Buddhist Influence on End-of-Life Care in Modern Taiwan

Helen Craigie June, 2012

Buddhist End-of-Life Care in Modern Taiwan Abstract

In recent history, Taiwan has exhibited some fascinating social trends in the development of both Buddhist outreach programs and socially funded medical care. Specifically, modern Taiwan presents an interesting case study for the interaction between religious practice and modern medicine in that newly socialized government health programs must meet the needs Taiwans population which has a basic Chinese culture combined with a strong modern, secular culture influenced by both the west and Japan. Remarkably, government health agencies are given immense support in their mission to provide appropriate healthcare through the numerous health related service projects organized and developed by Buddhist organizations. For instance, outreach volunteer services provide health services for individuals through free medical care from doctors and educational seminars lecturing on how to cope psychologically with life and death issues. Massive projects have been enacted such as the construction and staffing of large-scale hospitals in areas without convenient access to health services, the funding of biomedical research studies and the creation of medical universities to train future healthcare providers. End-of-life care for the elderly and terminally ill is provided through volunteer outreach home care for elderly and sick individuals, and Buddhist chaplaincy programs train monastics to provide spiritual care in religious and secular
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Buddhist End-of-Life Care in Modern Taiwan hospitals. Outreach services also provide end-of-life ritual chanting and funeral arrangement as well as grievance counseling for the remaining family members. As Taiwanese government health agencies and Buddhist outreach programs become increasingly intertwined in providing care services for the sick and dying, it is important to consider how the two groups influence one another and the effects of their close relationship on the types of care that are provided. On one hand, the religious body has great potential for influence over public health policy and program decisions as they build large-scale medical hospitals, train medical staff and fund medical research. On the other hand, the field of modern medicine could affect the development of modern Buddhism as traditional practices and beliefs are incorporated into the clinical setting. Understanding how these two entities interact with one another to provide care for the modern Taiwanese patient will reveal compelling information on how modern liberal-minded social health programs interact with the thriving religious beliefs associated with Taiwanese Buddhism.

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Buddhist End-of-Life Care in Modern Taiwan Contents

Abstract ....................................................................................................................................................... ii Acknowledgements ........................................................................... Error! Bookmark not defined. Contents ..................................................................................................................................................... iv Introduction .............................................................................................................................................. 1 Methodology.............................................................................................................................................. 6 Chapter 1: Spirituality and Death Culture Throughout Chinese History ........................... 9 Section 1: Defining Spirituality ........................................................................................................................... 9 Section 2: Death and Funeral Culture Throughout Chinese History ...............................................11 Chapter 2: Taiwanese Reformist Buddhist Movement .......................................................... 23 Section 1: Chinese History of Taiwanese Buddhist Reform ..................................................................23 Section 2: Modern Taiwanese Buddhist Groups ........................................................................................37 Chapter 3: Social Changes and Healthcare in Modern Taiwan............................................ 48 Section 1: Prosperity and a Changing Social Demographic ................................................................48 Section 2: Taiwan Healthcare Reform For The Aging ............................................................................52 Section 3: Biomedical Research On End-Of-Life Needs Of Taiwanese Patients ..........................54 Chapter 4: The Hospice Movement In Taiwan And Buddhist Chaplaincy ....................... 60 Section 1: Hospice and Palliative Care in Taiwan ....................................................................................60 Section 2: The Taiwan Association of Clinical Buddhist Studies .......................................................65 Chapter 5: Articles From The Taiwan Association For Buddhist Studies ....................... 70 Section 1: The Role of the Buddhist Chaplain .............................................................................................71 Section 2: Buddhist Life and Death Education in the Clinical Setting ............................................79 Section 3: The Use of Buddhist Doctrine in End-of-Life Care ..............................................................81 Section 4: The Role of the Chaplain in Rituals at Death ........................................................................92 Conclusion ............................................................................................................................................... 95 Bibliography......................................................................................................................................... 100 Primary Sources.................................................................................................................................. 100 Secondary Sources ............................................................................................................................. 100

