The Development of Indigenous Hospice Care and Clinical Buddhism in Taiwan
The Development of Indigenous Hospice Care
and Clinical Buddhism in Taiwan
Jonathan Watts & Rev. Yoshiharu Tomatsu
Published in Buddhist Care for the Dying
and Bereaved.
Edited by
Jonathan S. Watts and Yoshiharu Tomatsu
(Boston: Wisdom Publications, 2012) in
collaboration with the Jodo Shu Research
Institute (JSRI)
繼續閱讀請點選下面這個數字 [26.9.23]
Introduction
As we have seen in the opening chapters of
this volume, although Japan is considered a
predominantly Buddhist country with a long
and deep tradition dating back to the 6th
century, Buddhism has been in decline in
the modern era. The advance of modern, secular
culture has driven it out of most public
places and facilities. Taiwan, on the other hand,
presents us with an interesting comparative
case in that it too has inherited a deep
Buddhist tradition from Mainland China as
well as developing a strong modern, secular
culture from both the west and Japan.
Taiwan, as a relatively new nation, however,
exhibits some fascinating trends in the
development of Buddhism in the social sphere.
With the weight of ancient Chinese
traditions being somewhat lighter in this
new nation state and little influence from
communist China’s strong anti-religious
sentiment, Taiwanese Buddhism has been able
to recreate itself and its role in society.
Since the 1960s, a number of large and
prominent, new Buddhist denominations have
arisen in Taiwan, most conspicuously the
“Four Mountains” of Fo Guang Shan, Tzu Chi,
Dharma Drum, and Zhongtai Temple. They have
revived a rigorous monastic study and
practice that has been largely lost in
Mainland China and given birth to the strongest
movement of fully ordained women
(bhikkhuni) in the Buddhist world. At the same time,
these groups have developed very robust lay
memberships. In general, this revival
movement has paralleled Taiwan’s rise as
one of the Asia’s economic tigers. In this way,
many Taiwanese, monastic and lay together,
find no apparent separation or alienation
between their Buddhist faith and practice
and their daily lives and work. Indeed, many of
these new Buddhist organizations have
promoted civic participation and volunteerism as
a core value to their monastics and lay
followers. These trends are in great contrast to the
wide chasm between the Japanese Buddhist
world and mainstream Japanese society.
2
In this chapter, we will look at one of the
most compelling forms of this
integration of Taiwanese Buddhist practice
and modern, secular culture in the Clinical
Buddhism movement. It is fair to call this an actual movement as the training and
dispatch
of Buddhist monks and nuns in hospice
and end of life care has spread throughout the
country and is being sponsored by numerous
different medical and Buddhist
organizations. In this chapter, we will
focus on the most prominent and compelling
example of this work based out of Taiwan’s
largest and most prestigious hospital, the
National Taiwan University Hospice and
Palliative Care Unit.
Preparing the Ground
The National Taiwan University Hospice
(NTUH) and Palliative Care Unit was the first
public unit established in Taiwan in 1995,
after private hospices had been established at
the Christian Mackay Memorial Hospital in
Tamsui in 1990 and the Catholic Cardinal
Tien's Hospital in Hsindian in 1994. At
this time, Prof. Rong-chi Chen was the Vice
Superintendent of NTU hospital and had
become aware of the need for Buddhist
monastics to be involved in patient
care. He explains, “Although spirituality
doesn’t
necessarily pertain to religion, if
religious representatives can become fully involved, the
spiritual care that they could provide
would be much more effective.”1 Prof. Chen also
notes that Christian denominations have had
specific training for chaplains to serve in
hospitals and other places yet Buddhist
groups have not. As 70-80% of Taiwanese are
Buddhist, he and his colleagues thought it
would be good to identify some enthusiastic
monks and nuns to begin such training. The
major obstacle they discovered, however,
was that Buddhist monastics were not used
to working in such intensive medical
environments. Eventually, everyone in this
first training group of candidates dropped out.
From this experience, Prof. Chen and his
colleagues realized they needed a systematic form of chaplain training.
In the previous year, 1994, a group of
people from Buddhist universities, both ordained and lay, created the
Buddhist Lotus Hospice Care Foundation (BLHCF) to promote hospice and
palliative care and Life & Death Education. Prof. Chen was serving as the
President of the BLHCF and together they began a systematic plan for a
full-fledged clinical Buddhist monastic,
hospice training program. They asked Dr.
