Session 3: Buddhism and Science—Buddhist Practice and Science-Based Functions that
Address Physical and Mental Health

Medical Ethics and Buddhism—
A Focus on Euthanasia and Death with Dignity

Yoichi Kawada
Translated by Shin’ichi Hashimoto

I. Introduction: Medicine and Bioethics

I

N the dialog between contemporary science and Buddhism, the areaof bioethics has become critically important as advances in modern
medical technology create increasingly complex situations. This is anarea where views on human life, ways of thinking about life and death,and the dignity of human life have to be directly addressed.
Medical science and medical treatment have a long history, and in theEast, this is also true in Buddhist medicine. There are numerous references in Buddhist texts related to medical practices. However, the advances in modern medicine have come so far, that we face many issues
today that could not be imagined in the ages when those Buddhist texts
were written. One reason for this is because the advances in the areas ofgenetics and molecular embryology within life science and the field of
neuroscience have been implemented into practice at a rapid pace.
How should contemporary Buddhism respond to the current issues inbioethics which have been created by developments in medicine lead byadvances in life science and neuroscience? This is not only a question
posed to Buddhists, but to all other religions as well.
In addition, this question interconnects an incredibly wide variety of
specializations. For example, to name areas related to the bioethics ofbirth, there is the issue of artificial termination of pregnancy, in-vitro
fertilization, surrogate motherhood, genetic treatments, as well as embryo stem cells, iPS cells, and cloning. On the other hand, areas related
to the bioethics of death are euthanasia, death with dignity, persistent59

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vegetative state, suicide, brain death, organ transplants, terminal healthcare and palliative care to name a few.
Within all of these issues, only abortion, euthanasia and suicide are atleast somewhat mentioned in Buddhist texts, but even so, the contexts
for these issues have dramatically changed since the days they wereoriginally written. For example, the issue of euthanasia, which is one of
the central themes in this paper, has already shifted in focus to dying
with dignity.
This paper will discuss the dignity of human life in the realms of birthand death (as well as in the context of birth, old age, sickness and death)and how varied the areas of modern day medical ethics are. I will propose that all of these areas require deeper consideration, by elucidating
why life is inherently respect-worthy. The issues of euthanasia, deathwith dignity and a persistent vegetative state (PVS) will receive particular focus.

II. Dignity for Human Beings—From Euthanasia to Deathwith Dignity
Euthanasia and death with dignity are similar in that they both present
an approach to medical practice in the terminal stages of patient careand push the limits of medical technology. However, there is also an
important difference. Whereas in euthanasia, the patient is conscious
and the focus lies in lessening or alleviating physical pain, death with
dignity focuses on whether or not to extend the life of patients who
seem to have lost their dignity as a human being, including those whoare in a vegetative state.
Here lies the divide between euthanasia and death with dignity. First,
I would like to discuss issues surrounding euthanasia. Depending onwhether the patient’s free will is taken into consideration, euthanasia canbe divided into two categories: voluntary euthanasia and involuntary(forced) euthanasia. When the will of the patient is ignored, forced
euthanasia results in a situation such as Nazi Germany. Therefore, inthe present day, when discussing euthanasia and death with dignity,
it is under the presumption that consent has been given by the patient.
The next division is the difference between active euthanasia and passive euthanasia. Active euthanasia is “the shortening of a patient’s life asa result of the administration of a lethal substance by a physician inorder to alleviate pain caused by a terminal illness.” This narrow definition of euthanasia is usually what is meant in general use. In contrast,
passive euthanasia is “the termination of life-extending measures ofmedical ethics and buddhism