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Buddhist End-of-Life Care in Modern Taiwan Introduction

In recent history, Taiwan has exhibited some fascinating social trends in the development of both Buddhist social outreach and socially funded medical care. Specifically, modern Taiwan presents an interesting case study for the interaction between religious practice and modern medicine in that newly socialized government health programs must meet the needs Taiwans population which has a basic Chinese culture combined with a strong modern, secular culture influenced by both the west and Japan. Remarkably, government health agencies are given immense support in their mission to provide appropriate healthcare through the numerous health related service projects organized and developed by Buddhist organizations. For instance, outreach volunteer services provide health services for individuals through free medical care from doctors and educational seminars lecturing on how to cope psychologically with life and death issues. Massive projects have been enacted such as the construction and staffing of large-scale hospitals in areas without convenient access to health services, the funding of biomedical research studies and the creation of medical universities to train future healthcare providers. Endof-life care for the elderly and terminally ill is provided through volunteer outreach home care for elderly and sick individuals, Buddhist chaplaincy programs train monastics to provide spiritual care in religious and secular
1

Buddhist End-of-Life Care in Modern Taiwan hospitals. Outreach services also provide end-of-life ritual chanting and funeral arrangement as well as grievance counseling for the remaining family members. As Taiwanese government health agencies and Buddhist outreach programs become increasingly intertwined in providing care services for the sick and dying, it is important to consider how the two groups influence one another and the effects of their close relationship on the types of care that are provided. On one hand, the religious body has great potential for influence over public health policy and program decisions as they build large-scale medical hospitals, train medical staff and fund medical research. On the other hand, the field of modern medicine could affect the development of modern Buddhism as traditional practices and beliefs are incorporated into the clinical setting. Understanding how these two entities interact with one another to provide care for the modern Taiwanese patient will reveal compelling information on how modern liberal-minded social health programs interact with the thriving religious beliefs associated with Taiwanese Buddhism. Starting from around the 1960s prominent new Buddhist denominations flourished in Taiwan, becoming highly influential in Taiwanese society. The success of these movements, such as Fo Guang Shan , Tzu Chi and Dharma Drum Mountain , can be largely attributed to their active efforts

Buddhist End-of-Life Care in Modern Taiwan to provide for the needs of the modern individual through social activism and encouragement to participate in volunteer Buddhist outreach programs. This Buddhist motivated social activism, or humanistic Buddhism aims to provide services that help the modern individual through educational endeavors, health services, relief work and widespread community involvement.1 The leaders of these organizations claim that the driving force behind their outreach services is their devotion to Mahyna Buddhist values and that their mission in todays society is based on Buddhist notions of compassion through alleviating the suffering of others. Although such large-scale involvement in public activism is not commonly associated with the behaviors of traditional Buddhist groups, the leaders of these organizations find inspiration for their social outreach pursuits from Buddhist textual sources. Among the many outreach programs offered from these organizations, particular attention is given to providing care for the sick, the elderly and individuals as they approach their death. Caring for the sick and dying is strongly rooted in Buddhist doctrine and throughout Buddhist texts there are numerous examples of the Buddha speaking to the importance of alleviating the suffering of individuals who are sick and as they approach their death.2 Of

1 2

Hung-Yok Ip, Buddhist Activism and Chinese Modernity, pp. 145-192. Notably, in the Chinese Vinaya authority Daoxuan (696-667) in his work, the Abridged and Explanatory Commentary on the Four Part Vinaya (Sifen l shanfan buque