1 The Lotus Blossom: The Clinical Buddhist Monastics Practicing in Hospital Sites, DVD
(Taipei, Taiwan:
Buddhist Lotus Hospice Care Foundation,
August, 2009).
1 Ching-yu Chen, the Head of the Department of Family
Medicine at NTU Hospital who oversees the NTU Hospice, to design, coordinate,
and run this training program. Dr. Chen sees himself as a mediator helping to
merge Buddhism and medical science and to provide monastics with proper
clinical training. He remarks that 10% of the Taiwan
population is now elderly but that this
will climb to 20% in the next twenty years. In this way, the issue of death is
becoming increasingly important, yet education about life should also be
developed. Thus, Dr. Chen feels monastic clinicians with their grounding in a
traditional and deep understanding of life based on Buddhism can offer Taiwan’s
industrialized society something very
important in these coming years.
2 Finally, Ven. Huimin, the President of Dharma Drum Buddhist
College, was brought in as Dr. Chen’s spiritual, clinical counterpart. With the
support of the Buddhist Lotus Hospice Care Foundation (BLHCF), they began an
initial three-year period of preparatory work in 1995 that focused on
developing doctrinal and teaching standpoints from Buddhism for hospice and
palliative care. Besides training and supporting Buddhist clinical chaplains,
BLHCF also works to educate the larger public through seminars on
death and dying issues. This education of
the general public is equally as important as some Taiwanese, like Japanese,
fear the site of religious professionals in the hospital as harbingers of
death. Eventually, this collaboration between NTUH, the Buddhist Lotus Hospice
Care Foundation, and Ven. Huimin an other Buddhist monastics led to a national
program for training monks and nuns in hospice and terminal care through the establishment
of the Association of Clinical Buddhist Studies in 2007. The mission of
this
association is:
1. To integrate medicine with Buddhist
studies, develop a spiritual care model indigenous to the culture of Taiwan,
and enhance the quality of palliative care for terminally ill patients.
2. Plan and host research activities,
education programs, and training courses with a focus
on clinical Buddhist studies.
3. Incorporate hospice/palliative care and
life education as integral components of health
promotion activities and courses.
4. Assist in the professional education of
clinical Buddhist chaplains and expedite
2 The Lotus Blossom.
4 ongoing development and research.
Developing an Indigenous Spiritual Care
Model
The senior doctors at NTU who established
this hospice, specifically Dr. Chen, received a strong influence from the
hospice tradition of the United
Kingdom after visiting and studying at St. Christopher’s
hospice with Cecily Saunders. They have also been influenced by hospice care in
Hong Kong and Singapore, which has also been influenced
by the U.K. hospice movement. The deputy
superintendent of NTUH, Prof. Rong-Chi Chen who established this hospice,
received a strong influence from the hospice traditions of Japan after visiting
several hospice and palliative units in Japan in 1994. On the other hand, Ven.
Huimin has been one of the leaders in the group to develop an indigenous
spiritual care model that better suits the style of Taiwanese culture that is predominantly
Buddhist. At the same time that NTUH was set up in 1995, Ven. Huimin and his
colleagues began to look for a pattern and vocabulary that would fit the
cultural
background of Taiwan and the needs of this
region. Defining “Clinical Buddhism” was an important first step, and
they eventually developed the following one: Clinical Buddhology is the
contemporary excellence of integrated medicine with the Buddha’s
teachings for end of life care. This work
covers six areas: 1) end of life suffering, 2) death preparation, 3) life
meanings and affirmation, 4) clinical practice of the Buddha Dharma, 5) fear of
death, and 6) spiritual and life education.
3 Another important task was addressing the
differences in the occidental and East Asian view of the person and the self.
Ven Humin explains that when the idea of “whole person care” was introduced to
Taiwan, medical care was developed that addressed “physicality, mind, and
spirit.” This type of occidental thought, which typically sees the human as
consisting of body, mind, and spirit, puts a greater focus on “spiritual care.”
For example, in cases regarding the administering euthanasia, Ven. Huimin remarks
that we often find two emphases: one that separates the person into body and
mind; and a second that focuses on a
“spirit” that transcends the body and exists separately. If we follow the
explanation that the essence of life is nothing but the body and mind, then
curative medical care that prolongs life will be emphasized, for example, in the
case of a patient with terminal cancer.
3 Ching-Yu Chen, “End of Life Indigenous
Spiritual Care in Taiwan: Foundation for Clinical Buddhology”
(lecture, National Taiwan University
Hospital, Taipei, September 28, 2009).
