, and volunteers, and often religious counsellors or clergy as well. The goal is to allow the patient to live as fully as possible by providing spiritual support, for the patient as well as the family. The hospice is a place to prepare for death and to reflect in a holistic way on the life one has led.

141Elisabeth Kübler-Ross (1926– ) speaks of a five-stage process the patient undergoes upon realizing that death is drawing near. The first is denial, followed by anger at fate. In the third stage, the patient bargains with supernatural beings like God or the Buddha. If nothing results from the bargaining, the next stage is depression, followed by acceptance.

142At the approach of death, the mind of the patient is heavy with anger, sadness and depression. It is the role of the terminal-caregiver to help the patient adopt a positive approach, overcome the suffering of death, and make the fullest, most self-expressive use of the remaining time. This role will be of growing significance in the years to come.

  • 3 Elisabeth Kübler-Ross. On Death and Dying. New York: MacMillan. 1969. Death: The Final Stage. New (...)

143bourgeault • Yes, but that said, I distrust—and I am not alone in this—the current tendency to sweeten death. You mention the ideas and work of Elisabeth Kübler-Ross. On the basis of innumerable dialogues with hospitalized dying patients, she presents death as a reality to be accepted and experienced as the final stage of growth. The acceptance is preceded by sometimes aggressive denial.3

144The testimonies she reports are often touching. They come from dying people who, informed of the gravity of their illnesses, find themselves obliged to prepare for death. Although they remain clear-minded, their failing powers seemingly facilitate a relinquishment—or in Kübler-Ross’s term, letting go—that is as much biological and physical as psychological and spiritual. They are accompanied in their illness by relatives, sometimes friends, members of the medical-care team, and by either Kübler-Ross herself or people who share her philosophy or spirituality.

145ikeda • Buddhism establishes three categories of pain: physical; psychological—caused by loss; and existential—caused by awareness of the transitory nature of the phenomenal world. Death is said to be the conjunction of these three.

146The first type of pain can be alleviated with the help of medical science. Social welfare systems and the combined co-operative efforts of family and the medical system can lighten psychological suffering. Overcoming existential suffering, however, is another story altogether. This is the anguish caused by the idea of our own mortality. I am convinced that belief in eternal life provides a way of thinking about life and death and of triumphing over the fear and apprehension of death. If people can internalize a spiritual view of life and death, it will enable them to overcome the despair of these three types of pain and greet the final chapter of their lives, tranquil and fulfilled.

147bourgeault • But very large numbers of people die abandoned or the victims of epidemics, famine, accidents, catastrophes, or war, often without regaining consciousness. All of these people who die violently and alone—and they are probably in the majority—fall outside the Kübler-Ross experience, limiting, though not invalidating, its pertinence.

Near-death experiences

148ikeda • That is very true. Still, many people have described near-death experiences. Sometimes when accidents, illness, or surgery leave people in a state of lowered consciousness and bring them to the point where death is actually encountered, these people regain consciousness—or “come back to life”—and relate their experiences.

149Since 1976, when the American internist Raymond A. Moody, Jr. (1944– ) published A Life after Life: The Investigation of a Phenomenon, Survival of Bodily Death, many physicians, psychologists, and psychiatrists have published data on the same phenomenon.

150Dr. Moody derived the following basic patterns from the experiences he collected. The most commonly experienced phenomena include the sensation of passing through a long tunnel just when the doctor pronounces the subject dead, followed by sudden consciousness of separation from the physical body, encounters with others, recollections of major life events, and the appearance of life as light. Later research has shown that these patterns are generally shared.

151bourgeault • Moody’s book was a best seller in Canada, as elsewhere. It seems to me that the phenomena he lists can be explained differently and more simply than he suggests. Perhaps I am over-rationalizing—maybe that is a habit of my job. You yourself refer to psychology. The knowledge we have of the physiological and psychological mechanisms of perception explains the phenomena in question in a way that, though nuanced and fragile, satisfies me better than the way proposed by Moody and his colleagues—or disciples.