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patients with an incurable disease or in an unconscious state,” whichis also referred to as death with dignity in contemporary terms.
In Japan, the four stipulations under which active euthanasia by aphysician is accepted are based on a 1945 decision by a Yokohama
court.
1. The patient is suffering from intolerable physical pain.
2. Unavoidable death of the patient is imminent.
3. All other measures to alleviate or lessen physical pain havebeen exhausted.
4. The wish to shorten life is explicit and consented to by thepatient.
However, from the 1970s, discussions about active euthanasia havegreatly shifted in focus to facing death while preserving one’s dignity as
a human being, in other words, death with dignity.
This has resulted from advances made by pain clinics. Shuhei Morita
comments on the current state of pain clinics, “We have not completely
uncovered all the mechanisms concerning the origins of pain, or thepaths in the nervous system along which the signals for pain travel.
However, methods for reliving or eliminating pain have advanced tremendously. Traditional approaches using nerve blockers or other drug
therapies were the norm, but in recent years, improvements in traditional
methods have been made, as well as the increased use of electric stimulation therapy and Eastern medicine approaches. The WHO’s Cancer
Pain Relief published in 1996 lists examples of various approaches…
Using these approaches, about 95% of the pain experienced can be reduced.”1 In other words, the first stipulation referring to “intolerablepain” experienced by the patient has been made irrelevant, and it ishoped that advances in this area will continue to be made.
Secondly, advancements in life-extending measures make it possible
to prolong life, but at the same time, create new questions such as how
to view death in terms of those in a vegetative state or in cases of brain
death. The invention of artificial ventilators has given rise to cases ofbrain death, and intravenous hyperalimentation (IVH), a method fordelivering high calorie nutrition to patients who cannot utilize theirdigestive tract, has given rise to the vegetative state and prolonged thelives of those in the final stage of cancer or an incurable disease.
When patients were seen lying in an intensive care unit, separated
from their families, being kept alive by a ventilator, people began tohave doubts as to whether this way of greeting death can be said to havedignity as a human being. Especially those in a vegetative state, withminimal consciousness, and little prognosis for recovery, being connect-

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ed to a ventilator and being fed through an IV tube, it was difficult tomake a case that this was a dignified way to live, instead, lendingargument against the case for prioritizing the prolonging of life, andthus eventually led to the idea of death with dignity.
Death with dignity directed the discussion toward the quality of life
(QOL) of the patient and also heightened awareness of the patients’right to self-determination. In addition, the relationship between physician and patient also underwent a change from a paternalistic model toan equality model, where the physician aids patients as they fight illness
together. From this arose “informed consent,” or the right of the patient
to choose their treatment based on information of all the choices available, and advocacy for this approach gained momentum. The American
Hospital Association adopted a Patient’s Bill of Rights in 1973 and theWorld Medical Assembly adopted the Declaration of Lisbon on the
Rights of the Patient in 1981, clarifying the right of death with dignitywith informed consent playing a central role.
In summary, on one hand, as the struggle to overcome physical pain
continued as outlined above, life-extending measures and IVH createdsituations of brain death or vegetative states. The issue of the patient’s
right to self-determination has become an important issue in preserving
dignity as a human being. This modern day phenomenon has prompted
the death with dignity approach, often executed in the form of a living
will.

III. The Condition of People in a Vegetative State
When considering the issue of death with dignity, the situation of people
in a vegetative state is brought up as a point of discussion. It should beclarified that in this discussion about death with dignity that we arereferring to those in a persistent vegetative state (PVS). This section
examines the current conditions surrounding such patients.
The definition of those in PVS is as follows, “after experiencing
severe brain damage, the state of being alive, but showing very little
response to external stimuli.” In 1972, the Japan Neurosurgical Society
issued the following six guidelines for determining cases of PVS. If apatient fits these guidelines for over three months, that person is said tobe in PVS:
1. Unable to move about on one’s own
2. Unable to ingest food on one’s own
3. Experiencing a state of incontinence
4. Although may be able to say something, communication ismedical ethics and buddhism

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unintelligible
5. Although may be able to open one’s eyes or slightly respondby squeezing someone’s hand when prompted, no further
intelligible exchange can take place.
6. Although the eyes are able to follow objects presented to them,
the patient does not indicate any recognition of that object.
In most cases, the patient is unable to continue in this state, and theircondition usually worsens over time. Consciousness becomes unclear,breathing becomes irregular, eventually requiring a ventilator to breatheand tubes are inserted to deliver nourishment.
Shinichi Kogure, a brain researcher, comments on the vegetative statefrom a cerebral biology standpoint saying, “There is no doubt thatpatients (in PVS) are alive. Primitive functions such as self-defense
mechanisms, maintaining posture, reflexes, breathing, circulatory
functions and body temperature are regulated. Cycles of sleep andwakefulness can also be detected. Therefore, from a broad view, thebrain stem and spinal cord are functioning at least minimally. In
contrast, expressions of instinct such as hunger and sex, emotional
responses such as anger, fear, pleasure or displeasure, and moreover theability to perceive or react on one’s own to external stimuli and otherhigher order functions are lost, indicating serious failure of the cerebral
neocortex or cerebral limbic system…On the other hand, it is not always
the case that a vegetative state results only from extensive damage to the
neocortex or limbic cortex. Dysfunction of the white matter (the nerve
fiber which connects the cortex to the brain stem) can also cause similar
symptoms. Therefore, it is extremely difficult to pinpoint the damage tothe part of the brain which is causing the vegetative state, and likewise,
it is difficult to say whether damage to particular sections of the brain
will definitely induce a vegetative state or not.”2Many specifics about the state of patients in a vegetative state are still
unknown. According to one study carried out by the Japanese Ministryof Health and Welfare3, it was reported that about 50 percent of cases result from failure of blood vessels within the brain such as hemorrhages,
subarachnoid hemorrhages or strokes. The other half result from damage
or trauma to the brain, brain tumors, or drug addiction. The population
affected most by natural causes are men in their 60s and 70s, whereas
many of those in a vegetative state due to brain damage are in their 30s
and 40s.
The duration of vegetative states for those suffering cerebral trauma,considering the number of cases of survival from three months to one
year as 100 percent, the number of survivors after two years is 55 per-