4
In contrast, Buddhism sees the person as
consisting of body, feeling, mind, and dharma (i.e. the Four Foundations of
Mindfulness 四念住 as taught in the Satipatana Sutta). This approach focuses more on
“awareness care” than “spiritual care.” The two
core Buddhist teachings of Not-self and
Dependent Origination offer a different view of life from the ones that posit
the separate existence of a “true self” or a “spirit” that eternally never
changes, or the idea that the body and mind both totally extinguish at death.
From the viewpoint of Buddhism, the essence of life comes down to a middle way of
seeing the reality of life as neither total extinction nor everlasting
eternity. Following
this middle way of thinking, besides the
body and mind, there is an object (not a “spirit”) that can experience absolute
illumination of the dharmas of reality, law, and duty. Further, the necessary
condition for the arising of “mind” is “feeling,” which changes in suffering and
happiness and in life and death. In terms of hospice care, euthanasia and
assisted death can be performed in accord with the concern for the person whose
feeling and mind
are experiencing unsuitable symptoms and
levels of pain. Through deeply recognizing the four aspects of a patient, their
own body, feeling, mind, and dharma, they can develop a keen awareness and
equanimity. By practicing this kind of “awareness care,” we can help the dying
person to purify their mind and at the same time enter the dharma of the fundamental
practice of Buddhism.
4 Ven. Huimin and this Clinical Buddhist
working group have developed a process for engaging in such “awareness care”
based on the Buddha’s Four Noble Truths as follows:
1) Suffering: Because of the comprehensive
suffering of a terminally ill patient, clinicians must engage in “truth
telling,” that is, inform the patient and their family of the patient’s terminal
prognosis. At NTU Hospital, they push doctors to engage in such practice, and approximately
50-60% of patients do know their prognosis. In Taiwanese culture,
however, 80% of families tend to not want
to have this information communicated to the patient.
5. Since they feel this is essential at
NTUH, they communicate such news through a family conference with the patient,
family, and the entire clinical team assigned to that
4 Huimin, “The Cultivation of Buddhist Chaplains
Concerning Hospice Care: A Case Study of Medical
Centers in Taiwan,” trans. Jonathan Watts
(lecture, Dharma Drum Buddhist College, Taiwan, September 29, 2009).
5 Chen, “End of Life Indigenous Spiritual
Care in Taiwan.”
6 patient.
2) The Cause of Suffering: If a patient’s
health continues to deteriorate, they are encouraged to accept death. On a
passive level, this means that in working with a patient’s physical and mental
pain and suffering helping them come to an acceptance of death can help relieve
this pain. On a more active level, such an acceptance of death can lead into
seeing death as part of the continual
learning process of the journey of life. In this way, the team tries to fulfill
the patient’s final wishes and to affirm the meaning and value of their life
(strength from inside), and to affirm the care of the medical team (strength
from outside)
3) Nirvana: The end of suffering happens in
the development of a sense of spirituality, which in passive terms means
achieving relief of physical pain and tranquility of mind, and in active terms
means a change in one’s behavioral patterns through cultivating Buddha nature,
nurturing compassion, and letting go of possessions. In the following
chapter on Thailand, we will see a similar
emphasis on the potentiality of the person to continue to grow spiritually in
their final days even as their bodies completely deteriorate.
4) The Path to Nirvana: The path involves
the practice of Buddha Dharma, which in passive terms means the feeling of
being guided towards salvation, and in active terms means one’s own attainment
of salvation. The result is a “good death,” which includes awareness of death,
accepting it peacefully, preparing properly including arranging one’s
will, and timing the death appropriately.
Dr. Ching-yu Chen recalls one patient
suffering from terminal oral cancer as a good illustration of this above
process. The primary care Buddhist chaplain in this case designed many survey
methods to communicate with the patient and to evaluate his
physical and mental conditions everyday.
The patient had his first contact with Buddhism upon arriving for palliative
care at NTUH, but quite shortly he became a very active practitioner, either
reciting Amitabha Buddha’s name or listening to the dharma talks on
tape everyday. He developed great
confidence in Buddhist chaplain’s care and dreamed one night that the chaplain
led him to Amitabha’s Pure Land. On the day before his death, he took formal
refuge in Triple Gem of Buddha, Dharma, and Sangha, even managing to chant out
loud through his severely damaged throat. On the day of his death, his
consciousness was very clear. About an hour
and half before his death, he knew his time was coming and under the guidance
of the Buddhist chaplain, he lied on his bed and peacefully passed. Dr. Chen
notes that this patient re-affirmed their belief that
palliative care provides one of the best
chances for spiritual cultivation not only for patients and families but also
care staff. For the care staff, the patient becomes a teacher, for them in how
practice dying. Dr. Chen concludes that the Palliative Care Unit “is a
vihara or practice hall (道場) that encourages
the patients, the relatives, and the team members to grow together.”
