WHEN I RETURNED to the United States after fifteen years in Asia, many American colloquialisms were new to me. I often had to ask people to explain the significance of one slang expression or another. When I heard some young motorcycle riders referred to as “organ donors,” a friend explained that people with young healthy bodies riding motorcycles without helmets were prime candidates for the kinds of serious head injuries that would result in the surgical transplantation of their vital organs to others. Reacculturation 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 spectacle of a Buddhist nun driving a motor vehicle would be met with incredulous horror in an Asian Buddhist country, 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 work for Sakyadhita (The International Association of Buddhist Women), 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 this very new concern.
To begin with, all Buddhist schools agree that nothing is dearer to a sentient being than its life. In fact, reverence for life is taught in nearly all religious traditions and can itself be deemed a definition of spirituality as, for example, among 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.
The question of organ transplants has created a furious debate and is partly responsible for the newfound prominence of the field of medical ethics. Starkly touching the most crucial issues of life and death, the discussion elicits deep, instinctive responses on all sides. Therefore, it is necessary to investigate all facets of the question from various cultural and philosophical points of view, including the ramifications for organ donors, medical practitioners, and organ recipients and their families.
Nowadays, with the globalization of almost everything, I thought it would be a good idea to ask Buddhist followers of various traditions how they felt about organ transplantation. I spoke with Japanese, Chinese, Burmese, Sri Lankan, Vietnamese, Tibetan, Canadian, and American Buddhists. When I asked, “How do you 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 slight hesitation or a perceptible glassing over of the eyes.
From the Buddhist point of view, the body, being merely a collection of five aggregates (form, feeling, perception, karmic formation, 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 it, since it is nothing but a heap of dead skin, bones, and flesh. 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—one, three, or eight days, depending on the country, the status of the person, and the wishes of the person’s family.
Mahayana informants 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 forsaken. The bodhisattva ethic, to sacrifice oneself for others, includes 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 Buddhist saints. For example, there is 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 Manjushri, the Bodhisattva of Wisdom.
In China, textual references to sacrificing the body were often taken literally. Occasionally, a young monk would burn off a finger or two as an offering to the buddhas and a symbol of his dedication to the welfare of sentient beings. Since Chinese culture in general declines to sever any part of the body for any reason, such a sacrifice was viewed as a powerful symbol of renunciation. 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, he or she should be willing to undergo a few minutes of discomfort on his or her account. Once in a while this custom even led to self-immolation. I remember seeing signs posted around a particularly attractive site at Pu-tou-shan, the sacred “Potala mountain” of Avalokiteshvara (the Bodhisattva of Compassion) in China, that said “Please do not immolate yourself here” and “Sacrificing of fingers and other body parts forbidden.”
Human rebirth is so precious, however, that 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. Yet, while taking the life of sentient beings is prohibited, we find numerous references in the Mahayana texts to giving up one’s life for others. To sacrifice one’s life with thebodhicitta 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 raksa, 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 raksa with his left hand, the only one he had left, however, theraksa got offended. 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 chod visualization practice of the Tibetans, we also find the symbolic offering of the body to assuage the hunger of harmful flesheating spirits with the motive of preventing harm to others. Though vivid and realistic, this practice 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. To die in an angry state of mind, for example, will lead to a hellish rebirth. Manuals such as The Tibetan Book of the Dead help direct the dying person’s consciousness through the bardo, or intermediate state between this life and the next. Such texts 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. If our untrained minds lapse into habitual patterns of fear, anger, and attachment, our rebirth 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 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 is thought to last 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 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 every day. When he remained for three days after death in meditation, however, everyone realized that he had actually been a great practitioner. Another well-known example, Gyalwa Karmapa’s 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 H. H. Dalai Lama, Kyabje Ling Rinpoche. When he passed away in Dharamsala some years ago at the age of eighty-two, 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 bother 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 states allows a body to be left in repose for three days after clinical death. In fact, most religious traditions tend to leave the body lying in state for some time, 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, kidneys, and other organs. 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. That is an excellent compassionate bodhisattva action.” When I questioned him as to whether the dying person’s consciousness might not be disturbed by the surgery to remove an organ, he said, “That’s okay. 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. “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 organs. But for the Buddhist practitioner, it might be better to wait until the bodhicittaresolve is strong and stable. He himself would like to donate his organs anyway.
In Theravada Buddhism also, great importance is attached to the state of mind of a person at the moment of death. The customary attitude toward death stresses the importance of a mind free of craving, hostility, and agitation, since a peaceful, kindly state of mind is conducive to a happy rebirth. Hence, reflection on the three marks of existence—suffering, impermanence, and no-self—is considered the best preparation for the moment of death. And although the Theravada doctrine of personal salvation rejects the notion of transfer of merit from one individual to another, prayers and sutras are frequently recited at the deathbed in the belief that these rituals effect a higher rebirth for the deceased.