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cent, and after three years only 30 percent. This decrease is due mostly
to death, but there are rare cases where patients survive for more than 10
years or even revive from the vegetative state, although not to a fully
restored condition. Most cases of revival are reported to be younger
patients who suffered brain trauma.
The variety of symptoms experienced are also wide-ranging, making
it difficult to narrowly define it, or to say with any certainty how patients
will progress over time. The range of symptoms includes the possibilityof those with extensive damage to the cerebral cortex or cerebral limbic
cortex to recover, unlike those who are brain dead and have no hope of
becoming functional ever again. In addition, recent brain research has
revealed that beneath the superficial states of consciousness or ability torecognize stimuli, what has been called an “inner consciousness” may
be functioning at a deeper level.
Dr. Tatsuya Mima lists functional magnetic resonance imaging(fMRI) as “one of the non-invasive technologies that allow for the imaging of brain functions. This technology has opened a new era of discussions on medicine and ethics as it relates to people in a vegetative state,as this is very often connected to the issue of death with dignity.”4
In a 2006 Cambridge University study conducted by Dr. Adrian
Owen, the following was discovered5.
A 25-year-old female patient who had entered a vegetative state as aresult of a traffic accident in July of 2005, underwent an fMRI, during
which she was asked to envision playing tennis and envision walking
around her room at home. Her brain activity revealed similar patterns as
those doing the corresponding activities (tennis and walking around
one’s room have very different patterns.) In regards to this result, Mimasays, “despite the fact that this young woman was in a vegetative state,
unconscious and unable to physically move, she was able to follow the
prompt, and imagined doing these two different tasks in her mind.” Thiscase seems to indicate that although patients may be in a vegetative
state, partial consciousness (inner consciousness) still exists, suggesting
the possibility of providing some kind of “inner experience” forpatients.
The second case presented by Mima introduces the discovery of the
Minimally Conscious State (MCS)6. This condition is one in which a patient despite having persistent disturbance of consciousness, can manage
to show signs of an active mind or the possibility of communication.
Regarding the diagnostic criteria for MCS, a patient is able to do one ormore of the following:
1. follows simple instructions

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2. indicates yes or no through physical action or using language
3. makes comprehensible output
4. shows purposeful action (laughing or crying when appropriate,
responding to questions with a physical or verbal response,
attempts to grasp something, touching or gripping a particular
item, or to stare or follow something with one’s own eyes, etc.)
In Japan, the ability to follow simple instructions and to follow something with one’s own eyes is included in the diagnosis of PVS.
Mima comments on a case presented by Owen where one year afteran accident, a patient stared at their reflection two times after being presented with a mirror. He writes, “This case recounts the slow but steadyprogress of a patient developing their abilities from a vegetative state to
MCS. The core reason for developing high-tech medical equipment forbrain research is to not marginalize those in a vegetative state simply
because they are unconscious, but to provide a means for detecting
even the smallest evidence of minimal consciousness, so that better careand support can be provided to patients in clinical care.”7
The clinical application of fMRI seeks out minimal consciousness
within patients in a vegetative state to help open paths of communication. Supported by this hope, efforts will continue in the direction ofcollecting more and more examples from these kinds of cases.