152Several years ago, the theologian and psychoanalyst, Louis Beirnaert (1906–85) compared the mystical visions of Saint Ignatius de Loyola (1419?–1556) with those of prisoners of the Dachau concentration camp. He explained the similarities he observed as resulting from rigorous fasting, voluntary on the one hand and harshly imposed on the other. He added that the mystical saint probably experienced changes in body chemistry identical with those experienced by the starving prisoners and that these changes no doubt accounted for the similarity of their so-called visions. Saint Ignatius gave his own visions—or hallucinations—a different significance. It seems to me that the exhaustion of vital resources could account for Moody’s observations.

153ikeda • Near-death experiences are frequently analysed and interpreted as psychological phenomena, like drug-induced hallucinations, paroxysms of the temporal lobe, or cerebral disorders resulting from oxygen deprivation. As a Buddhist, I hope that much more data on near-death experiences will be gathered and analysed from the perspectives of psychology, physiology, psychopathology, ethnology, and anthropology.

154bourgeault • Nonetheless, I must admit that I am uneasy whenever the meaninglessness of death—and the radical rupture it causes—seems to be denied by affirmations of continuity of life and some kind of survival assured by its renewal. This appears to me to be consolation-seeking—the legitimacy of which, in spite of everything, I recognize.

155No matter what is said, death marks a radical rupture. The prospect of death confronts the living person, who has given meaning to and sought to enjoy life, with an absurd alternative. On the one hand, survival that, in spite of the most intense desire, cannot succeed in truly saving life and whatever gives it richness, savour, and value. On the other hand, annihilation reducing everything to inconceivable oblivion.

Facing death boldly

  • 4 The Complete Essays of Montaigne. Tr. Donald M. Frame. Stanford, CA: Stanford University Press. 19 (...)
  • 5 Gosho Zenshu. 1404.

156ikeda • Montaigne said, “To philosophize is to learn to die.”4 Similarly, Buddhism teaches us: “First learn about death, and then about other matters.”5 As both statements suggest, learning about death enriches life.

157No matter how we interpret near-death experiences, the lives of people who have undergone them have been revolutionized. Some have reported that a face-to-face encounter with death caused them to reflect critically on the way they had been living and to try to live as fully as possible, so as to be prepared for death whenever it might come.

158I think you will agree with me on the following points: First, people who have undergone near-death experiences no longer fear dying. Second, as long as they go on living, they strive to acquire knowledge. Third, no longer egotistically concerned with fame, power, and wealth, they resolve to live altruistically and compassionately. If we can return from death’s doorstep with this kind of change in attitude, then I believe such an experience is very valuable for whoever experiences it.

159In my 1993 speech at Harvard, on Mahayana Buddhism and Twenty-First Century Civilization, I pointed out that people today have averted their eyes from the problem of dying and given it a negative image diametrically opposed to the positive image of living. I called for people to bravely face death instead of ignoring it.

160bourgeault • In Canada and generally in North America, it has become extremely difficult to accept the negative aspects of the evolution of life for what they are. This can be attributed to the idea that when life encounters death, it can no longer expand but is condemned to the ultimate stage, that of extinction.

  • 6 One of the most fundamental concepts of Buddhism, hossho has many different meanings. It is most o (...)

161ikeda • Buddhism is based on the principle of hossho no kimetsu or the manifestation and latency of the eternal truth inherent in all things. According to this principle, hossho6 becomes manifest and latent repeatedly in accordance with its karmic relationships with all phenomena—including life and death—which obey the creative process of evolution.

162bourgeault • Can life, defined and constantly compelled by creative personal liberty, escape death? Jean-Paul Sartre (1905–80) and Simone de Beauvoir (1908–86), both non-believers and atheists, ascribed to a view and a dynamic that defy death and its meaninglessness and seek to break its hold on life. In a sense, through the soaring of the thoughts that constitute our humanity and give meaning to our lives, through the bonds of love and friendship, through our children, and through the works we leave behind us, we each transcend the death that will ultimately engulf us. Because death is stronger than we are, and its meaninglessness drives us up against the absurd, even during life. But does death swallow everything up? Beyond death there remains what Jean-Paul Sartre called being-for-others. The French philosopher Vladimir Jankélévitch (1903–85) would also evoke the “having been,” “having lived,” and “having loved.”

