How do clinicians reconcile conditions and medications?The cognitive context of medication reconciliationGeva Vashitz • Mark E. Nunnally • Yisrael Parmet •Yuval Bitan • Michael F. O’Connor •Richard I. CookReceived: 17 April 2011 / Accepted: 22 August 2011Ó Springer-Verlag London Limited 2011Medication omissions and dosing failures aresubjects matched conditions and medications rel
Deathandreligion.plamienok.skDescribing anything as ‘Buddhist’, including in this case law of the universe, and the acts that lead to bad karma, a distinctively Buddhist bioethics, is fundamentally prob- such as killing, stealing, lying, sexual misconduct and in- lematic from both a historic and Buddhist point of view. Historically, the Buddhist tradition has evolved in dozens The problem with Buddhist ethics as natural law is that of countries for 2500 years, with no one tradition having the soteriological goal is one of liberating oneself from the clear doctrinal authority over the others. Internally, even if constraints of karmic causality to become an enlightened a common Buddhist ethics was implicit in the practices of being. The traditional anthropological explanation of this the dozens of Buddhist cultures or the exegetics of their tra- paradox has been to ascribe the natural law ethics of kammic ditions, the core philosophical insight of Buddhism is that reward and punishment to the laity and the nibbanic path all things are empty of essential, authentic being, including of escape from natural law to the monastics (King, 1964; the Buddhist tradition. So, starting from the understanding Spiro, 1972). More recent scholars (for instance, Keown, that there is no authentic Buddhist bioethics to explicate, 1992; Unno, 1999) have challenged this dichotomy and ar- and only a constellation of practices and ideas related to gued that monastic ethics have always revolved far more medicine and the body among Buddhists throughout his- around the exchange of accumulated merits for alms than tory, which may or may not be tied to core ideas of the Buddhist tradition, we can interrogate the tradition for the Nonetheless, the Buddhist ethical tradition does argue lessons it may hold for contemporary bioethics.
for an escape from all mundane karmic constraints, and the illusions of material existence, to achieve a state of per-fect wisdom and compassion. Damien Keown, (1995) the BUDDHIST ETHICS
leading Western scholar explicating Buddhist bioethics, calls this a ‘teleological virtue ethics’. As in Aristotelian There is a vigorous debate among Buddhist scholars about virtue ethics, Buddhists are to strive for the perfection of a the correspondence of Buddhist ethics to the ethical tradi- set of moral virtues and personality attributes as their prin- tions of the West, and three traditions have the strongest cipal end, and all moral behaviour fl ows from the struggle resonances: natural law, virtue ethics and utilitarianism.
to perfect them. But unlike the Aristotelian tradition, the The Western natural law tradition holds that morality is ethical goal for Buddhists is teleological because they gen- discernible in the nature of the world and the constitution erally believe that a fi nal state of moral perfection can be of human beings. In the Buddhist cosmogony all sentient achieved. As virtue ethics, Buddhist ethics focuses on the beings cycle through multiple rebirths, infl uenced by their intentionality of action, whether actions stem from hatred, past moral behaviour, karma. When the Buddhist properly greed and ignorance, or insight and empathy.
understands the structure of mind, the effects of immoral In the Mahayana tradition the being who embodies these behaviour in creating suffering in this life and the next, and virtues is the bodhisattva, who strives to relieve the suffer- the importance of sila or moral discipline as the basis for ing of all beings by the most skilful means (upaya) neces- release from suffering, morality is the only rational choice. sary. As the bodhisattva is supposed to be insightful enough In this sense, Buddhist ethics are grounded in the natural to understand when ordinarily immoral acts are necessary Principles of Health Care Ethics, Second Edition Edited by R.E. Ashcroft, A. Dawson, H. Draper and J.R. McMillan 2007 John Wiley & Sons, Ltd to alleviate suffering, and it is either willing to assume the asserting that beliefs and practices that are shown to be karmic consequences or is not subject to the karmic conse- unscientifi c and not empirically supported should be set quences of such acts, the consequentialist utilitarian tradi- tion is also especially compatible with Buddhist ethics. The utilitarianism of J.S. Mill is most resonant with this interpre-tation of Buddhist ethics because Mill emphasized distinc- NO-PERSONHOOD ETHICS AND
tions between coarse and fi ne states of mind, weighting the REINCARNATION
contentment of the refi ned mind more heavily in the utility calculus than base pleasures. From a utilitarian approach, A basic, and nearly unique, aspect of Buddhist philosophy Buddhist moral precepts can be considered ‘rule utilitarian’ is its emphasis on the nonexistence of the self, anatta. Con- general guides to action, but not deontological absolutes.