IV. Buddhist Viewpoint and Approach(1) Regarding Euthanasia
First, to understand the base of Buddhist thinking about euthanasia, I
would like to take up some relevant examples from early Buddhist texts.
Of course, the state of development of medical procedures in theseexamples take place under conditions where today’s advanced Western
medicine is completely absent, therefore take place in a completely
different setting. Put simply, there were no artificial ventilators to extend
the lives of patients, or pain clinics to help manage pain. Only traditional Indian medicine (Ayurvedic medicine) was available at the time.
However, learning from Shakyamuni’s teachings concerning thesufferings of illness and death, we can gain insight into the Buddhist
approach to modern medical situations.
Please also note that the following examples take place within thesamgha, the body of Buddhist followers, and are not specific instancesof a doctor dealing with a patient per se, but an approach toward euthanasia can be gleaned from the actions of the monks and laypersons that

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appear in the narrative.
A monk became very sick, so a second monk asked him, “How is
your illness? Will you be able to endure the suffering?” The sick monk
replied, “No, I am not coping well, so could you please provide me witha sword or rope or poison?” The second monk honors the sick monk’s
request, and then, the sick monk takes his own life. Seeing this, the second monk is overcome with remorse, and together with Ananda, seeks
an audience with the Buddha. The Buddha, upon hearing the news, reprimands the second monk saying, “How foolish of you! How could you
provide another with the means to take their own life?” As punishment,that monk receives the strictest punishment, which is expulsion from thegroup—for violating a påråjika8.
In a different section of the text, another monk refuses the request of asick monk to provide him with a sword or poison to take his own life,
but instead, asks a hunter to take the life of the sick monk. Here again,
the Buddha says, “It should not be that one asks another to aid in thetaking of life,” regarding this also as a grounds for expulsion from the
Buddhist Order9.
From these examples, it can be seen that even if a person desires toterminate their own life, to provide them with the means of doing so, or
asking someone to help terminate another’s life, is among the gravest ofoffenses.
The times have greatly changed from Shakyamuni’s time to that ofcontemporary medicine, however, in the spirit of Buddhism, to desire
death as a means of escaping physical pain or suffering, in other words,
voluntary active euthanasia, is not acceptable. Even if the aim is to takeaway someone’s suffering to give them peace, ending a life is not an
option as treatment.
In Buddhism, suffering is divided into three categories according totheir characteristics. The first kind is physical suffering, in other words,
physical pain. The second kind is psychological or mental suffering. The
third kind is the suffering caused by death itself, or rather the fundamental pain of knowing the impermanence of our existence as a humanbeing.
These three sufferings are all encapsulated within the suffering of
those who contemplate an early death. Experiencing intolerable pain diminishes human dignity very quickly. Physical pain is closely linked
with psychological pain, and feed off of each other to multiply theeffect, heightening our awareness of the reality of the third suffering,i.e. the fear and unease that surrounds death.
Nowadays, more and more, physical pain can be controlled and inmedical ethics and buddhism

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many cases removed, without shortening our lifespan thanks to advancements made by pain clinics. Nevertheless, eliminating the psychologicaland mental suffering that magnifies physical pain requires utmost carefrom medical staff, a strong connection with family members andfriends, as well as a robust system of welfare and administrative support.
This is where the wisdom and care of Buddhists can play a vital role.
A more detailed description will follow later, but members of the SGI
Nurses Group (Shirakaba Group) endeavor to take the compassion andwisdom learned through the Bodhisattva Way of Mahayana Buddhism,
and put it into practical use.
The third suffering, which is a suffering embedded within all humanbeings, is most appropriate for religions to address. Buddhists shouldbase their interactions with patients and their families on Buddhist viewsof life, death and happiness. Overcoming worries and fears about deathand helping others achieve a serene state of life is the role of a Buddhist.
One keyword in contemporary terminal care is Quality of Life (QOL).
Buddhists, alongside health care professionals, have a responsibility to
improve the QOL of patients and their families.
(2) Regarding the Persistent Vegetative State
Next I would like to share Buddhist perspectives on patients in PVS,
as this is strongly linked with the discussion on death with dignity. Understandably, it is extremely difficult to find portions of Buddhist textthat refer to this condition, because a vegetative state and brain deathcan only occur when life-prolonging machines such as ventilators are introduced. This condition of the final stage of human life simply did notexist before the implementation of new medical technology. Therefore,
in order to introduce Buddhist principles that can be applied to approaches to PVS and brain death, I turn to the ideas presented by theConsciousness-Only (or Representation Only) school in the Mahayana
Buddhist tradition.
Vasubandhu10, in The Thirty-Stanza Treatise on the Consciousness-Only Doctrine, states that in the deepest regions of life, lies a“cosmos of the mind” which manifests in three forms of consciousness.
Namely, from the fundamental base of the alaya-consciousness, arises
the mana-consciousness, and from there the sixth sense (the mental
consciousness), and finally the five senses. For the purposes of this presentation regarding vegetative states, I will focus the discussion on “thefive senses and the mental consciousness” and the mana-consciousness.
Professor Koitsu Yokoyama, a Buddhist scholar, explains the functions of the mental consciousness and mana-consciousness in the68