163ikeda • I agree with Sartre and Jankélévitch on that point. Life is short and what we can accomplish during its brief duration is naturally limited. Nonetheless, those who come after us and the heirs to our achievements will follow in our footsteps and continue our works. In this sense, our life continues eternally.

164Worldwide sgi anti-war, pro-peace, and pro–human-well-being activities are founded on Josei Toda’s heritage, expressed most notably in his condemnation of nuclear weapons and his philosophy of global citizenship. As our activities spread around the world, we have the firm conviction that our first president Tsunesaburo Makiguchi and Mr. Toda “live” today in sgi members and all our undertakings.

6. Birth

165ikeda • Buddhism emphasizes the equal importance of birth and death by combining the words in a single compound term, shoji.

166bourgeault • Birth is as decisive for humans as death. And the moment at which human life starts is just as hard to determine as the moment when it ends.

167ikeda • What are the Christian views of this topic?

168bourgeault • In the Judeo-Christian tradition, life was described in such terms as psyche (soul; literally, breath) and pneuma (vital spirit; literally, wind). This corresponds to the ancient belief that life is animated by some substance flowing inside the body. People believed that life came from the Spirit of God and therefore had to be treated with the greatest care and respect.

169Later, after Christianity was established, imposed Christian civilization and adopted the Greco-Roman heritage, discussions about life took a different turn. For instance, attention was directed toward determining the moment when life becomes human, the moment in its development when the fetus becomes a human entity.

170ikeda • In other words, emphasis shifted from the appearance of life to the birth of the human being.

171bourgeault • Yes. People tried to distinguish between the embryo and the completed human being. Paradoxically, some people came up with the discriminatory thesis that a male fetus becomes human after three months’ pregnancy but that this occurs only after six months’ pregnancy in the case of a female fetus. The traditional view that the fetus becomes human when it starts breathing by itself—that is, at birth—finally held sway.

172Recently people have been using the completely unscientific term pre-embryos to designate so-called young embryos frozen for implantation or for research purposes. Actually, I think it is impossible to determine the precise moment when human life begins or actually becomes human. The process is perhaps gradual in that, with the passing time, the human entity grows in complexity until it finally becomes human.

173ikeda • Buddhist scriptures hold that life begins at the moment of conception. Modern prenatal physiology clearly reveals conditions in the mother’s womb that were impossible to determine in ancient times. To deal with the issues of in-vitro fertilization and artificial insemination, we must re-examine our interpretation of the nature of life on the basis of scientific and medical findings.

174Buddhism teaches that birth, like death, is a process. Some sutras describe conception as the establishment of an “entity of intermediary existence” or the introduction of consciousness. The consciousness in question here is the eighth or alaya consciousness, the collective subconscious I mentioned earlier in relation to death. From the viewpoint of reincarnation, life is an “intermediary existence” between the moment of death and the moment of the next birth. Conception is the moment when this intermediary existence is wedded to its next human form. As the embryo develops, the other levels of consciousness develop: first the seventh, then the mind or sixth consciousness, and finally the five senses.

175Cerebral physiology divides fetal development into two stages. During the initial five to six months of pregnancy, cell division, proliferation, and movement take place. During the second stage, networking functions evolve—neurites, axones, dendrites and synapses develop. The second stage is a process during which the various functions of the human body emerge. Scientific discoveries seem to confirm the Buddhist interpretation in which the subconscious, the conscious and the five senses gradually emerge.

176This concept of birth as a process agrees with your theory of the increasing complexity of the developing human entity.

Ethical issues in prenatal diagnosis

177ikeda • Recent technological progress has been made at a dizzying speed. It is not surprising that technology, which makes artificial manipulation of human life possible, is generating new and serious ethical problems.