Buddhist End-of-Life Care in Modern Taiwan particular importance in Mahyna scripture is the significance of the final thoughts of the dying.3 Additionally, there is a long textual history in Chinese Buddhism outlining the importance of ones end-of-life experience, and the experience of family members, as contributing to a positive afterlife experience and many specific Buddhist practices are deemed as essential for fulfilling the requirements of this time of transition.4 However, since the time that these texts were written, modern developments in biomedicine, medical technology and the invention of largescale medical facilities have completely revolutionalized the experience of aging, sickness and death. Throughout the modern world, death has evolved into a highly medicalized process5 in that increasingly individuals are spending their final days within hospitals, defining their experiences using distinctly medical concepts. Experiencing death biomedically involves understanding the dying process explicitly as a breakdown of biological bodily functions. As such, medical end-of-life care strives to provide highly advanced methods for
xingshi chao), he emphasizes the importance of this time in the life of a Buddhist and lists specific recommendations for deathbed practices that were highly influential throughout East Asian Buddhism and particularly, Pure Land groups. See Koicki Shinohara, The Moment of Death in Daoxuans Vinaya Commentary, pp. 105-132. 3 Many Buddhist deathbed practices from various schools emphasize the importance of the last thoughts in this life. In his Vinaya commentary, Daoxuan address this importance, among other places, in a chapter entitled, Attending the Sick (Zhanbing songzhong)(ibid).
4

For todays Taiwanese Buddhists, two of the most common of these texts are the Stra of the Past Vows of Earth Store (Ksitigarbha) Bodhisattva and the mitba Stra (Shorter Sukhvatvyha Stra) .

Michel Foucault, The Birth of the Clinic, pp. 67-77; Ivan Illich, Medical Nemesis, pp. 1-15.

Buddhist End-of-Life Care in Modern Taiwan diagnosing illnesses, providing therapeutic interventions and developing pharmaceutical drugs for pain relief. These modern advances in biomedicine that have lead to a revolution in the experience of sickness and death are part of a larger scientific worldview that is not typically considered compatible with religious, non-scientific ways of understanding and experiencing this time. Such inconsistencies between medical and religious ways of conceiving of the end-of-life experience have lead to questions of whether or not religious belief and practices are relevant modern medical care. Despite the seeming incompatibility of religious beliefs and biomedical perspectives of death, Taiwanese socially engaged Buddhist organizations have not shied away from developments in medical technology and have instead embraced revolutionary ways of alleviating suffering. As such, large-scale social programs have been developed to provide Buddhist religious support for individuals to complement modern medical end-of-life care. The central focus of this paper is to develop an understanding of the incorporation of traditional Buddhist doctrine and practice into modern Taiwanese end-of-life care facilities. Specific attention is paid to analyzing modern interpretations of Buddhist doctrine to address developments in clinical care in Taiwan and examining which Buddhist beliefs and practices are incorporated into the clinical setting.

Buddhist End-of-Life Care in Modern Taiwan Methodology

As the topic of this research study investigates a fairly recent phenomena and it bridges two fields of inquiry, there is no literature directly addressing the topic and there are no predecessors in the field in which to follow. As a result, this study is predominantly a literature review examining various aspects of the topic separately and combining them together for analysis. To contextualize this study, sources include historical Chinese belief and practices, Chinese political history and research on the behavior of Chinese and Taiwanese Buddhist reformists. Historical research is offset with a review of contemporary Taiwanese Buddhist outreach services, mostly obtained from the websites of the Buddhist reformist groups. This study also includes an in-depth review of the development of Taiwanese social health policy and recent bioemedical research on spirituality in end-of-life care in modern clinical settings. Additionally, throughout the time spent in Taiwan pursuing this project, hospice care facilities were visited throughout the country including, a Fo Guang Shan seniors home in Yilan, the palliative care ward at National Taiwan University and the hospice ward in a Tzu Chi Hospital. Lastly, on April 13, 2012 Dr. Rong-Chi Chen from the Lotus Foundation was met with to discuss the development of the Taiwanese Buddhist hospice movement. As the meeting