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following way:
“In addition to the superficial ego consciousness (a.k.a. the mental
consciousness) which regards the fusion of the five aggregates as theself, it was discovered that there is a deeper consciousness at thesubconscious level. That deeper consciousness is what we referred toearlier as the mana-consciousness.
The main function of the mana-consciousness is to recognize the existence of an even deeper consciousness, the alaya-consciousness, andregard all that arises from the alaya-consciousness as ‘the self’ and toform an attachment with that ‘self’…The shallower superficial ego consciousness which can manipulate concepts and observes one’s mind or
body, thinks that the observable mind and body is the ‘self’—it keeps
telling itself, ‘this is me, this is me’ on a day-to-day basis. In contrast,
even a person in a vegetative state (whose superficial ego self is incapacitated) due to a traffic accident, still seeks nutrition and continues to try
to maintain the self, proving that at a deeper subconscious level, there issome sort of attachment to the self that drives the will to continue living.
In the Representation Only school, we refer to this function as theseventh, or mana-consciousness.”11
In summary, the sixth level of consciousness (the superficial egoconsciousness/mental consciousness) is the self-consciousness which
can manipulate concepts, and the seventh level of consciousness(mana-consciousness) is the fundamental ego consciousness which liesin the deeper layers of our psychology. Yokoyama points out that the
mana-consciousness is active even in individuals who are in a vegetative
state.
From the perspective of brain research, Kogure comments on theConsciousness-Only view saying,“Thinking about the issue of patients in a vegetative state, especiallywhen evaluating the condition of a patients’ ability to maintain
consciousness or awareness, we must be extremely careful in making adiagnosis. As explained earlier in the section concerning the definitionof a vegetative state, patients are able to breathe on their own and havecycles of wakefulness and sleep indicating a functioning brain stem.
Although difficult to detect, patients may be responsive in many otherways. Even in such a state, the fifth and sixth levels of consciousness are
partially at work. It is highly possible that the seventh level, which contains the characteristics of internal existence and universality, and thelevels of consciousness deeper than that may actually be more active in
PVS patients, just as the other senses become more acute in those withvisual and hearing impairments.”12

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According to Kogure, the fifth and sixth levels of consciousness are atwork, albeit incompletely, and does not deny the possibility that theworkings of the seventh (mana-consciousness) may be stronger than the
more superficial levels of consciousness.
Even though the functions of the fifth and sixth levels of consciousness become subdued, the seventh level (mana-consciousness) is still
functioning and if it is working stronger than normal, it means that thefundamental ego is optimally functional. In other words, the fundamental ego in PVS patients is striving to continue life.
Borrowing the words of the Consciousness-Only School, it can besaid that patients like those introduced in the previous section by Owen,
are people who are living in the sixth and seventh consciousnesses.
Examples of PVS patients living in the sixth and seventh levels ofconsciousness have been reported by nurses.
Yumi Nishimura reports the experiences of Nurse A. “The staff at
Nurse A’s workplace regard PVS patients not as people with impairments of their consciousness, but rather, as people with impairments intheir motor and nervous capabilities which make them unable to express
themselves. They care for patients with the understanding that they areaware, and Nurse A, of course, fully supports this approach.”13
In other words, patients in PVS are not lacking a consciousness, but
are experiencing disability in expressing their consciousness. Therefore,
communication between nurses and patients during one-on-one carebecomes possible. Nishimura introduces interactions between Nurse A
and Ms. Sumida, a PVS patient.
In regards to Ms. Sumida’s line of sight, Nishida writes, “Nurse A
said, ‘When I look into her eyes, I feel as though as she is looking backat me.’ ‘There are times when I feel our gazes meet.’ ‘I look at her eyes
as I talk to her, and her eyes seem to understand what I am saying toher.’ There are many instances when Nurse A feels that understanding
takes place in their exchanges.”14
There is another episode where Nurse A recalls a time when Ms.
Sumida laughed.
“One day, I caught Ms. Sumida yawning, and in the middle of her
yawn, I called out her name with a loud voice. Ms. Sumida’s mouth
stopped moving, and when I saw that, I said to her, ‘I surprised you,didn’t I?’ to which she responded by slightly raising the corners of her
mouth. I regarded this as a smile from Ms. Sumida.”15
There is another instance when Nurse A received a reply from Ms.
Sumida.
“Ms. Sumida was sitting up by herself on the bed, so I said to her,