178The possibility of prenatal examinations has added new aspects to the issue of artificially induced abortion. Prenatal tests like amniocentesis, ultrasound, and chorionic villi sampling (cvs) allow us to monitor the very early stages of fetal development and identify a growing number of congenital and hereditary disorders.

179bourgeault • In effect, well before birth, prenatal tests—pre-implantation tests in the case of in-vitro fertilization—reveal the “quality” of life in store for the gestating human being if it is allowed to develop. New options present new questions. The need to choose among them continues to the end of life. In its very last moments, we can partially dissociate life from suffering and agony. We are in a position to hasten or retard death itself, whose ancient power can be, if not abolished, perhaps held temporarily in check.

180ikeda • Apparently the maternal serum marker test (or maternal serological screening) is very easy to perform. This test could easily be included as a standard prenatal test without debating its ethical implications. To examine this and other similar problems, the Japanese Ministry of Health and Welfare set up a committee of specialists, in October 1998, to deliberate ethical issues and the safety of prenatal diagnoses, including pre-implantation diagnoses. Where does Canadian medical opinion stand on this issue?

  • 7 Based on research reports conducted under the auspices of the Royal Commission on New Reproductive (...)

181bourgeault • A 1990 inquiry at twenty-two specialized centres in Canada revealed that frequent recourse to prenatal diagnosis is becoming practically routine. It is part of the usual prevention protocol or follow-up for pregnant women over 35 years old or women who have reason to fear giving birth to a malformed child or a child with a grave hereditary sickness.7 In 1990, of the at least 22,000 women who visited one or another of these 22 centres, 78% did so because of age (older than 35 during pregnancy). The others had various reasons such as previous personal experiences, family history, or abnormal results from routine examinations.

182Generally the women interviewed considered prenatal diagnostic tests useful, if unpleasant. They were universally satisfied with services offered or actually rendered. But—before, during, and after the tests and possible subsequent treatments—they wished that the overall process was managed in such a way that their actual experiences were taken into account. The doctors and “genetic counsellors” were on the whole favourable to general implementation of these tests for women over 35 and for women with some reason to fear giving birth to an infant suffering from an anomaly or a serious condition. There was also a fairly broad consensus on the need to communicate the results of the tests to the women, so they could freely give informed consent to continue or terminate their pregnancy.

183ikeda • If a congenital deformation is detected, the decision of whether to carry the child to term is left to the mother. The burden of the child’s abnormality falls on the woman’s shoulders, when it ought to rest with society as a whole.

184bourgeault • Can such a thing be called freedom? In another Canadian inquiry—this one, too, conducted in 1990—the women interviewed generally affirmed that their freedom to choose had been respected. Several indicated, however, that a subtle pressure was exerted on them, arising more from a prevailing atmosphere or the general influence of a dominant ideology than from a particular professional’s desire to impose his or her viewpoint.

185The women felt and lived an ambivalence related to two social constructs or two images of pregnancy—on the one hand, a rich, natural experience affecting their entire being, and on the other, reduction to the object of tests performed with the help of diverse techniques and analyses. The book Womens Experience with Technology in Pregnancy, written by Sari Tidiver at about the time of this survey, looks closely at this ambivalence. It casts in sharp relief the limits that various pressures impose on women’s liberty. It also explores the women’s dissatisfaction at seeing their experiences ignored in a process fragmented into a series of separate medical procedures.

186Many women who underwent prenatal diagnoses expressed ambiguous or ambivalent feelings and sometimes resentment. They realized that the technology had simultaneously helped and invaded them, and that afterward they were left on their own to make difficult decisions. Here we have a double paradox. Since the child is wanted, pregnancy itself is often wanted and experienced as a happy event. This rich and fulfilling experience is suddenly troubled and tormented by the possibility—suggested by the very proposal to undergo prenatal diagnosis—of an “abnormal” birth. Yet the proposed tests are a reasonable and necessary outcropping of the mother’s sense of responsibility to her unborn infant. When the results are bad, however, the technological equipment believed to make possible the birth of a perfect baby fails, abandoning the woman to her sadness and distress.