sequently, one of the most fundamental Buddhist contribu- Some writers have also explored the compatibility of Bud- tions to be made to contemporary medical ethics will be in dhism with the ‘ethics of care’ articulated by Carol Gilligan (1982). Gilligan argues that women are more likely to draw The thrust of the no-self doctrine is complicated within on compassion in their moral reasoning, whereas men are the Buddhist tradition, however, by the doctrine of reincar- more inclined to employ ethical principles. Gilligan’s work nation. If there is no self, what reincarnates? The traditional is very resonant for those who see Buddhism as a ‘situation answer has been that the evolving constellation of mental ethics’ relying on direct intuition and empathic sensitivity substrates, the skandhas, causally encoded with karma, for appropriate behaviour, as teachers in the Zen tradition pass from one body to another but lack any anchor to an often do (Curtin & Curtin, 1994).
unchanging soul, just as a causal chain connects a fl ame passed from one candle to another even though it cannot be said to be the same fl ame. (The fi ve skandhas are the body, BUDDHISM AND MEDICINE
feelings, perceptions, will and consciousness.) Buddhist humanists and sceptics, most notably Stephen Batchelor From the outset the Buddhist tradition presents itself as (1997), have argued that the doctrine of reincarnation is not a clinical diagnosis of the cause of human suffering, and essential to Buddhist spiritual practice and that Buddhists a prescription for its alleviation (Duncan et al, 1981; Soni, have explicit doctrinal authorization to remain agnostic on 1976). The tradition does not set out divine commandments reincarnation and on all beliefs without empirical support. but simple statements about the dis-ease (dukkha) affl icting Buddhist agnostics note that, in the context of Buddhism’s human life, and the way the dis-ease can be treated. Although rejection of Hindu beliefs in an eternal soul, the teach- the emphasis is on a spiritual cure, Buddhism specifi cally re- ing on no-self is actually a negation of the importance of jects ascetic mortifi cation of the fl esh and accepts that medi- cine is necessary for monks and laity. Although the monas- Nonetheless, most Buddhists profess belief in reincarnation, tic code forbad monks and nuns from practising medicine, and belief in reincarnation shapes Buddhist practices and be- they were instructed to provide medicine to one another and liefs around abortion and dying. Interruption of the instan- to keep it at hand (Keown, 1995). The use of medicine for a tiation or transmigration of the reincarnating being, through longer, healthier life is in no way seen as incompatible with abortion or cadaveric organ transplantation, is therefore po- spiritual practice, but rather is seen as an aid for it.
