Buddhism and Organ Transplants
By Bhikshuni Karma Lekshe Tsomo
There are many contemporary social issues that need to be investigated from a Buddhist point of view. One of these is the question of organ transplantation. Since organ transplants were not medically possible until very recently, there are no explicit statements on this question to be found in the texts. What might we infer from the texts and what do the living Buddhist traditions have to say about this vital ethical concern?
When I returned to the United States after spending fifteen years in Asia, there were many colloquial English terms that were new to me. I often had to ask people to explain the significance of one or another slang expression. Sometimes, for example, I heard young people riding motorcycles referred to as "organ donors." I asked a friend why this term was used. My friend explained that people with young, healthy bodies riding motorcycles without helmets were prime candidates for donating their vital organs for transplantation using modern surgical methods. Therefore, these foolish young people were facetiously called "organ donors." Re-acculturation to modern American life was full of enlightening experiences such as this.
On another occasion, I went to the Honolulu Police Department to apply for a driver's license. The spectre of a Buddhist nun driving a motor vehicle in an Asian Buddhist country would be met with incredulous horror, for sure, but in America driving is practically essential. Like most patriotic Americans, I had been driving cars since I was sixteen years old, so now when someone kindly offered a used car to facilitate my work , I resigned myself to the inevitable. A surprise awaited me at the HPD, however: I was asked whether I wished to have "organ donor" marked on my license. That experience started me thinking about possible Buddhist views on a very new problem.
To begin with, all Buddhist schools agree that nothing is dearer to a sentient being than its life. 11 In fact, reverence for life is taught in practically all religious traditions and can itself be deemed a definition of spirituality as, for example, among the native Hawaiian people. Buddhism in particular teaches us to cherish life and to protect the life of even the smallest living creature. To refrain from taking life is the first precept for Buddhists, both lay and ordained. To protect the lives of animals, to say nothing of humans, is said to ensure long life, both in this and future lives. It is said to be the karmic cause of good health, beauty, and rebirth in a pleasant place. To save the lives of living beings by purchasing them from the butcher is a time-honored custom among Buddhists in Tibet, China, and other Mahayana countries.
Nowadays, with the globalization of practically everything, I thought it would be a good idea to consult Buddhist followers of various traditions to see how they felt about the idea of organ transplantation. So I spoke with Japanese, Chinese, Burmese, Vietnamese, Tibetan, Canadian and American Buddhists on the subject. When I asked "How do feel about the idea of people donating their organs when they die ?" the response was always spontaneously positive. Every person I questioned, of every Buddhist persuasion, believed that giving organs was clearly an act of compassion as well as an act of generosity. When I asked "How do you feel about the idea of donating your organs when you die ?" the response was still always positive, even if there was a very slight hesitation or perceptible glassing over of the eyes in a few cases.
From the Buddhist point of view, the body, being merely a collection of five aggregates ( form, feelings, perceptions, karmic formations, and consciousness ) has no usefulness after death. Theravada followers tended to emphasize this point of the teachings. They told me that at the time of death, the consciousness leaves the body and there is no harm in touching, washing, or cutting the body, since it is nothing but a heap of dead skin, bones, flesh, and other rotting ingredients. It seems to be the custom in Thailand, for example, to wash the dead person's body and dress it in fresh ( usually white ) clothes. Nevertheless, it also seems to be the custom to leave the body lying in state for a certain length of time, whether it be one, three, or eight days, depending on the country, the status of the person, and the wishes of the person's family.
Mahayana informants answering my query tended to emphasize the teaching on the precious human rebirth. Since a human rebirth is difficult to attain, easily perishable, and the most desirable state in which to make progress toward enlightenment, they saw donating bodily organs as an excellent way to contribute to human happiness. By donating a liver or kidney, we may extend another person's life and give the person a chance to practice Dharma and " take the essence " of the human opportunity. To put the welfare of another human being above one's own by giving away an organ would be the ultimate act of self-sacrifice and an excellent opportunity for practice.