187ikeda • If the kind of responsibility you have just described is imposed on pregnant women, prenatal diagnosis is more likely to curtail than to strengthen their rights. Society already exerts many pressures on women—both implicitly and explicitly—especially in the areas of giving birth and raising children. Providing equipment for prenatal testing is important, but we must also create the kind of social system that can support and advise women trapped in untenable situations.

188bourgeault • In certain cases, prenatal diagnosis permits us to detect anomalies or pathological conditions. But the genetic therapies that will someday effect the necessary corrections are not ready, at least not in the majority of cases. In practice, the objective of prenatal diagnosis is usually information—forecasts or “predictions”—and “prevention” in the form of pregnancy termination.

189ikeda • In Japan, when amniotic-fluid tests reveal fetal anomalies, abortion is considered as a matter of course. This is one of the major problems with prenatal tests.

Quality of life

190bourgeault • Here we encounter the crucial and fundamental questions of bioethics. What do we mean by genetic anomaly? What is susceptibility or predisposition to such-and-such a sickness? What is abnormality? What is a handicap? At what stage can we judge these ills serious enough to justify abortion?

191Two questions among the many capture the attention. First is the definition of the boundary between normal and abnormal (or pathological). To establish this boundary is to define the quality of human life. The second question, underlying the first, deals with so-called soft eugenics.

192ikeda • Both truly fundamental questions.

193bourgeault • The definition of the quality of life harks back to the concepts of normal and pathological. Some sufferers from serious, genetically transmitted defects or diseases consider their lives happy and worth living. Contrary to our spontaneous judgments and the opinion of specialists, they believe their lives have truly human quality.

194Essentially, a handicap is not so much a medical problem as a social problem, a matter of social acceptance. In any case, who can judge the quality of life of a person as yet unborn? Drawing boundaries between the normal and the pathological is not easy.

195ikeda • I agree entirely. In March and June 1998, the Japan Society of Obstetrics and Gynecology sponsored public discussion meetings of pre-implantation diagnosis. Representatives of the disabled spoke at the meetings, insisting above all that the presence of disabled people in the world should be considered a given, that we must eliminate all discrimination against them and instead offer them all the support they need to take their rightful place in society.

196In defining quality of life, we must not draw boundaries and relegate everything beyond those boundaries to the “abnormal.” Instead we must do everything in our power to build the kind of broadminded society in which people living with disabilities do not have to consider themselves “handicapped” and can manifest their full potential.

197bourgeault • Testimonials received in numerous inquiries demonstrate remarkably unanimous rejection of the use of prenatal diagnostics for eugenic ends. Nonetheless, all genetic research, intervention, and medicine seem to me to fall into the category of what I call soft eugenics. Throughout life and even before birth, we attempt to improve the health of individuals and whole populations, not by suppressing handicaps—as has been done in many countries, not only in Nazi Germany during the thirties—not by what I call hard eugenics, but by soft eugenics. Soft eugenics begins before birth, in the egg, if I may put it that way.

198ikeda • People are often suspicious of eugenics because of its natural link with Nazi policies of racism and ethnic cleansing.

199bourgeault • In my opinion, we must tackle the ethical debate on eugenics on new grounds. If we believe that life is not simply handed to us as a divine gift but is entrusted to our responsibility, we cannot condemn all forms of eugenics out of hand and a priori.

200ikeda • Of course, everyone wishes to have healthy children. If reproductive technologies can help, their use should be considered with all necessary prudence. But I am apprehensive that this might lead to actions based on intolerance. Though the object of reproductive technologies is the fetus, society or individuals might use these technologies to control or impose constraints on the lives of others. In keeping with the Buddhist concept of the sacredness of life, we must demonstrate extreme caution in applying technologies capable of manipulating life itself.

201We must also take into consideration effects on the mother's body of carrying the child to term. All decisions must be made carefully and with the co-operation of both parents and the medical team to find the solution that is most beneficial to the child.

Abortion and a feminine philosophy of life

202ikeda • I understand that you participated in discussions on bioethics concerning abortion in Canada.