Buddhist End-of-Life Care in Modern Taiwan was not a formal interview I have not included my questions within the thesis, but I do reference some information shared within the time of our meeting. The first chapter of this research paper establishes the foundation of modern Taiwanese conceptions of death by providing a brief explanation of the multi-faceted concept of the spirit in Chinese thought along with an outline of various Chinese beliefs and practices surrounding death throughout Chinese history. The second chapter introduces some of the main reformist Chinese thinkers, whose visions for the future of Chinese Buddhism have greatly influenced the development of Taiwanese Buddhist thought and proceeds to explore the development of three major reformist Taiwanese Buddhist groups. Specific attention is paid to social outreach programs that pertain to modern clinical outreach and end-of-life care provided to the Taiwanese public. In chapter three, the efforts of these health related Buddhist outreach programs are contextualized through presenting some of the major political, economic and social changes that have taken place in modern Taiwanese history. Chapter four explores the development of the countrys newly reformed healthcare policy relating to palliative and hospice care, discussing factors in this reformed policy that gave rise to modern Buddhist clinical outreach programs and how these programs are meeting the need of the modern Taiwanese patient. In modern Taiwan the medical community works collaboratively with Buddhist

Buddhist End-of-Life Care in Modern Taiwan organizations to support one another in providing care, so this research paper looks at recent Taiwanese biomedical studies surveying terminally ill patient opinion on what aspects of care are deemed important at end-of-life. The opinions revealed in these studies are then discussed in reference to the traditional Chinese notions of death outlined in chapter two. As a follow-up to these studies, this paper surveys modern Taiwanese Buddhist outreach programs that work within the medical arena, comparing the objectives of these programs with the needs specified by Taiwanese end-of-life patients. Lastly, chapter five investigates the development of the role of the Taiwanese clinical Buddhist chaplain by examining a number of recent articles written on the subject, outlining specific practices and doctrines that are regarded as applicable to the modern Taiwanese terminally ill patient. Throughout the entire paper, discussion centers on the development of Taiwanese Buddhist outreach services that attempt to meet the needs of modern society as they face complicated issues related to biomedicine, bioethics and religious ideas of what it means to die well.

Buddhist End-of-Life Care in Modern Taiwan Chapter 1: Spirituality and Death Culture Throughout Chinese History

Section 1: Defining Spirituality

Given that this essay is an exploration of modern Taiwanese incorporation of a type of Buddhist spirituality into modern end-of-life care, it seems appropriate to begin with a general discussion of the concept of spirituality, as it applies to Chinese beliefs around end-of-life. According to the Oxford Online Dictionary, the term spirit comes from the Latin word spirare breathe and means, the non-physical part of a person which is the seat of emotions and character; the soul.1 As such, there is no equivalent Chinese character that carries the same connotations, making the use of the term problematic in describing both traditional and modern Chinese thinking. Modern research investigating the spiritual beliefs in terminally ill Chinese patients indicated that participants expressed difficulty in understanding and expressing the definition. Chinese patients viewed spirituality as an integration of mind and spirit, which is very different from Western perspectives that differentiate between the body and the soul.2 Patients saw the spirit as

1 2

Spiritual, accessed April 24, 2012, http://oxforddictionaries.com/definition/spiritual. Esther Mok, Frances Wong and David Wong, The meaning of spirituality and spiritual care among the Hong Kong Chinese terminally ill, pp. 360-370.

Buddhist End-of-Life Care in Modern Taiwan integrating xin (heart/mind) and ling (spirit) together and saw the practice of spirituality as multi-dimensional. The human spirit was described as an aspect of the person, but as an integrative force, rather than something separate from the body. It is the spirit that was described as enabling and motivating a patients search for meaning and purpose in life and a connection with the spirit enabled them to accept the dying process.3 Research on conceptions of the spirit in Chinese ritual practices surrounding death reveals that the concept of the spirit has been multidimensional throughout Chinese history. Scholars of Chinese history explain that numerous terms are used to describe the non-physical aspect of the individual that could be described as the spirit in English terms. Historian Susan Naquin writes that in late Imperial China the notion of the soul, or spirit was composed of several parts4. She writes that when a Chinese person died, it was believed that his hun (cloud soul) left the body and descended to the underworld to be judged then was either released to be reborn or, depending on his merits, to ascend to paradise. Naquin notes that there were connections between the hun and the next rebirth, but they were extremely subtle. Other aspects of the deceased survived the death such as the po (white soul) with components of
Esther Mok, Frances Wong and David Wong, The meaning of spirituality and spiritual care among the Hong Kong Chinese terminally ill, pp. 360-370. 4 Susan Naquin, Funerals in North China: Uniformity and Variation, pp. 37-70.
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Buddhist End-of-Life Care in Modern Taiwan the ling. Unlike the more passive hun, which leaves the body quickly, the po actively remains with the body and stays in the family home, needing continuous attention from the family or it may become wrathful and cause harm. Other accounts of traditional Chinese notions of the soul indicate that the hun and the po are made up of numerous parts and that Chinese terminology for these concepts is not consistent.5 For instance, Anthropologist from Columbia University Myron L Cohen writes that although it is commonly reported in historical Chinese texts that there are three hun and seven po that still many other texts have varying numbers and associations for these terms. Also, terms like gui (ghost) and shen (spirit/god) are sometimes used together with hun and po to convey slightly different meanings, or they are often used to replace them altogether.