6 Clinical Monastic Training Program
In 1998 the training program for clinical
Buddhist chaplains began. The Buddhist Lotus Hospice Care Foundation sponsored
this initial training. They continue to support these students and the already
certified chaplains with small stipends for transportation, since it is
considered that monks and nuns should not receive salaries. Monastics ranging
in age from 28-40 participate in nurse medical training and receive academic
credentials. The
program lasts of over five years with more
than sixty hours of hospice and palliative care study. Candidates are first
interviewed about their motivation and education level and then are selected
for the program. The training consists of four stages:
1. General Education: a twenty-eight hour
course delivered by the experts in the hospice care team on the meaning of
hospice and palliative care and the roles played by each and every one of the
care team, which includes physicians, nurses, psychologists,
social workers, monastics, and volunteers.
2. Shared Courses: a 16-hour course open to
Buddhist monastics and also to clinical professionals, which communicates the
definition and meaning of spiritual care developed in their research system and
how it works.
3. Profession 1: a 14-hour course for only
monastics who have undergone the first two courses. It covers key issues for
working in hospice and palliative care environments, such as “How does
spiritual care work?”; learning how to read, understand, and make
use of a patient’s medical record; how to
use Buddha Dharma to care for the patient and what dharmas are frequently used.
4. Clinical Internship: a 4-week course in
which the monastic must be involved in one
6 Ching-Yu Chen, “Clinical Buddhist
Chaplain based Spiritual Care in Taiwan” (lecture, International
Association of Buddhist Studies Conference,
Dharma Drum College, Taiwan, June 25, 2011).
8 complete case. They must keep records of
their dialogues with patients that are then given critical comments and
suggestions by the instructors and professors. There is then an assessment of
the student’s qualities as to whether they are fit for the work.
After passing this assessment, they may
proceed to clinical training in which the monastic participates in fuller
practice as a member of the care team. The clinical experience follows a
self-learning, problem oriented model. The trainee should continuously assess
what problems need to be solved and evaluate carefully
problem-solving priorities. During the
process, they observe and determine themselves
whether they have to go further. They are
supported in this process through small group
discussion and sessions focused on the
integration of clinical medicine and Buddha
Dharma with leading staff at NTUH.
Over the last ten years, seventy-three
monastics have been involved in the training
program, beginning with just two in the
initial year of 1999 but quickly growing to
seventeen by 2002. By 2009, twenty-nine had
completed the full internship, all of whom
are now working as clinical monastics in
hospice and palliative care wards across the
country, such as at Chungshan Medical
University Hospital, Chinese Medical University
Hospital, and Veterans General Hospital
Taichung.
Bhikkhuni Tsung-Teung was the first
monastic to be trained in this program,
under the guidance of Dr. Ching-yu Chen,
and is now the Secretary General of the
Association of Clinical Buddhist Studies.
She has been a nun since 1987 and has been
involved in this training since 1999. She
recounts that she had a hard time adjusting from
a monastic environment to a hospital one.
She had to learn how to interact and
communicate with people in a way very
different from interactions at the temple. At first,
this is a big challenge for monastics. The
monastic clinician must learn to refer to the
physicians and nurses to find out about the
patient’s family and about their needs as well.
By developing a relationship with the
family, they can better make a connection with the
patient. The monastic clinician also
develops a care plan, which is re-evaluated and
altered as needed before continuing on.
Despite these challenges and new skills that must
be learned, Ven. Tsung-Teung says that the
role of religious professionals in a hospital is
an ordinary thing. She notes that patients
will usually ask more from a religious
professional than from a nurse or social
worker and that 71% of patients will ask for
9
spiritual care from monk or nun.7
Bhikkhuni Der Chia completed the training
in 2005 and became chief instructor
responsible for training and assisting Ven.
Tsung-Teung at NTUH. Ven. Der Chia also
speaks of the difficulties for monks and
nuns to learn how to do this kind of work. She
says that many monastics, even high level
ones, may just offer the dying very standard
phrases like, “Just think positive.”; “You
have to let go.”; “You cannot do anything now.”;
“Just try to clear your mind for Birth in the Pure Land of the West.”