Theravada Buddhists generally believe that a person takes rebirth immediately after death. Nevertheless, in Burma, a Theravada Buddhist country, the body of the deceased is washed and left undisturbed for several days before the funeral is held. The funeral service, performed by monks, consists of chanting the refuge, giving the five precepts, reciting the Metta Sutta (the sutra on loving-kindness), and delivering a sermon. The service ends with transferring the accrued merit for the benefit of the deceased. The corpse may then be either buried or cremated.
Although normative Theravada doctrine teaches that the consciousness has already departed, monks are invited to hold services for seven days after the funeral. On the seventh day, they perform a special ceremony believed to facilitate the transition of the person’s consciousness to the next rebirth. In an expression of folk beliefs, friends reside in the house throughout this period to protect the family from the person’s ghost and assure its departure from the village. Annual memorial services are held thereafter, with the merit dedicated to the departed.
Reverend Shunko Sakai trained for many years at Aoyama Nisodo, an exemplary Soto Zen training center for nuns near Nagoya. For five years now she has continued her Zen practice while serving the needs of parishioners of the Soto Zen Mission in Honolulu, where she frequently performs funerals and commemorative services. She explains that most Japanese would not want to donate their organs after death because, like the Chinese, they prefer not to cut open the body. This preference for leaving the body intact is influenced by Shinto thought, she assumes, or possibly by Taoist ideas. A Buddhist, she feels, should not be concerned with what happens to the dead body, since life has already ended. She would be willing to donate her liver, kidneys, and other organs after she dies. “No problem. We cannot say what happens to the consciousness of the dead person or know if it continues to a future rebirth. That is out of our control.” She considers the Buddhist teachings concerning rebirth in other realms of existence—the heavens, hells, the animal realm—an example of skillful means, an expedient device to prod beings on the path. “We have no way of knowing whether such realms actually exist. Speculation on such things is foolish and irrelevant to practice.”
In Zen, she explains, we concentrate on the present moment. The past is finished, the future has not come, so we are only concerned with now. Would most Zen practitioners in Japan agree with her ideas? Would they also be willing to donate their organs when they die? “Intellectually, they would probably agree that there is no harm in cutting the body once the doctors declare a person dead,” she says. “But emotionally, they would prefer to keep the body intact. That is how human beings are. They may understand things intellectually, but when the time comes they submit to fear. It is believed that the consciousness leaves the body at the moment of death, yet the Japanese custom is to wait for at least one day before cremating the body. In fact, it is against Japanese law to dispose of the body within twenty-four hours after death. A priest may be requested to perform the funeral anytime after that, and once the funeral has been held, the body may be cremated. There is no prohibition against touching the body, only a taboo against cutting it up. There are no teachings concerning an intermediate state and no practices related to guiding the consciousness in the after-death state.”
Roshi Robert Aitken, respected both for his Zen practice and his concern with social issues, responded to questions in a similar way. He would gladly donate his organs to others if they could be of benefit. Since the person is dead, the organs have no other usefulness and may as well be of some service. At the same time, he admitted, we have no way of knowing what happens to the consciousness after death, so it is wise to be open-minded regarding the possibilities.
As Zen practice emphasizes, it is each moment of life that is of concern, not necessarily the quantity. Tibetans contend that long life is valuable only for the virtuous; the non-virtuous would be better off with a short life, with less time to create negative actions. This leads us to reflect on the quality of life of organ recipients, the motivation for wishing to extend life, and the state of mind of those waiting for a suitable organ to become available. If greed, grasping, and attachment are motivating factors in wishing to extend one’s life, these unwholesome mind states will affect both the quality of one’s life and the quality of one’s death. Can we imagine the mental state of a recipient whose transplant is unsuccessful?
A responsible decision by individual Buddhists on these bioethical questions requires that we view them from various practical angles, as well as the religious and the cultural. What psychological adjustments and temperament changes ensue when an organ from one person’s body is transplanted into another? How do we weigh the benefits of generosity and compassion against the possible danger of an organ donor’s rocky transition to the next life? How is it possible to judge whether one’s altruistic motivation will remain stable enough at the moment of death?
The profound dilemmas raised by these new medical procedures seem to multiply as we look more deeply into these questions. We must also consider the potential abuses by medical practitioners and organ procurers: a donor’s life might be prematurely terminated, these procedures may be performed to gain repute or funding, there may be biases against disabled or economically disadvantaged recipients. Economic issues plague medical practitioners daily: is a procedure more or less justifiable if it is privately or publicly funded? Can we in good conscience support a very costly procedure to sustain an individual life while thousands die of starvation?
What is the wisest and most compassionate way to deal with these life-and-death concerns? Precisely because there are no teachings in the sutras that specifically answer these questions, Buddhists must exercise their own dharma wisdom. This responsibility places us at the crossroads between the wisdom of the ancients and the harsh realities of modern life.