tentially as harmful, and has as weighty karmic implications, Buddhism has blended with the medical traditions of each country in which it has taken root. Zysk (1991) and Mitra (1985) discuss links between early Buddhism and the Indian medical tradition of ayurveda, and in China ABORTION
and Tibet Buddhism mixed with traditional medicines and magic to create distinctive psycho-spiritual healing Certainly abortion has been generally disapproved of in practices and meditations. In the West, Buddhist-infl uenced Buddhist culture on the grounds that it is a form of mur- clinicians, such as Jon Kabat-Zinn and his Center for der. Traditional Buddhist beliefs about the exact timing of Mindfulness in Medicine, Healthcare and Society at the the instantiation of the reincarnating being in the embryo University of Massachusetts, are exploring the health or foetus are not doctrinal, however, but drawn from latter benefi ts of Buddhist meditation. The Dalai Lama, the exiled monarch of the Tibetan kingdom and head of the Some contemporary, and especially Western, Buddhist Gelugpa sect of Tibetan Buddhism, has been distinctive writers on abortion have argued for a more tolerant posi- among religious leaders in embracing the application of tion, on a number of grounds. First, if the moral status of the scientifi c method to the spiritual experience and in the embryo and foetus are contingent on the instantiation of a sentient being, then current neurophysiological evidence support the heart-death standard instead, but Keown em- that suggests that sentience only emerges late in foetal devel- braces the whole-brain argument that brain stem death opment would validate abortion up to that point (Barnhart, will quickly cause all other bodily functions to cease.) The 1998; Hughes, 1999). Keown (1999) argues against this neocortical view, on the contrary, would apply to people in point of view, emphasizing the moral importance of the the ‘permanent vegetative state’ such as the Florida cause creation of just the fi rst of the fi ve skandhas, the embry- celebre Terri Schiavo. In Buddhism and Death: The Brain- onic body. However, as Barnhart (1998). makes clear, the Centered Criteria, John-Anderson Meyer (2005) argues scriptures emphasize that a sentient being is created only that the neocortical understanding of death is ‘most in con- when all fi ve of the elements, including consciousness, are formity with general Buddhist doctrine’.
Some Buddhists reject even the whole brain defi nition of Moreover, insofar as Buddhism is similar to a utilitarian death, and resist any organ transplantation, on the grounds ethics towards general happiness, or an ethics of care, or an that tampering with the corpse in the critical days after ethics of virtuous intent, then the immorality of the abortive death may interfere with the transmigration of the skand- act of violence can be outweighed by the intentions of the has to their rebirth. The Japanese only adopted brain death mother and the greater suffering that it may prevent to standards after a protracted debate, with resistance partly mother, potential child and society. The Dalai Lama has ar- due to Buddho-Confucian veneration of ancestors (Lock gued, for instance, that although abortion is generally inap- and Honde, 1990; Lock, 2001). Other Buddhists have de- propriate, it may be permissible in cases of severely handi- fended organ transplantation on the grounds that it is the fi - capped foetuses that may suffer in life; ‘the main factor is nal compassionate act (Lecso, 1991; Tsomo, 1993) and even motivation’ (quoted in Tsomo, 1998). Additional consider- a means to acquire merit for a better rebirth (Hongladarom, ations would be the degree to which the mother had become pregnant and aborted carelessly, without suffi cient attention to the gravity of the act (Tworkow, 1992). Depending on Buddhists’ beliefs about the importance of consciousness to SUICIDE, EUTHANASIA AND THE GOOD
the moral status of the embryo and foetus, the intentional- ity of the actor and the consequences of the action, some Buddhists will therefore come to different conclusions on Buddhism has been seen by many Westerners to be indiffer- derivative issues such as the use of embryos in cloning and ent to death, or even to nihilistically valorize suicide. This stem cell research (Schlieter, 2004).
misconception is perpetuated by images of self-immolating Much attention has also been paid to the Japanese Vietnamese monks and disgraced samurai committing sep- Buddhist tatari rituals for aborted foetuses (mizuko) which puku (ritual suicide). Some scriptures even appear to show acknowledge and expiate the mother’s karmic debt (Lafl eur, the Buddha condoning the suicide of enlightened monks 1992). For some Western Buddhists the ritual for aborted foetuses is a way to acknowledge the moral weight of the Buddhist meditation does include many contemplations choice while accepting its occasional appropriateness of the inevitability of death and the stages of the decompo- sition of the corpse. There are also many stories of Buddhist monks, and the Buddha himself, accepting their deaths with equanimity and even humour. But, in fact, Buddhist scrip- BRAIN DEATH AND ORGAN
ture and tradition, like most religions, holds that suicide and TRANSPLANTATION
euthanasia are forms of murder. As with abortion, however, consequentialist and compassion-based moral reasoning The debate about the importance of consciousness for moral may legitimate suicide and euthanasia on the grounds that standing also shapes Buddhist approaches to brain death, they alleviate suffering and permit a ‘good death’.