Since the Mahayana path stresses the conjunction of wisdom and compassion as essential for attaining enlightenment, no chance for developing these two qualities should be missed. The bodhisattva ethic is to sacrifice oneself for others, including postponing one's own enlightenment for their sake. We find many examples of such heroism in the past lives of the Buddha when he was practicing on the paths and stages as a bodhisattva.
In the Jataka Tales , we read of him giving his eyes and his flesh. One of the most well-known instances was when he gave his body to the hungry tigress at the spot now called Namo Buddha in Nepal. We also find examples of self-sacrifice in the lives of the Buddhist saints. For example, we read the famous story of Asanga who cut flesh from his own thigh to entice maggots away from the vermin-infested body of a dying she-dog. By this act of great compassion he achieved the direct vision of Maitreya.12
In China, textual references to sacrificing the body were often taken literally. Occasionally a young monk would burn off a finger or two as and offering to the Buddhas and a symbol of his dedication to the welfare of sentient beings. Even today in Chinese Buddhist communities, sacrificing the body for the welfare of others is symbolically enacted by burning small cones of incense on the heads of bodhisattva candidates. After all, it is reasoned, if a person makes a commitment to descend to the lowest hells for eternity to benefit even one living creature, she should be willing to undergo a few minutes of discomfort on their account. Once in a while this custom even led to self-immolation. I remember seeing signs posted around a particularly tempting site at Pu-tou-shan, the sacred " Potala mountain " of Avalokitesvara 13 in China, that said " Please do not immolate yourself here " and " Sacrificing of fingers and other body parts forbidden. "
For the reasons explained in connection with the preciousness of the human rebirth, however, suicide is certainly not sanctioned in Buddhism. To take the life of any sentient being, especially a human being, including oneself, violates the cardinal principle of Buddhist ethics. While taking the life of sentient beings is prohibited, we nevertheless find numerous references in the Mahayana texts to giving up one's life for others. To sacrifice one's life with the bodhicitta motivation ( the wish to achieve enlightenment for the sake of others ) is particularly excellent. To make such a vow, however, one's resolve must be strong and unwavering. Otherwise, there is a danger of regretting one's decision at the crucial time -- the actual moment of death.
There is a story, for instance, of a raka, or wrathful being, who came to test a practitioner's resolve. When he asked for his eyes, the practitioner plucked them out without hesitation. When asked for his right arm, he sawed that off and offered it, too. When he offered it to the raka with his left hand, the only one he had left, however, the raka got offended.14 At this, the practitioner lost his temper, destroying all the merit of his virtuous deed of generosity. Thus, we see that the motivation behind our actions must be both positive and stable.
( In the Chφd practice of the Tibetans, we also find the symbolic offering of the body. This is a visualization practice which, though vivid and realistic, generally does not entail the actual giving of organs and limbs. This symbolic ritual of offering our body parts to others is regarded as a very effective means of cutting through mental defilements, especially attachment to our physical components. In addition, it is seen as an excellent method for cultivating the perfection of generosity. )
In the Tibetan tradition, particular attention is given to an awareness of death and impermanence. That " death is definite, but the time of death is indefinite " is repeatedly reaffirmed. Only one breath separates us from the next life. If we do not reflect on death in the morning, we will waste the day; if we do not reflect on death in the evening, we will waste the night. Attention is similarly given to the actual process of dying. As in other Buddhist traditions, the so-called " self " is considered merely a name given to the grouping of the five aggregates. At the time of death these aggregates dissolve without leaving a trace. Only the very subtle, momentary stream of consciousness, imbued with imprints of the actions we have created, " travels " from this life to the next.
The state of mind at the moment of death is therefore considered of crucial importance in determining the quality of the next life. For example, to die in an angry state of mind will lead to a hellish rebirth. Thus, we find manuals such as The Tibetan Book of the Dead ( Great Liberation through Hearing during the Intermediate State ) which help to direct the dying person's consciousness through the bardo, or intermediate state between this life and the next.