  • 8 La société québécoise face à l’avortement. Montreal: Leméac. 1973. The French expression “face à” (...)

203bourgeault • During the tumultuous debates held in Quebec at the beginning of the 1970s on decriminalizing abortion, I helped write a report for the League of Human Rights (later renamed the League of Rights and Liberties). The title of the report discreetly indicates its fundamental orientation: Quebec Society Facing Abortion.8

204Discussions and legislation against abortion are often hypocritical. As is clearly evident in the United States, those who condemn abortion—more often men than women—call for the maintenance or restoration of the death penalty, defend the right to possess and use arms, and favour repression of criminals and deviants over social aid and reform. This stance is full of contradictions: the right to life is blindly defended on the one hand and summarily denied on the other. Moreover, what ought to be a shared responsibility is unloaded on women.

205Abortion is connected with social issues. Poverty and its consequences frequently thwart the possibility of even carrying pregnancy to term (in Quebec and the rest of Canada, single mothers are among the poorest of the poor). Job insecurity is another key factor: the free play of competition—itself a cause of unemployment—threatens rights we thought were ensured, like maternity leave. Then there is inadequate community support: both the government and the church display an indifference that belies their words.

206Our report recalled the responsibility of society—that is, of each of its members. Participants in the working group unanimously agreed that it is absurd to separate the right to life and the right to freedom. Respect for life and respect for rights and freedoms are inseparable. Respect for life has no meaning if that life is not free. But the converse also is true: rights and freedoms are impossible without respect for life.

207ikeda • What you say is very wise. I too feel that the concept of respect for life and the insistence on rights and freedoms can be made compatible. Unfortunately, in Japan, with little public discussion, abortion is used as a means of population control. In consequence, reproductive technology tends to be seen as a mere medical treatment. The ethics of the issue go largely unconsidered, and legal restrictions are lax. And as we know perfectly well, it is women who are directly affected by abortion. Men, far too often, seek to escape their responsibility as parents.

208bourgeault • The women I have met over the years have seemed very solicitous of life. They have equally rejected the intransigence of grand principles and rules on the one hand, and judgments and condemnations on the other. They have made me examine my own personal rapport with life—with my own life and with the lives of others.

  • 9 Based on Proceed With Care, the report published in 1993 by the Royal Commission on New Reproducti (...)

209We must remember, however, that termination of pregnancy is not the only solution to problems occasionally revealed by prenatal diagnosis. In certain cases, gene therapy is now effective. Hopes aroused by treatments still in their infancy will surely not all be deceived.9

210ikeda • While women are obviously the most profoundly affected by it, abortion is intimately entwined with the attitudes the mother, both parents, the family and society at large hold toward the fetus. The issue requires serious, considered debate.

211From the point of view of traditional ethics, Buddhist precepts against murder extend to abortion. One sutra reads: “One of the most serious sins a nun can commit is to provoke death within her body by taking action with the intention of killing a fetus.” If a Buddhist nun deliberately uses a method to provoke abortion and the fetus dies, she has committed one of the worst sins. Whoever adopts the premise of Buddhist compassion must therefore radically reject intentional abortion. In my opinion, it is much better to use contraception.

212Of course, other considerations play a role. When birth endangers the mother’s life or when pregnancy is the result of rape or other violent sexual relations, the will of the parents—especially the mother—must be respected in making a decision.

213If genetic therapy progresses far enough in the future and provides solutions for certain problems, it should be considered as an option, but first it must be carefully and seriously examined to determine the best way to use it. Of course, all possible precautions must be taken to prevent therapy from degenerating into the manipulation of people for non-therapeutic ends.

214I believe that traditionally, Christianity—particularly Catholicism—has forbidden abortion out of respect for life as a gift from God.

215bourgeault • I have two comments to make on that topic. First, there is no clear reference to abortion in the Bible. Second, there is an obvious contradiction between the logic of the Crusades and the so-called just wars, of the Inquisition and religious torture, capital punishment and so on—a logic, long embraced by Christianity, that excludes all dissidents and denies their right to life—and the permanent interdiction of abortion on the basis of respect for the dignity of human life.