the permanent vegetative state and organ transplantation. The ‘good death’ is especially important for the Buddhist Keown (1995). argues, for instance, that Buddhists should who believes that their state of mind at death will be partly adopt the ‘whole brain’ theory of brain death, which re- determinative of the quality of rebirth they achieve in the quires evidence that all brain function, including brain next life. This view is expressed in the Tibetan tradition stem activity, has ceased, rather than the ‘neocortical’ through the bardo meditations which are chanted for the view that only the irreversible cessation of conscious- dying and dead to remind them of the 49 days of diffi cult ness should be adequate for declaring death and remov- visions they will traverse as they transition to their next life. ing life support. Keown cites Buddhist scriptural sources Consequently, Buddhists may prefer to be as awake and that imply that death only occurs when vitality, heat and aware at the moment of death as possible, even if they must consciousness have all left the body. (This would seem to endure pain (Levine, 2000). On the contrary, appropriately calibrated pain medication can allow for greater focus during CONTRACEPTION, SEXUALITY, GENETIC
terminal care, and there is no necessary reason for a Buddhist ENGINEERING AND REPRODUCTIVE
to embrace pain when it can be medicated (Anderson, 1992). TECHNOLOGY
There is a growing literature on Buddhist approaches to end-of-life care and counselling exploring these issues from Ti- Buddhism is decidedly indifferent to whether people have betan (Rinpoche, 1994; Sachs, 1998), Zen (Kapleau, 1989; children or not. Buddhist laity are enjoined to avoid sexual Levine, 1982) and Vipassana (Smith, 1998) perspectives.
misconduct, but not to be fruitful and multiply. Buddhist Beyond death, emerging technologies suggest that mem- monks were forbidden to perform weddings or bless ba- ories and consciousness may eventually be transferred to bies, although they eventually developed ceremonies that new bodies or to computers. As technological reincarnation functionally do both. In the last fi fty years Buddhist coun- becomes a possibility, the Buddhist understanding of the tries like Sri Lanka, Japan and Thailand have aggressively transmigration of our illusory, personal identity will be- embraced contraception, and their birth rates are among come even more relevant (Hughes, 2004). Indeed the Dalai the lowest in Asia, to the consternation of some Buddhist Lama has opined that human consciousness could be in- stantiated in a suffi ciently advanced computer (quoted in More fundamentally, Buddhism rejects any notion of a ‘natural’ and inviolate human body or procreative act which needs protection from ‘artifi cial’ contraception, genetic engineering or reproductive technologies (Loy, SPECIESISM AND THE HUMANE TREATMENT
2003). The important questions from Buddhist ethics OF ANIMALS
are the intentions of the would-be (non)parents, and the consequences of their actions. Concerns about children not Buddhist doctrine holds that animals are part of the knowing who they ‘really are’, when they are products of reincarnate chain of being, being potentially both former artifi cial reproduction or cloning, are foreign to Buddhism and future human beings, and moral subjects whose which does not recognize an ‘authentic self’ to begin with behaviour accrues karma. Many of the Jataka tales, about the Buddha’s previous lives, concern his lives as a coura- This tolerance of the ‘unnatural’ extends to homosexuals geous and self-sacrifi cing animal; for instance as a deer and the transgendered. Although homosexuality, as sex that convinces a king to stop his hunt. The murder of ani- outside of marriage, has always been seen as a violation of mals is therefore karmically unskilful, and Buddhists have the precept against sexual misconduct, it is seen as no worse considered vegetarianism praiseworthy, opposed hunting than heterosexual misconduct. Although the monastic code and animal sacrifi ce, and frowned on butchery and leather- bars the ordination of gay men and eunuchs, the Buddha working as inappropriate occupations. The monastic code permitted some transgendered males to ordain and live allows monks to eat meat that is offered as alms but not to with nuns and transgendered females to ordain and live drink water that might contain living creatures. The Cak- with monks (Jackson, 1998). Thailand has an active and kavattisihanada Sutta says that the righteous ruler will pro- tolerated gay and transgender subculture, and it is an in- vide for wild beasts and birds. The most famous example of ternational centre for transgender surgery (Jackson, 1998). a Buddhist code of humane animal treatment are the edicts Gay and transgender people are welcome in the Sri Lankan of the fi rst Buddhist emperor, Asoka, which include numer- and Thai armies. Male homosexuality was common among ous decrees that various species not be hunted and that their the Buddhist warrior caste samurai and monastic culture of habitats should be protected. In India and China, Buddhists Japan (Jñanavira, 2005), and gay and transgender images released captive animals as a means of acquiring merit.