Section 2: Death and Funeral Culture Throughout Chinese History

Just as it is essential to understand the multi-dimensional concept of the spirit in Chinese culture, it is also important to discuss the extraordinary culture surrounding death throughout Chinese history. Chinese traditional beliefs and social practices surrounding death have been explained by scholars

Myron L. Cohen, Souls and Salvation: Conflicting Themes in Chinese Popular Religion, p. 182.

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Buddhist End-of-Life Care in Modern Taiwan primarily through a combination of the teachings of Confucius, Daoist beliefs and Buddhist doctrine and practices. Understanding the history of Chinese culture surrounding death can help generate a better understanding of the beliefs and practices that may still have an affect on modern Taiwanese terminal patients. In Chinese culture there is a widespread taboo of speaking of death and still today, many Chinese families will not discuss issues of death and dying for fear of invoking bad luck. Historically, the cultural taboo is believed to be a result of Confucian reluctance to speak about death, as one scholar says: The Taiwanese society's taboo toward life and death is inherited from Confucius' views concerning life and death.6 Regardless of whether or not the origins of this superstition are accurate, the taboo is deeply embedded into Chinese culture. The fear of speaking about death is so ingrained into the culture that the superstition extends to include the number four (si) which sounds like death (si). An example of this is that it is common for buildings in Taiwan not to have a floor numbered four. In hospitals, a four bedded room will not have a bed number four as nobody wants

6,

," p. 195.

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Buddhist End-of-Life Care in Modern Taiwan to be assigned into the death bed, instead the bed numbers will skip from three to five.7 Confucian beliefs can easily be identified as affecting Chinese death culture in its emphasis on customary social relationships and filial piety. The teachings of Confucius are primarily interested in improving human relationships and promoting peace and harmony in society through clearly defined, agreed upon social customs and ritual for relating to one another. The Neo-Confucian teacher Zhang Zai (10201077) explains that proper relationships are carried on to the afterlife as a continued exchange of love and respect for the deceased family member.8 For the surviving family, customary rituals performed for the dead provided a socially acceptable and dignified form of grieving, a means to affectionately remember their deceased loved ones and a method for keeping a positive relationship with them after they die. To live well within the Confucian society is to contribute positively to family and society. So notions about dying well include a feeling that one has made a positive contribution to the world, will be remembered fondly and maintain a reciprocal connection with living relatives.9

This information was obtained from a meeting with Dr. Chen, Rong-Chi at the Buddhist Lotus Hospice Care Foundation Taiwan, 10:30-12:00 April 13, 2012. Paul E. Irion and Dennis Ryan, Death: Eastern Perspectives, pp. 75-112. Ibid.