216ikeda • Buddhism is founded on tolerance. Just as the Buddhist precept against taking life extends to fetal life, this spirit of toleration recognizes the dignity of all life. This logic of tolerance could provide the foundation for a society that values individuality and enables people to live in self-respect, confident of the future. Modern society as a whole must effect a shift from the logic of exclusion to the logic of tolerance, which makes harmonious coexistence possible.

7. Reproductive Technology

Abuse of reproductive technology

217ikeda • The use of biotechnology based on emerging life sciences now permits such life-manipulative technologies as artificial insemination, in-vitro fertilization, and embryo transplants.

  • 10 Édouard Boné and Jean-François Malherbe. Engendrés par la science: enjeux éthiques des manipulatio (...)

218bourgeault • Thanks to scientific and technological developments, we can now give substance to our dreams. As Jean-François Malherbe remarked in discussing the ethical aspects of medically assisted procreation, three ancient dreams have now been realized.10 First, thanks to various contraceptive techniques, it is possible to avoid having unwanted children. Second, even sterile people can have children by way of artificial insemination, in-vitro fertilization, and surrogacy. And third, thanks to prenatal diagnosis, abortion and, soon, genetic intervention, it is possible to have only the kind of children one wants.

219ikeda • How are such life-manipulative techniques evaluated in Canada from the bioethical standpoint? How do Canadians feel they can be used to benefit humanity?

220bourgeault • Between 1990 and 1993, the debate on these issues was nourished by the work and frank discussions of the Royal Commission on New Reproductive Technologies. In addition to its report, in 1993, this commission published fifteen lengthy supplements detailing the results of its inquiries and research.

221In the wake of these consultations, the Canadian parliament began work on a bill to control new reproductive technologies and eliminate all kinds of commercialization and possible irregularities. The measures in the bill were intended to forbid certain practices current in the United States and elsewhere—sometimes even in Canada. For instance, recourse to surrogacy, selection of fetus sex for non-medical reasons, trafficking in ova and sperm cells (only unremunerated donations are permitted), sales and purchase of embryos, development of embryos in artificial uteruses, cloning of human embryos, creation of human/animal hybrids, transfer of human embryos into animals, development and conservation of human embryos for research purposes, and sampling ova or sperm from cadavers.

222Some of the measures announced were generally well received. Others aroused reservations and outright opposition from people who felt that they would only nourish unfounded apprehensions. To use the time-honoured expression, the bill died on the Order Paper. A second bill met the same fate.

223Louise Vandelac, a sociologist with a lively interest in these questions, lamented that after a $30 million commission and two bills killed before they saw the light of day, Canada still has not defined a specific legal framework for such matters. The medical technology industry prospers with little or no regulation. Still, the debate goes on.

224ikeda • Artificial insemination is currently practised in many countries. Homologous insemination—artificial insemination by the husband—has proven to be an effective procedure in infertility cases and provokes few problems, since the child is genetically the couples, however much medical technology may have contributed to its birth. On the other hand, when sperm is provided by a donor—heterologous insemination—serious bioethical problems may arise, even though the technology is the same.

225In America, reproductive functions are already being commercialized. Some sperm banks collect the sperm of celebrated people like Nobel Prize laureates and Olympic athletes, and agencies can be hired to find surrogate mothers and oversee the birth and placement of the child. There has even been some movement toward the sales of fertilized ova. I am opposed to the practice of selecting certain types of sperm for artificial insemination. The dignity of human life does not depend on IQ or special abilities. It is determined by the kind of life a person lives.

226Fundamental human rights have been infringed in connection with the commercialization of reproductive technology. One court case closely followed by the media concerned the bitter battle of a divorced couple over frozen fertilized ova. In another case, a surrogate mother who had grown attached to the child she was carrying decided to keep him, provoking a heart-rending legal battle with the woman who had hired her. In an even more tragic case, a baby born through surrogacy had a congenital abnormality and the contracting couple refused to “take delivery.” These kinds of situations are proliferating left and right, giving free reign to a multitude of flagrant violations of human rights.