are pervasive in contemporary Japanese culture. The larg- Although the Buddhist tradition is clearly less anthropo- est sect of Japanese Buddhism, the Jodo Shinshu, performs centric than the Abrahamic faiths, in which only human be- ings are ensouled, Buddhist rulers only rarely advocated an ‘animal rights’ legal code forbidding the killing of animals, which would be consistent with a belief in the full equality of BRAIN SCIENCE, PSYCHOPHARMACOLOGY
human and animal life (Waldau, 2002). Vegetarianism was AND THE MYTH OF THE AUTHENTIC SELF
seen as an extreme form of asceticism in the Tibetan tradi-tion, and the Dalai Lama like most Tibetan monks eats meat, Brain science and psychology have eroded the idea of an although he counsels that those who can should become veg- autonomous, continuous and authentic self, in ways quite etarian. Nonetheless, some Buddhists are beginning to argue compatible with Buddhist psychology. Bioethics is just begin- that Buddhism should adopt a more consistent vegan and ani- ning to grapple with the implications. Do anti-depressants, stimulants or pain medications create an inauthentic self, or a more authentic self? How can we respect patient auton- principles of medical ethics articulated in the classic work omy when preferences change in illness and pain, and from of Beauchamp and Childress (1983) – autonomy, nonma- moment to moment? Within Western philosophy Derek lefi cence, benefi cence and justice. Florida concludes that Parfi t’s (1984) Reasons and Persons posed the most radi- Buddhist ethics, being centrally concerned with compas- cal challenge by arguing, parallel to Buddhism, that per- sion, is strongly compatible with the nonmalefi cence and be- sonal identity is only statistically related over time. After nefi cence principles, but that there is no Buddhist doctrinal a certain point we share as much with all future people as basis for an egalitarian social order or the defence of indi- we do with our future selves. This Parfi tian/Buddhist view vidual liberty. Although Buddhism, like all the world’s an- may, for instance, legitimate the delegation of health care cient faiths, developed before the European Enlightenment decision-making for the incapacitated to family, friends and and has only recently entered into dialogue with democratic society (Kuczewski, 1994), and support a general regard for and humanist ideas, Florida appears unaware of an extensive social welfare over individual self-interest.