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medical ethics and buddhism‘Su-san, you’re sitting up by yourself!’ to which she ‘replied’ by slightly
moving her head and giving me a look. Then I said, ‘If you can hear myvoice, please blink’ and Ms. Sumida blinked her eyes. I took that as a‘yes’.” 16These examples clearly show that through attentive care, nurses are
somewhat able to communicate with patients’ sixth and seventh levelsof consciousness.
Furthermore, among Jungian psychologists, there are those who claim
to have developed a way to “converse” directly with a patient’s
mana-consciousness. Arnold Mindell, who founded process oriented
psychology, developed a technique called coma work which aims toconverse with those in PVS.17
Mindell and his wife worked with Sam, a PVS patient, over thecourse of several weeks. They were able to establish communication
with him through Sam’s eye movements. When the Mindells asked Sam
whether he wanted to continue living, Sam gave the sign for yes, which
consisted of contorting his face and opening his mouth. Sam also
learned the technique of inner work from the Mindells, and relayed tothem that he was engaged in an inner trip. Sam conveyed to the couple
that in his fantasy, he was attempting to climb a mountain to meet withan unknown woman.
As can be observed from the above examples from brain research,
Jungian psychology, and the experiences of nurses, PVS patients can be
regarded as people trying to live in what Consciousness-Only scholars
refer to as the mana-consciousness.
The next question is how to care for patients in PVS. This issue began
receiving attention during the case of Karen Ann Quinlan in 1976.18
After the ventilator was removed, she continued to breathe on her own
and remained alive in PVS. She passed away in 1985 due to pneumonia.
Nishimura states her concerns regarding the changes in the medical
field after this case, “In the United States, there have been many important decisions handed down by the courts concerning terminal care. The
conclusions reached there indicate that when patients with incurable
conditions have the cognitive wherewithal to decide, they can chose notto receive life-extending treatment including nourishment and water ifthey so desire.”19
Nurse Reiko Inamitsu introduces the difference between “regulartreatment” and “special treatment” in the context of terminal care.
According to her, “providing nourishment through a tube” is included
in “regular treatment.” Therefore, discontinuing this means death forthe patient. “Special treatment” includes treatment such as the adminis-medical ethics and buddhism

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tration of antibiotics and the use of a ventilator. Inamitsu also states,“In the process of terminal care, it is the norm to cease treatmentsthat do not seem to aid the patient in a meaningful way—especiallythose of a ‘special treatment’ nature.”20
From the standpoint of the Consciousness-Only School, using a ventilator is critical in supporting the existence of the fundamental ego consciousness of patients in PVS and in those cases, should be employed as“regular treatment.” It goes without saying that traditionally recognized“regular treatment” should be continued in all cases, as ceasing this
discontinues life.
(3) Death with Dignity and Buddhist Nursing Care
Members of the SGI Nurses Group (Shirakaba Group) make efforts inproviding terminal care to patients, including those in a persistent vegetative state, using a Buddhist teaching approach. Many examples ofnursing care using a Buddhist approach exist, but here I will present justtwo cases.
The first case is of a seventy-six year-old female cancer patient S who
passed away after having overcome the three sufferings: 1) physical suffering, 2) psychological suffering, and 3) the suffering of knowing theimpermanence of our existence. She had bile duct cancer, which spreadto other parts of her body, and had received surgery for drain insertion.
The doctors predicted that she would live for about one more monthafter that. Patient S had helped raise four step-children from her husband’s previous marriage. Every week the children came to visit her.
After a successful surgery to remove the drain, she was able to leave thehospital and return home for a time. She completed some calligraphy
artwork and even had some of her work displayed in a city-sponsoredculture festival.
However, she had to be readmitted to the hospital and received an IV
into her central artery, and also had a urinary catheter, which highly
restricted her movement. It was during this time that a close friend ofpatient S helped locate her daughter, who she had not seen since she wasthree-years-old. They were able to have a moving reunion just threedays before she passed away.
Inamitsu writes of their encounter, “there was a long silence at first,
but then tears welled up in both their eyes, and with great effort, patient
S was able to say to her daughter, ‘Thank you for coming. I’m sorry,please forgive me. Please become happy!’ Emotions that were bottled
up for fifty years were released all at once. After that, she spent eachfulfilling day meeting with all the other people that she wanted to say