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Buddhist End-of-Life Care in Modern Taiwan Traditional practices surrounding ancestor worship foster a continuing bond with the deceased after death, which is believed to be beneficial to both the dead and the surviving family. Following these traditions, for Chinese dying patients and their families, dying at home makes it easier for the deceased to maintain a close relationship with the family leading to a distinct preference for elderly Chinese to die within the home.10 This particular factor has been essential in Chinese culture around death and still holds a distinct importance for todays Chinese patients.11 Unlike the Confucian interest in creating optimum human relationships, Daoism focuses on non-obstruction of the natural harmonious flow of nature. The greatest obstruction to the natural way of nature, according to the great Daoist writer Zhuangzi , who lived around the fourth century BCE, is not to take conventions and the traps of societal values too seriously.12 Death is part of this natural way of nature and is inevitable for all living things. It is believed that since this continual change is natural it is illogical to be anxious about our own death.

Alice G. Yick and Rashimi Gupta, Chinese cultural dimensions of death, dying, and bereavement: focus group findings, pp. 1-11. 11 Paul E. Irion and Dennis Ryan Death: Eastern Perspectives, pp. 75-112. 12 Ibid.
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Buddhist End-of-Life Care in Modern Taiwan Although Daoists regards death as a natural part of life, the Daoist Dao De Ching (attributed to Lao-Tzi , from the 6th century BCE) creates a very different picture in that it portrays death as an inauspicious event that should be avoided. And so, in an attempt to avoid prolong life, throughout history Daoist self-cultivation techniques enjoyed widespread popularity amongst Chinese laypeople and royalty alike.13 Lao-Tzis viewpoint regarding death and dying have not only contributed to a culture of life-prolonging selfcultivation techniques, but such ideas have influenced the Chinese taboo against speaking about death. Such negative associations with death are still apparent in modern Chinese culture and affect the interaction between dying patients and their caretakers. Modern representations of Chinese death culture will be elaborated upon further in chapter six through a survey of the various needs of modern Taiwanese terminally ill patients. Chinese Buddhist conceptions of death have played an important role in belief surrounding death and the afterlife throughout history, greatly influencing various ritual practices for the deceased. Similar to the Daoist belief that death is a natural part of life, Buddhist doctrine surrounding death asserts that death is inherent in the nature of every living thing. An individual life can be seen as

13Chiung-Yin

Hsu, Margaret OConnor and Susan Lee, Understandings of Death and Dying for People of Chinese Origin, pp. 153-174.

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Buddhist End-of-Life Care in Modern Taiwan simply a compounded being and death is the dissociation of the constituent elements of that being.14 These elements that come together in life and dissipate in death, are known as the five skandhas or aggregates, which are form, sensation, perception, mental formations and consciousness. Buddhist belief associated with death instructs that the last thoughts in life are essential in that they have a direct influence on what is experienced in the afterlife, and the situation of rebirth in the next life.15 Since the process of dying can be frightening and is often associated with pain, which can lead to negativity at death, Buddhists have traditionally offered assistance with this time through collective chanting and other ritual ceremony preparations. Another popular Buddhist belief relating to the time of death has to do with the last thoughts being tied to an aspiration of rebirth in the Pure Land.16 Pure Land practices at death center on continuous chanting of the name of Amitbha Buddha, which helps the dying experience a more peaceful death and a good rebirth in the Pure Land.17 Not only is the time of death important, but ritual assistance in the forty-nine days that follow death are also essential for helping facilitate a good rebirth for the dead,

Ling, Seekers Glossary of Buddhism, p. 132. Ibid. 16 Donald Lopez, Seekers Glossary of Buddhism, p. 133. 17 Pure Land Buddhism signifies a wide array of practices and traditions within Mahyna Buddhism directed to the Buddha Amitbha and his realm, Sukhvati (Land of Bliss), which came to be referred to in Chinese as the Pure Land. See Daniel A. Getz, Pure Land Buddhism, p. 701.
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Buddhist End-of-Life Care in Modern Taiwan as the dead navigate their way through afterlife scenarios.18 An important practice to assist the dying individual, also benefiting the dead during the period afterward, is the transference of merits to the deceased. The Stra of The Great Vows of Kitigarbha Bodhisattva is a popular Chinese Buddhist text that highlights the importance of transferring merit to the deceased to assist them in their afterlife experience as a form of filial piety.19 Transferring merit involves the single-minded concentration and sincerity of the individual to recite stras to alleviate the repercussions of the deceaseds negative karma. The importance of filial piety within the Kitigarbha Stra indicates that this concept is not unique to Confucian thought and was also a prominent Buddhist idea, reinforcing the importance of maintaining close bonds with family members and assisting them even after they have died. Another important point to note from the influential Kitigarbha Stra that will be discussed in more detail later in this paper in reference to modern Taiwanese Buddhist groups, is that it emphasizes the great concentration and effort to transfer merits to deceased relatives. The stra suggests instead of waiting until after someone dies, that it is much more effective for the individual to cultivate their own merit while they are still alive.20