literature on the implicit egalitarianism and individualism Buddhist meditation teachers, and most famously the Dalai Lama, have embraced the emerging fi eld of A classic work that explicates the latent, revolution- neurotheology, which explores the neurophysiology of the ary egalitarianism of early Buddhism is the The Buddha meditative experience. Some Buddhist neuroscientists, such by Trevor Ling (1973). Ling points to the radical demo- as James Austin in Zen and the Brain, have explored the cratic structure of the Buddhist monastic order and ideals many neurophysiological bases for meditative experience of Buddhist governance and to the many dialogues of the (Austin, 1999). The collection Zig, Zag, Zen: Buddhism Buddha which disparage the Hindu caste system and the and Psychedelics (Badiner, 2002) documents how many emerging monarchism and mercantilism of his time, which Western Buddhists found their way to Buddhism through together suggest a Buddhist strategy for liberal and egali- the use of psychedelic drugs, which many still consider pos- tarian social reform. The Buddha’s story of the origin of governance is of a social contract between citizens and But anti-depressants in particular pose a challenge for their chosen rulers to protect public order, similar to the Buddhists (Chambers, 2001), since the beginning of the Hobbesian view. One of the obligations of the righteous Buddhist path is embracing the fundamental unhappiness of Buddhist king is to ensure that citizens do not fall into pov- life (dukkha), whereas the idea of ‘happy pills’ would sug- erty, from which all other social ills are said to fl ow. In In- gest a short-circuiting of spiritual growth. In other words, is ner Revolution Tibetan Buddhist scholar Robert Thurman Prozac cheating? Most Western Buddhist psychologists have (1999) argues that the social welfare measures enacted by articulated the view that there should be a distinction between the Buddhist Asokan monarchy prefi gured modern social the fundamental dissatisfactoriness of ego-bound life, which democracy. In the twentieth century Buddhists have devel- is present for the depressed and happy alike, and the immo- oped these strains into Buddhist-socialist syncretism, most bilizing depression of the chemically unbalanced mind. For notably the Buddhist socialism of U Nu in Burma (Sarki- people with clinical depression anti-depressant therapy is a syanz, 1965) and Bandaranaike in Sri Lanka, the Dhammic necessary adjunct to spiritual growth, returning their capac- socialism of Bhikkhu Buddhadasa (Buddhadasa, 1986), the ity for compassion, mindfulness and energy (Hooper, 1999). Buddhist feminist movement (Gross, 1992), and the myriad Just as Buddhists have generally accepted stimulants such as ongoing activities of the ‘engaged Buddhism’ movement tea as helpful in maintaining mindfulness during meditation, (Kotler, 2005; Queen, 1996, 2000). Whether social de- this approach would presumably also apply to other drugs mocracy is validated by doctrinal and historical Buddhism, that enhance capacities for empathy or attention, such as there is clearly a stronger case for universal health care stimulant medications for attention-defi cit disorder.
provision in Buddhism than for a system based on unequal Conversely, Buddhists are enjoined to avoid mind- altering substances that interfere with spiritual growth, The case for a Buddhist ‘human rights’ doctrine is more such as alcohol, narcotics and opiates, and warned that complicated, however, because Buddhism”s fi rst move is absorption into blissful states is a spiritual dead-end. If and the deconstruction of the autonomous individual on which when true ‘happy pills’ are available, these would be more the Western rights tradition is based. Like contemporary socialist (Sen, 1999), feminist (Binion, 1995; Sherwin, 1998) and communitarian (Glendon, 1993) critics of the Lockeian autonomous individual, a Buddhist approach to HEALTH CARE ACCESS AND HUMAN RIGHTS
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Q1: Please include reference Levine (2000) in the reference list.
Q2: Please provide publisher’s location in References- ‘Keown D. (1999)’, ‘Lock M. (2001)’, ‘Sachs R.’, ‘Levine S.’, ‘Austine J.’, ‘Beauchamp TL’, ‘Thurman R.’, ‘Gross R.’, ‘Queen C (1996)’, ‘Queen C. (2000)’ ‘Kotler A’, ‘Sherwin S.’, ‘Glendon MA’. Q3: Please provide names of all editors in Reference ‘Sherwin S.’Q4: Please provide the citations of References marked with ‘*’.
Q5: Reference number, not consistant, please check.
ET DE LEUR ÉLIMINATION ADOPTÉE PAR LA CONFÉRENCE DE Conscientes des dommages que les déchets dangereux et d'autres déchets ainsi que les mouvements transfrontières de ces déchets risquent de causer à la santé humaine et à l'environnement, Ayant présente à l'esprit la menace croissante que représentent pour la santé humaine et l'environnement la complexité grandissante et le dével