Such guidebooks describe in vivid detail the stages of dissolution of the mental and physical elements during the death process. By learning to recognize these stages, including the terrifying visions and bizarre experiences that might be encountered, we can train our minds intelligently and learn to die consciously. Unless we are mindful during this process and can skillfully control our minds, we will simply be " thrown " by our karma into the next state of rebirth which, judging from our present performance, is likely to be an unfortunate one.
The length of the bardo, or intermediate stage, varies depending upon the person and situation. It is said to last anywhere from an instant to a period of forty-nine days. In the case of a sudden accidental death, the elements are said to dissolve quickly, the consciousness leaving the body and taking another rebirth almost immediately. In the case of an ordinary person dying a natural death, the bardo experience lasts from one to three days on the average. Among Tibetans, surviving family members will normally request a divination to determine the appropriate time for performing the sky burial or cremation. This is to ensure that the person's consciousness has already departed from the body. The family will also seek advice as to what prayers should be said for the benefit of the deceased.
In the case of serious Dharma practitioners, the bardo may last longer, affording numerous possibilities for realization and even enlightenment. It is in this sense that life is seen as preparation for the moment of death. If one has practiced meditation well and purified the mind of defilements, the clear light nature of the mind and the emptiness of all phenomena may be recognized during this interim and the individual liberated from bondage within the cycle of existence.
During my twelve-year stay in the Tibetan community of Dharamsala, India, cases of practitioners remaining in a state of meditation for several days after their heartbeat and breathing had ceased were quite common. One such person, my Tibetan calligraphy teacher, was a monk of Nechung Monastery named Sonam. Friendly and easy-going, he appeared to be just an ordinary monk doing Dharma practice and strolling to the bazaar everyday. When he remained for three days in meditation after death, however, everyone realized that he had actually been a great practitioner. Another well-known example, of Gyalwa Karmapa remaining in meditation after clinical death in Mt. Zion Hospital in Illinois, has been medically documented. Another astonishing case was that of the senior tutor of His Holiness the Dalai Lama, Kyabje Ling Rinpoche. When he passed away in Dharamsala some years ago at the age of 82, he remained in meditative equipoise for thirteen full days, an event that was witnessed by countless people.
Tibetans, in any case, reason that it is important not to touch or distract a dying person, lest the person become upset or distracted and the death experience be disturbed. Greed for possessions, grasping at loved ones, and especially anger are to be avoided at all costs. Once the pulse and breathing have stopped, it is thought best to leave the body quiet and alone; prayers and positive thoughts for the person's welfare may be generated from another room. Interestingly, the law in California and a number of other states allows a body to be left in repose for three days after clinical death. In fact, we find that most religious traditions tend to leave the body lying in state for some days, and a period of three days is quite common.
If we accept, then, that consciousness does not end at the time of death, that a "person" may have valuable spiritual work to do in the intermediate period before the next life, and that it is best not to touch the body of a person undergoing this transition, we are faced with a dilemma. On the one hand, it is beneficial and an act of compassion to donate one's eyes, liver, and kidneys. On the other hand, it is important to evolve spiritually and to achieve a positive rebirth in order to benefit others physically and mentally. We are faced with the irony that, while a full-fledged bodhisattva may easily give up the entire body with no hesitation, a bodhisattva-in-training who has not perfected this selfless resolve may be wiser to avoid risking a disastrous rebirth due to undergoing organ transplantation at the time of death.
When I first asked Lama Karma Rinchen, the spiritual director of Kagyu Thekchen Ling in Honolulu, whether he thought it was a good idea to donate one's organs at the time of death, he immediately answered in the affirmative. " Definitely, " he said, " That is an excellent compassionate bodhisattva action. " When I questioned him as to whether the dying person's consciousness might not be disturbed by getting an organ cut out, he said, " That's OK. The doctors can wait for a few days. " When I said the doctors have to cut the organ out immediately in order to save the organ recipient, he gasped, appalled. " Fresh? They want it fresh ?!? " In the end, he concluded that for an ordinary person who believes the mind dies with the body, it is fine to go ahead with donating the organs. But for a Buddhist practitioner, it might be better to wait until the bodhicitta resolve is strong and stable. He himself would like to donate his organs anyway.