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farewell to. Finally, after asking those around her, ‘I don’t think there isanything left undone, is there?’ she entered a peaceful sleep.”21
The second example is of a patient in a vegetative state, and is similarin nature to the experience reported by Nishimura. This is an experience
related by Nurse B of the SGI Nurses Group about patient U who suffered from multiple brain tumors. After the surgery, patient U’s
consciousness would come and go, but for the most part, she was
unconscious the whole day. Despite this, Nurse B continued to talk topatient U while caring for her, saying, “You have just had surgery, so
please try to get better. Let’s talk again after you get better.”
However, her lack of prolonged consciousness continued for several
weeks, and she would go back and forth from being completely unresponsive to being drowsy. She was not able to move her body voluntarily, and was only able to show slight pain reflexes. Then, the night shift
nurse noticed some behavior which was reported to the daytime staff.
Patient U had her eyes open, and seemed to be looking up at the sky, butthen her eyes met with the nurse. Patient U suddenly said, “It’s not you,”after looking at the nurse’s face, and then seemed to point to anotherperson. Shortly after that, Nurse B switched shifts with the night shift
nurse. When she was changing patient U’s body position, patient U
called out, “It’s you. You were the one that was nice to me.” Nurse B recalls, “I was so surprised, that I asked patient U without thinking, ‘Do
you recognize me? Were you looking for me?’ I really felt the incredible
power of life, and I was filled with appreciation for patient U.”22 Patient
U’s mana-consciousness (fundamental ego consciousness) or the mental
consciousness registered Nurse B’s words, but until patient U’s level ofconsciousness rose to a higher level, she was not able to express her
thoughts. This was the last thing patient U said before passing away.
These two examples show that dignity of human beings is not dependent on whether or not someone is on a ventilator, or is receiving drain
treatment, or looks as if they are not conscious. It is the function of thethree sufferings that cause confusion in the mind which leads people
away from a “good death” or “death with dignity.”
Inamitsu presents four points of view regarding QOL that are essential in maintaining the dignity of human life:23
1. To be free of physical pain, and to have as much freedom of
movement as possible.
2. To feel secure and satisfied in the psychological aspect.
3. To be fulfilled and satisfied in the social aspect, by having thefreedom to exchange with family, friends and acquaintances.
4. To be fulfilled and satisfied in the religious aspect.

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Of these points, 1) is related to physical suffering. Today, this is thearea that pain clinics and other medical institutions specialize in. In thetwo examples of patients who overcame the three sufferings, this aspect
was under control. 2) and 3) are related to psychological suffering. The
range of social activities lessened compared to when they were healthy,
but they were able to continue communicating with their family, friends
and acquaintances. Until the end, both women were able to feel a senseof fulfillment and security, with appreciation and trust for those aroundthem.
In the first case, Patient S was able to fulfill her wish of once again
seeing her child after being separated for fifty years with the help of
those around her. In this way, her psychological suffering was overcome. Likewise, Patient U, who was in a vegetative state, was also able
to overcome her psychological suffering by having a chance to express
her appreciation to Nurse B before she passed.
Point 4) corresponds to the third suffering of coming to terms with
our own mortality. Overcoming this suffering is the role of religion. The
two cases introduced here are of patients who practice Buddhism. They
were able to completely overcome the real sufferings—insecurities andfears concerning death. As these two examples show, even if in a vegetative state, or receiving drain treatment or nutrition from a tube, bothpatients retained their dignity as human beings, and shining brightly,
they were able to accept death in a state of peace.
This was possible because they were able to overcome the three sufferings caused by earthly desires that arise from the three poisons(greed, anger and foolishness). Their minds, i.e. their mental consciousness and mana-consciousness, were centered on goodness and shinedwith the state of Bodhi (free from all greed, anger, and foolishness).
Buddhism defines the loss of dignity of human life as a mind controlled
by the three poisons, as this prevents the peaceful acceptance of death.
On the other hand, the condition of human life where a mind is ruled byfeelings of goodness such as serenity, wisdom, trust, and gratitude in themental and mana-consciousness enables a person to face death with
dignity.
The members of the SGI Nurses Group who carry out Buddhist nursing care, aim to provide assistance to patients so that they are able toovercome earthly desires such as insecurity, fear, dissatisfaction and afeeling of leaving something undone, and transform their minds to one
centered on serenity, fulfillment, gratitude, and trust. This exemplary approach to nursing improves the quality of life of patients and preserves
patients’ dignity as a human being.