Okaz, Seekers Glossary of Buddhism, p. 135. Wendi L. Adamek, "The Impossibility of the Given: Representations of Merit and Emptiness in Early Chinese Buddhism," pp. 135-180. 20 Venerable Yifa and P.M. Romaskiewicz, (trans) Sutra on the Past Vows of Ksitigarbha.
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Buddhist End-of-Life Care in Modern Taiwan Throughout history, the ritual ceremonies performed at death have been central to definitions to Chinese cultural identity. Preoccupation with rituals around death, such as funeral ceremonies, affected Chinese individuals in every social group, regardless of wealth or political standing.21 Practices and beliefs around death were of particular cultural importance for Chinese in asserting the importance of filial piety. Not just individuals, but also by government officials, valued filial piety as the concept also effectively promoted the legitimacy of government agencies, and specifically, the emperor.22 This is especially evident in the Chinese state during the Ming and Qing periods, as Chinese funeral culture was extremely popular in China. From his study on late imperial Chinese death culture throughout the country, Professor of Chinese Society and Anthropology from Harvard University, James L. Watson notes that there was a remarkable uniformity in beliefs, attitudes and conceptions regarding the dead, geographically and throughout various social classes.23 In addition, it is noted that the performance of death rituals took precedence over specific beliefs associated with such rituals, in that variations in beliefs were more apparent than variations in specific practices, and people went to great lengths to assure that rites were carried out

James L. Watson and Evelyn S. Rawski, Preface, p. ix. Evelyn S. Rawski, A Historians Approach to Chinese Death Ritual, p. 26. 23 James L. Watson, The Structure of Chinese Funerary Rites: Elementary Forms, Ritual Sequence, and the Primary of Performance, p. 11.
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Buddhist End-of-Life Care in Modern Taiwan properly.24 Cohens essay on death culture in late imperial China, notes that ideas of salvation after death was not a major ideological force in Chinese popular religion, at least in comparison with what is found in the religions of other cultures. It is suggested that the reason for this comes from the fact that the notion of salvation contradicts fundamental tenants, such as ancestral worship, belief in reincarnation, and the close interaction between the living and the dead.25 Cohen notes that throughout history Chinese popular religion has embraced a number of varying beliefs regarding the afterlife and so contradictions in specific beliefs was not difficult to overcome. So, for the majority of the population, afterlife beliefs concerning salvation were part of rituals surrounding death, but were not central to beliefs surrounding this time.26 Specific customs that were found throughout China included; family members wailing aloud, washing and dressing the dead in clothing suitable for the afterlife journey, collecting items to transfer to the dead to assist them in the afterlife, and the employment of professionals specializing in the performance of ritual acts for the dead, i.e. Buddhist or Daoist monastics, or other spiritual guides.27