She says that, “Before
I came to the training program, that was
the method I used to treat a patient. Even though
I knew that at that time and situation this
method was incorrect, I was at a loss for what
was the correct thing to say and
consequently had a lot of apprehension … When
speaking those phrases, I feel like I’m
walking upon clouds with a large sense of
disconnection. Even to the point that when
I finish those phrases, I feel very sad deep
down.” This way of dealing with a patient
may often neglect their needed emotional
support and recognition. Thus, in the
training program they learn how to listen and to
empathize with the patient’s predicament
and then guide them through a more realistic
process of their eventual death.8
In this way, the program has the stated
goal that every fully trained monastic
clinician must have the following
qualities:
Possesses a full understanding of hospice and palliative care
Respects medical teamwork and the need to develop various clinical
skills
Capable of rendering care as a listener, supporter, and provider of
new ideas
Enthusiastic and eager to serve people as a life-death explorer
These competencies, especially the shift
from the method of preaching for a temple
minister to the method of listening for a
hospital chaplain, are fundamental points for the
training of chaplains, which we have seen
across cultures in the chapters presented in this
volume.
Building a Team Care System
At NTUH, there are seventeen beds, which
are almost always full and are predominantly
for cancer patients who are at or after
stage four. Liver cancer and lung cancer are the
7 The Lotus Blossom.
8 The Lotus Blossom.
10
most common forms. ALS patients are also
admitted, though these cases represent only a
very small rate of 1%. Taiwan’s national
insurance system limited public hospice care to
these two diseases until September 2009
when it expanded care to cover almost all
terminal illnesses, such as the terminal
stages of organ failure to the brain, heart, lung,
liver, or kidney. Seventeen days is the
average stay at the hospice, and this short period is
partly because of the misconception by
people of what palliative care means. There is still
fear and stigma among Taiwanese behind
being admitted to a hospice, so many do not
want to come any earlier. At NTUH, they do
not perform resuscitation, and the patient’s
family must sign a waver upon their entry.
In Taiwan, such decisions are still usually the
role of the family, since many Taiwanese,
like Japanese, do not believe in “truth telling”
to the patient. In this way, the patient
may not really know they are dying when they are
first admitted to the hospice. Dr. Rong-chi
Chen and the NTUH team have thus been
promoting the Do Not Resusciate (DNR) advance
directive in order to change both the
modern medical culture of heroism and the
traditional Chinese culture of filial piety that
chooses saving a person’s life at all costs
over compassionately guiding them to death.9
NTU Hospice has two senior doctors on call
out of a pool of fourteen. There are
two to three 3rd year residents, who do a
two-month residency and a one-month home care
residency. There are seventeen nurses, one
per bed as by national regulation. There are
also three to four clinical psychologists
who are still in training and shift every six months.
They do psychological assessments, give
advice to the team on care, and deal with patient
depression and anxiety, etc. They will also
seek help from their supervisor who may come
to the hospice to assist. There are two art
therapists who do bereavement support and help
for the families as well as the patients;
for example, supporting an elder sister who was
feeling neglected by her parents because
they were attending to the younger sister who
was dying. The art therapists may guide
patients in copying pictures of Kannon
Bodhisattva, and the patients may add their
thoughts to these pictures or actually speak to
Kannon through them. There is also the
sense of traditional Buddhist making merit from
copying such pictures. There is a pool of
seventeen to twenty monastic chaplains with
two to three on call in the ward at any one
time. The team is rounded out by a base of fifty
volunteers who work in shifts of five in
the morning and five in the afternoon. They assist
the medical professionals, cook food that
may include Chinese medicinal herbs, read the
9 Rong-Chi Chen, “The Spirit of Humanism in
Terminal Care: Taiwan Experience,” The Open Area Studies
Journal 2 (2009): 7-11.
11
patients books, help organize special
events at the hospice like concerts and birthday
parties, and help patients with special
requests like facilitating a visit by a particular
person or taking the patient on a final
visit somewhere.
The core principle of the NTU hospice is
“team care” amongst the doctors,
nurses, social workers, psychiatrists, and
clinical chaplains. Every Tuesday morning for
two hours the entire team goes on rounds
together to all seventeen beds. Dr. Chien-An
Yao, the Head Doctor and Director of the
NTU Hospice, relates that, “Our team does an
assessment of good death after each patient’s
death, usually every week, to audit the
quality outcome of the patients’ dying
process. At that time, clinical Buddhist chaplains
often give important information about
spiritual well-being. They also help the palliative
team learn how to approach a good death by
spiritual care.”10
Dr. Yao also notes that it has not been
easy to build this team care model. He
says in order to introduce this system,
they had to prove that spiritual care is effective. He
says that NTU medical students are the top
in the country, and they have a high level of
pride. They think education is very
important, so it was very important to make an
impression on them concerning spiritual
care. Therefore, this was another one of the key
areas of research in which they engaged
during the formational period of 1995-98. Dr.