Admittedly, it is the quality of life that is critical, not necessarily the quantity. Tibetans say that virtuous people should live long, but that a short life is better for non-virtuous people, since there will be less time to commit negative actions. This leads to reflection on the quality of life of the organ recipient, the motivation for wishing to extend life, and the person's state of mind while waiting for a suitable organ to become available. If greed, grasping, and attachment are motivating factors in wishing to extend life, these unwholesome mind states will affect the recipient's quality of life and quality of death. Can we imagine the mental state of a recipient whose transplant is unsuccessful ? Moreover, honestly speaking, it must be a great temptation for medical practitioners to terminate the life of an organ donor prematurely in order to ensure a successful transplant.
Possibly in reaction to the extraordinary methods currently being used to prolong life artificially, there are many who advocate natural death, death with dignity, and mindful dying. Venerable Prabhasa Dharma Roshi of the International Zen Institute in Los Angeles, among others, has long dreamt of creating a Buddhist hospice setting which provides facilities conducive for spiritual practice at the time of death. She envisions creating a serene, meditative environment for the dying person and a nirvana hall simulating the Pure Land where a person can calmly make the transition to an enlightened realm undisturbed by medical paraphernalia.
This discussion leads to the larger issue of extending life. When we speak of using extraordinary means to extend life, what does extraordinary mean? Does that include blood transfusions? Who makes the decisions? Who physically pulls the plug?
Medical professionals make decisions such as these on a daily basis. For example, although it is general practice to attempt saving the life of a dangerously premature infant, there are a number of variables that enter into the equation. For the parents these factors may include the number of other children in the family, expense, and even gender. Economic variables may include whether necessary surgeries are being performed at private or public expense. Might it be that expensive surgeries are justifiable when the insurance company pays, but not in welfare cases? What about cases of multiple health problems? If an infant requires heart surgery ( to the tune of $100,000 ), it should be warranted regardless of economic status, but what if the child is blind, has Down's syndrome, and has missing limbs as well? What if the father is alcoholic and abusive, the mother is a prostitute with AIDS, and the child needs to be on oxygen indefinitely requiring constant nursing attention? These are some of the sticky wickets that health professionals are required to negotiate every day.
Another complex aspect of this issue that needs to be investigated is the nature of mind, its relation to the physical constituents, and the state of mind ( located at the heart, traditionally, for Buddhists ) in the case of organ transplants. What psychological adjustments or temperament changes are entailed when another person's organ is transplanted into one's own body ? These important bio-ethical questions need to be looked at from various religious and cultural perspectives, as well as the physiological and economic.
Last but not least, the issue of organ transplantation needs to be appraised in the larger global context. The irony of spending $100,000 or more to extend a life when the earth faces disastrous overpopulation cannot be ignored. That is a hefty expenditure to be made for a single human being when 40,000 children starve to death every day and the number continues to increase exponentially. What is the wisest and most compassionate way of dealing with these harsh realities? What would the Buddha say?
11 : In the Buddhist context, a sentient being is any being with consciousness. Thus fish are sentient beings, but not plants, though plants may have sentient beings closely associated with them.
12 : Maitreya : ( Sanskrit: From maitri, loving-kindness | Tibetan: Jampa) The Buddha To Come, prophesied to be the Teacher of the next age.
13 : Avalokitesvara ( Chinese: Kwan Yin | Japanese: Kannon | Tibetan: Chenresig ) represents the compassion of all the Buddhas.
14 : In India, there is a stigma attached to the left hand since it is used for certain unclean bodily functions.
Karma Lekshe Tsomo is an assistant professor of Theology and Religious Studies at the University of San Diego, California teaching classes in Buddhism and World Religions. She studied Buddhism in Dharamsala for 15 years and completed a doctorate in philosophy at the University of Hawaii with research on death and identity in China and Tibet.
She specializes in Buddhist philosophical systems , comparative topics in religion, gender issues in Buddhism, and Buddhism and bioethics. Her work includes research and publications in the areas of women in Buddhism, death and identity, Buddhist monasticism, Buddhist/Christian dialogue, and the western adaptation of Buddhism.
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