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Notes
1
The Institute of Oriental Philosophy, ed. (2009) Daijou Bukkyou no Chousen (4)Aratana Seishikan wo Motomete ‹Jou› [Challenges by Mahayana Buddhism (4) Toward
a new view of life and death, vol. 1], The Institute of Oriental Philosophy, p. 133. trans.
from Japanese.
2
Soka Gakkai Ethics Research Group and The Institute of Oriental Philosophy, ed.
(2001) Anrakushi / Songenshi wo Doumiruka [How to view euthanasia and death with
dignity], Daisan Bunmei, pp. 48–49. trans. from Japanese.
3
Koseisho Shokubutsu Jotai Kenkyuhan [Ministry of Health and Welfare ResearchGroup on Patients in a Vegetative State] (1972–1976) (Group leader: Suzuki J., Professor of Tohoku University) trans. from Japanese.
4
Mima, T. (2010) Nouno Esshikkusu—Noushinkei Rinrigaku Nyumon [Ethics of theBrain—Introduction to Cranial Nerve Ethics], Jimbunshoin, pp. 107–8. trans. fromJapanese.
5
Ibid., pp. 118–9.
6
Ibid., pp. 122–3.
7
Ibid., pp. 123–4.
8
TaishØ ShinshË DaizokyØ, vol. 22, p. 7.
9Ibid., p. 8.
10Vasubandhu was a Buddhist scholar who appeared around the fourth century, roughly 900 years after the passing of Shakyamuni Buddha. He was from Northern India, bornin Purushapura in the country of Gandhara.—from (2002). the Soka Gakkai Dictionaryof Buddhism, Soka Gakkai, p. 801. The Thirty-Stanza Treatise on the Consciousness-Only Doctrine is thought to be his last work, in which the Consciousness-Only
philosophy is explained.
11
Yokoyama, K. (2002) Yuishiki Shisou Nyumon [Introduction to Representation-Only
Thinking], Daisan Bunmei, pp. 158-9. trans. from Japanese.
12
Soka Gakkai Ethics Research Group and The Institute of Oriental Philosophy, ed.,pp. 61–2.
13
Nishimura, Y. (2001) Katarikakeru Shintai—Kango Care no Genshogaku [Thestorytelling body—Study of phenomena in nursing care] Yurumi, pp. 16–7. trans. fromJapanese.
14
Ibid., p. 151.
15
Ibid., pp. 176–7.
16
Ibid., p. 177.
17
Mindell, A. (2002) Konsuijoutai no hitoto taiwasuru—Purocesu shikou shinrigaku
no aratana kokoromi [Conversing with people in a vegetative state—A new approach inprocess oriented psychology], Fujimi, Y. & Ito, Y., trans., NHK books, pp. 3–4. trans.
from Japanese.
18
Bai, K. (1976) Zoku Kaidai Karen Jiken—Supreme Court no Baai [Bibliography(part 2) of the Karen A. Quinlan case—From the perspective of the Supreme Court],
Jurist, v. 622. trans. from Japanese.
19
Nishimura, Y., p. 18.
20
Soka Gakkai Ethics Research Group and The Institute of Oriental Philosophy, ed.,pp. 201–2.
21
Ibid., pp. 77–9.
22
Shirakaba Group, ed. (1994) Inochi Gambare! Kango Taikenshu [Fight for life! Collection of experiences from nurses], Daisan Bunmei, p. 22. trans. from Japanese.

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23
Soka Gakkai Ethics Research Group and The Institute of Oriental Philosophy, ed.,p. 68.

Author Biography
Yoichi Kawada was born in Kagawa prefecture in 1937. He graduated from the University of Kyoto in 1962 and received his Ph.D. in immunology in 1968. He is also a recognized authority in Buddhist Medicine, bringing the insights of Buddhism to bear oncontemporary issues of bioethics, medical and clinical practice. In 1988, Kawada
was appointed director of the Institute of Oriental Philosophy. His publications include
Buddhist Thoughts on Symbiosis—And its Contemporary Implications (2010), The
Buddhist Perspective of Life and the Idea of Human Rights (2011), The New Humanism
for World Peace (2011), and Contemporary Civilization and the Lotus Sutra (2012).