Ching-yu Chen notes that no medical
education in Taiwan has tried to incorporate these
four aspects of holistic care: the
physical, social, psychological, and spiritual. Taiwanese
medical doctors generally do not learn
about spirituality at all in their medical training.
Therefore, they have difficulty facing
death and talking to the dying. Palliative care
training exposes them to these issues. Dr.
Yao notes that mutual respect for the rest of the
team by the doctor is a key element, and
now every doctor at NTU hospital must study
end of life care. However, in other hospice
units around the country, the lack of a
complete care team that includes chaplains
and doctors trained in engaged in holistic care
means that an inordinate amount of the
emotional and spiritual care of patients falls on the
nurses. In this way, some hospices, like
the Buddhist Tzu Chi Heart Lotus Palliative Care
Unit at Tzu Chi General Hospital in Taipei,
cannot operate at full capacity due to a
shortage of nurses who are reluctant to
enter such a demanding field.
Indeed, stress and burnout are common
problems among clinicians working in
10 Chien-An Yao, “Spiritual Care in
Palliative Care Team” (lecture, 24th General Conference of the World
Fellowship of Buddhists, Tokyo, Japan,
November 15, 2008).
12
this field. Priests and doctors,
especially, tend to neglect their own health. They work hard
for their patients but neglect their own
well being and development and in turn the well
being of the team. Dr. Yao says that,
“Ongoing involvement with dying and bereaved
persons may cause a severe drain of energy
and uncover old and new spiritual issues for
the caregiver. As such, spiritual
education, growth, and renewal should be part of a staff
support program as well.”11 In this way,
NTUH feels it is important to teach and develop
such self-care. NTUH team members will
often consult the monastic chaplains when they
have their own personal problems. Nurses
attend spiritual care programs for their own
well being. However, since doctors tend to
avoid such issues, they have started to include
such issues and study as part of the training
for medical students. 6th year medical
students take courses in spiritual studies,
ethics, and counseling as basic knowledge in
their education, while also studying
outside of class in the NTUH ward. Concerning
self-care for the monastic clinicians
themselves, Ven. Tsung-Teung says there is training
for chaplains to control and deal with the
strong emotions that come up in hospice work.
The Lotus Foundation and the Association of
Clinical Buddhist Studies have also created
their own internal counseling sessions. As
an extension of the team care building work,
the NTUH team participates in an internet
video conference every two weeks with
palliative care units around the country at
which they present case reports like truth telling
and informed consent, symptom control,
spiritual care, and success and failure stories.
These conferences began twelve years ago
with only four hospitals but have now grown
to include forty.
Medical Ethics and the Final Moment of
Death
As in the Tibetan Buddhist tradition,
Chinese Buddhists believe that moving the
deceased’s body or causing any abrupt
environmental change will disturb the deceased
subtle consciousness. Thus, the body should
not be disturbed (in some cases even not
touched or moved) for at least another
eight hours after it has gone cold. The part of the
body where warmth lingers until the rest of
the body has become cold is called the Gate of
Death in the sense that the consciousness
finally leaves the body through this spot. Its
relative position on the body is believed
to indicate to which realm the consciousness has
11 Yao, “Spiritual Care in Palliative Care
Team”.