Disintegration or transformation of the family

227bourgeault • Today we dissociate procreation from formerly indispensable sexual relations and from traditional forms of paternity and maternity. As you have noted, this dissociation is not without risk. By opening the door to new relationships, it forces us to reevaluate the connections between emotional life, sexual relations and commitment, in individual lives, in the framework of social relations, and in the reconstitution of what we call the family, which has taken so many forms throughout time and from civilization to civilization. It also entails the risk of the abuses you have already underscored: commercialization of human life; blatant or concealed eugenics; hopes betrayed; disillusionment; judicial battles in which individuals—children above all—pay the price, since their rights are trampled; and—lest we forget—the possibility of sorcerer’s apprentices in the form of inept practitioners.

228ikeda • Before turning to reproductive technologies, would-be parents must first address such basic questions as why they want a child and what they are prepared to do for the child. If parents can overcome their egotism and feel joy and gratitude at helping their developing child live a life worthy of humanity, the disintegration of the family can be avoided. It would then be possible to build the family on the basis of the new relationships you mention.

229Since its first successful performance in England in 1978, in-vitro fertilization has become everyday technology all over the world.

230bourgeault • Experimental and innovative research and practices in the field of assisted procreation are generally carried out in university centres, where regular exchanges among researchers and practitioners on the one hand and various evaluation and control mechanisms on the other at least limit the risks, even if they can never be totally eliminated. We can feel generally confident but we must remain vigilant, especially in the face of the proliferation of private research and treatment centres. In my opinion, a responsible ethic requires us not to reject innovation but to limit its risks and curtail, if possible, its harmful effects ahead of time.

231ikeda • No medical treatment is without risk. Reproductive technologies are no exception. Absolute priority must be given to ethical considerations and to the safety of individuals. This responsibility falls largely to the professionals who engage in this rapidly evolving field.

232In the final analysis, the parents’ responsibility toward a child born with the help of medical technology must dictate the use of that technology. Parents who care for their children must cautiously approach the use of reproductive technology on the foundation of firm views on life—how they themselves live and the kind of life they want for their child.

Notes

1 L’éthique et le droit face aux nouvelles technolopes biomédicales (Ethics, human rights and new biomedical technology). Brussels and Montreal: De Boeck-Wesmael/PUM. 1990.

2 The Path of the Law Sutra (Dhammapada), Volume XII.

3 Elisabeth Kübler-Ross. On Death and Dying. New York: MacMillan. 1969. Death: The Final Stage. New York: MacMillan. 1975.

4 The Complete Essays of Montaigne. Tr. Donald M. Frame. Stanford, CA: Stanford University Press. 1958.

5 Gosho Zenshu. 1404.

6 One of the most fundamental concepts of Buddhism, hossho has many different meanings. It is most often used to mean: (1) the Law, or ultimate truth; (2) the teaching of the Buddha who reveals the Law, or sutras; (3) the manifestations of the Law—phenomena, things, facts, existences, etc.; (4) the aspects of existence which, according to the Theravada school, are the most fundamental components of the individual and his or her reality; and (5) the precepts or behaviour that leads to the accumulation of good karma.

7 Based on research reports conducted under the auspices of the Royal Commission on New Reproductive Technologies led by Dr. Patricia A. Baird, and specifically on Volumes 12 and 13 on prenatal diagnosis in Canada, annexed to the official report entitled Proceed With Care.

8 La société québécoise face à l’avortement. Montreal: Leméac. 1973. The French expression “face à” has a connotation of opposition.

9 Based on Proceed With Care, the report published in 1993 by the Royal Commission on New Reproductive Technologies, led by Dr. Patricia A. Baird.

10 Édouard Boné and Jean-François Malherbe. Engendrés par la science: enjeux éthiques des manipulations de la procréation (Engendered by Science: The Ethical Issues of Reproductive Technology). Paris: Éditions du Cerf. 1985.

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