13
migrated. In general, higher spots on the
body such as the crown of the head indicate
heavenly realms while lower ones such as
the feet indicate unfortunate realms.12
In this way, it is ideal for a person to
die in a sitting posture so that the
consciousness may more easily leave the
body from a higher place. In contrast, dying in
sleep, in unconsciousness, under the
influence of drugs, or in other such abnormal or
violent ways is dangerous to the migrating
consciousness. The state of mind of the dying
person is considered most crucial to their
transcendence or rebirth. Therefore, the family
should withhold expressions of grief that
will disturb the dying and offer them
encouragement. As done in the Japanese Pure
Land tradition, many Chinese practice the
Death Bed Ceremony (臨終行儀) in which a monk
and groups of laypeople come to
chant the name of Amitabha Buddha for the
benefit of the dying person. In East Asia,
there is a strong popular belief that says
Amitabha Buddha will arrive at the moment of
death to guide the deceased towards rebirth
in his Pure Land. However, since the dying
person may be too lost in the pain of death
or their own delusion, all persons involved in
the moment of death should chant Amitabha
Buddha’s name to assist the dying’s
transcendence. Voluntary groups, usually
called “Help Chant Group,” and even audio
tapes may be used to continue with the
chanting of the Buddha’s name.13
In this regard, one of the distinctive
innovations of the Buddhist terminal care
movement in Taiwan is the spiritualization
of dying rooms in hospices in both private and
public hospitals. Regulations in Taiwan
require that hospices and palliative care units
have a special room to move patients for
their final moments. However, it was a Buddhist
chaplain at the NTUH who came up with the
idea for putting up a large painted image of
the Amitabha Buddha to assist in the
special deathbed practice outlined above14. These
rooms are also used for special counseling
and for housing religious images for people of
different faiths to pray. NTU hospital also
developed special rooms in the basement called
literally “Room for Rebirth in the Pure Land” (往生室), which have
become common in
12 Yutang Lin, “Crossing the Gate of Death
in Chinese Buddhist Culture,” in Living and Dying in Buddhist
Cultures, eds. David W. Chappell &
Karma Lekshe Tsomo (Honolulu: School of Hawaiian, Asian, and
Pacific Studies, University of Hawaii,
1997) 94.
13 Lin, “Crossing the Gate of Death in
Chinese Buddhist Culture”, 97. 14 For more on the use of Buddha images and
paintings in Pure Land Buddhist deathbed practices, see
Never Die Alone: Birth as Death in Pure
Land Buddhism, eds. Jonathan Watts and Yoshiharu Tomatsu
(Tokyo: Jodo Shu Press, 2008).
14
hospitals across Taiwan. Here the
deceased’s body may remain undistributed for the
traditional period of eight hours during
which Buddhist priests, family, and also members
of the care team may join together in the
chanting of Amitabha Buddha’s name. There is
also a room for observances by families who
are not Buddhist. For westerners used to
morgues that are nothing more than a room
of drawers for dead bodies or for Japanese
who’s Buddhist sectarianism and general
social secularism have led to the elimination all
vestiges of religion from hospitals, this
spiritualization of death is incomprehensible in a
public medical facility.
Organ Transplants & Grief Care
Unfortunately, this belief and practice of
not disturbing the body after death has also been
an impediment in Japan and Taiwan to the
modern medical practice of organ transplants
and of donating organs at death by common
citizens. In Japan, organ donation by
common citizens is not a common practice
and can be problematic. In general, Japanese
Buddhist organizations and priests have
been very slow to develop adopt more modern
views on such practices. It was this way in
Taiwan until recently when certain Buddhist
institutions and teachers, such as Master
Cheng Yen and the Tzu Chi Buddhist
denomination, began promoting organ
donations and transplants as a bodhisattva act of
compassion and self-sacrifice. Indeed,
numerous well-known Tibetan Buddhist masters,
who share the same tradition of leaving the
dead body undisturbed, have commented that
the power of a person’s intention to help
others with their leftover organs will protect and
override the negative influences of
disturbing their body in order to harvest the organs.
15
In this way, many Taiwanese Buddhist
organizations have begun to support and promote
organ donation by their followers. NTUH
supports this movement as well through
holding an annual, large memorial service
for all patients who have donated their bodies
for research or organ transplants. The
families and monks are invited to attend as well.
The Tzu Chi Buddhist denomination has taken
this movement a step further by
encouraging whole body donation to their
new medical school through their Silent
Mentors program that began in 1996. Because
of the Chinese and Taiwanese traditions of
“maintaining a whole body” and “being buried,” there has always been
a lack of cadavers
for medical study in Taiwan. The founder of
Tzu Chi, Master Cheng Yen, responded by
15 This view is expressed by the great
Tibetan Buddhist master, Dilgo Khyentse Rinpoche, in Sogyal
Rinpoche, The Tibetan Book of Living and
Dying (San Francisco: HarperSanFrancisco, 1994): 383-84.
15
trying to shift this traditional culture to
a new one grounded in the Buddhist ethics of
compassion and self-sacrifice. She notes
that, “We do not own our lives. We only have the
right to make use of them…. Turning the
useless corpse into teaching materials is a
liberating experience from life and death
as well as the wisdom of knowing how to teach
selflessly.”16
Tzu Chi Medical College does not simply
collect these bodies and use them in
the typical way that most hospitals and
medical schools use cadavers. They have
instituted a highly creative and systematic
method of putting teachers, students, bereaved
families, and the bodies of the donors in
intimate contact to encourage the development of
what they call “humane doctors.” Using the
cadaver as a basis for not only imparting
medical learning but also emotional and
spiritual learning, Tzu Chi has coined the phrase
“Silent Mentors.”
Before beginning the Gross Anatomy course
at Tzu Chi Medical College,
students will visit the families of the
donors on whom they will operate to learn more
about their lives. They look at photos and
listen to stories by the family members.
Afterwards, the family members provide a
photo of the donor, and the student writes a
short biography of the donor, both of which
are posted on the program’s website, in the
hall outside of the dissection room, and in
front of the dissection table itself. At the
beginning of the course, an opening ceremony
of gratitude is held that includes the
families of the donors. A Buddhist funeral
rite is conducted at this time in order for the
bereaved family to have peace of mind and
for the donors to rest in peace. The ceremony
is then moved to the medical operating
classroom for surgical simulation, where the
donor’s bodies are uncovered, and the
bereaved family members may face their departed
loved ones for the last time. The medical
students are actively involved in this moment,
learning to be present and to comfort these
families. In turn, the family members may also
ease the nerves of the young students by
reminding them of the vow of their loved ones to
be used for this very purpose. This
personal connection with the donor’s bodies and their
families is meant to emotionally move and
thus encourage the students to develop
themselves as more humane doctors.
The students will use this one personalized
cadaver for the whole semester.
Then, at the end of the semester, the
students sew up the bodies, redress them in clothes
16 Silent Mentor. DVD (Hua Lien, Taiwan:
Tzu Chi University, 2009).
16
and shoes, and place them in coffins. A
public funeral ceremony with the coffins is held in
front of the medical school attended by
Buddhist nuns, the school president, faculty,
students, volunteers, and the bereaved
families. After cremation, the students and the
families attend an internment ceremony for
each individual’s ashes at a special shrine
called the Great Giving Hall housed within
the medical college itself.
The comprehensive nature of this program
shows the great meaning that can be
created from building not just Buddhist but
general spiritual mechanisms into the often
alienating, secular culture of modern
medicine. The program clearly has a powerful effect
on the students who are deeply exposed to
the emotionality and spirituality connected
with medical work—an aspect that is usually
totally neglected in modern medical
education. The effects span out further in:
1) providing the dying with a sense of meaning
to their deaths and personal value that
will extend beyond their deaths; and 2) providing
bereaved families a sense of continuing
value to their loved one’s lives as well as offering
them a very profound form of extended grief
care through participating in the program.
Conclusions and Future Directions
The NTUH, Buddhist Lotus Hospice Care
Foundation, and Association of Buddhist
Clinical Studies program has developed
monastic clinicians who are serving all over the
country. This work has now been expanded to
include another hospital besides NTUH
where monastic candidates can train. The
Jinshan Hospital, located on the northern coast
near Dharma Drum Temple and Buddhist
College where Ven. Huimin serves as the Dean,
became an official branch hospital to NTUH
in 2010. They have one hundred beds in a
rural setting, which contrasts NTUH’s
downtown Taipei setting. With a more natural
setting and fresh air, this hospital will
specialize in patients with chronic diseases as well
as supporting a hospice and palliative care
unit. With its location within eyesight of
Dharma Drum Buddhist College, it will also
be tied into the educational program for
monastics at the college.
This is a development of which Prof.
Rong-Chi Chen would like to see more.
He says that in recent years there are many
freelance monastics engaging in this issue of
terminal care but that there are no
systematic programs being run by the large monasteries
and denominations, like Tzu Chi, Dharma
Drum, Fo Guang Shan, and Zhongtai Temple.
He feels that as these temples have major
Buddhist universities, chaplaincy and clinical
studies should be incorporated into the
curriculums. Such curriculums would encourage
17
and guide some students into the profession
since after their university training they could
directly proceed to internship. Prof. Chen
feels that this role should be provided by these
major Buddhist universities and not the
Buddhist Lotus Hospice Care Foundation, which
struggles to fund this work. BLHCF has an
assembly of different Buddhists who appeal to
society for donations, and the new
reductions on income tax for making such donations
have made doing so more popular, especially
at the end of the fiscal year. However,
without the generous donors behind the Foundation
who come from the laity and general
public, this work could not continue as
hospital insurance does not pay for chaplains.
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