Evelyn S. Rawski, A Historians Approach to Chinese Death Ritual, p. 22. James L. Watson and Evelyn S. Rawski, Preface, p. xiii. 26 Myron L. Cohen, Souls and Salvation: Conflicting Themes in Chinese Popular Religion, p. 181. 27 Evelyn S. Rawski, A Historians Approach to Chinese Death Ritual, p. 22.
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Buddhist End-of-Life Care in Modern Taiwan Thomas Laquer points out that there is no radical dualism in Chinese thought regarding the soul separating from the body as in the moment of death, as compared with European ideas of the transition between life and death. He notes that one of the primary goals of Chinese funeral rites was actually to keep the corpse and spirit together long enough for community ceremonies, as such rituals were essential for both the dead and their continued relationship with the living.28 Research indicates that in time of government reform, such as in the Republican Revolution in 1922, there were attempts by government officials to simplify funerary practices. But it wasnt until the rise of the Communist regime, particularly after The Great Leap Forward (1958 to 1961) that Chinese culture and rituals surrounding death changed dramatically. Starting from around the mid-1940s, the Chinese Communist Party sought to reform the funeral culture in China, and systematically change the way that Chinese people understand death.29 Communists deemed the idea of an afterlife, or ancestors worship as suspicious and harmful. Additionally, money and time spent on elaborate rituals, and land used for burial was thought to be wasteful. Instead, funerals should be done away with. The Great Leap Forward brought the first

James L. Watson, The Structure of Chinese Funerary Rites: Elementary Forms, Ritual Sequence, and the Primary of Performance, p. 8. 29 Martin K. Whyte, Death in the Peoples Republic of China, p. 289.
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Buddhist End-of-Life Care in Modern Taiwan concerted effort to change popular views on death. First of all, in the city greater numbers of hospitals were being opened, where more people were dying instead of in the home. Hospital personnel were encouraged to send bodies to crematoria, instead of allowing bodies to be taken for burial. Next, those who wanted to bury their relatives were met with obstructions, many urban cemeteries were condemned and land was redistributed for construction. The Cultural Revolution , from 1966 to the death of Mao in 1976, brought the greatest hostility to Chinese funeral and death culture.30 Coffin shops, funeral specialists, incense makers, etc. were all tabooed throughout the cities and in the rural areas of China. The Chinese Red Guard were also known for breaking into houses and confiscating any traditional items relating to the dead, including ancestral tablets and images of deities. During this time many temples and shrines in China were destroyed and monastics were forced to return to lay life. Since the death of Mao, tolerance for traditional customs and religious specialists in funeral culture has increased in China. Cremation instead of burial is still heavily encouraged, especially in cities. However, even though this practice has been promoted for a number of years now, many elderly Chinese still do not accept cremation. Since urban hospitals predominantly send their
30

Ibid, p. 300.

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Buddhist End-of-Life Care in Modern Taiwan dead to be cremated, many rural elderly Chinese are reluctant to accept referrals to urban hospitals for fear that they will die without the option of burial. So, although Chinese cultural practices around death have changed over time, there is still evidence that some core beliefs still resonate within the Chinese people. Exactly which beliefs and practices are still important in the modern world, and how they play out in modern end-of-life scenarios will be elaborated on in the following chapters.

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Buddhist End-of-Life Care in Modern Taiwan Chapter 2: Taiwanese Reformist Buddhist Movement

Section 1: Chinese History of Taiwanese Buddhist Reform

To understand the dynamic between Taiwanese social outreach programs and government funded medical end-of-life facilities it is necessary to first discuss the development of modern Taiwanese Buddhism as influenced by revolutionary Chinese Buddhist movements. Within the scope of this research paper the history of Taiwanese Buddhist thought will be drawn back to the late nineteenth and twentieth century and the religious movements that came about as China underwent numerous political and social crises and revolutions. Taiwans unique practice of humanistic, or socially engaged Buddhism is for the most part attributed to the teachings of an influential reformist monastic, Venerable Master Taixu (1889-1947), from Zhejiang Province, China, and was made popular in Taiwan by his student, Venerable Master Yinshun (1906-2005). These two masters advocated for the reform of the Chinese Buddhist institution through active social engagement to benefit the needs of modern society. Most significantly for our purposes, and what will be elaborated on throughout this paper, is that both Taixu and Yinshun strongly believed that the modern Buddhist Sangha should work alongside Buddhist laity to create social

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Buddhist End-of-Life Care in Modern Taiwan welfare projects that alleviate the suffering of individuals in this world, as opposed to a predominant focus on practices aimed at otherworldly attainments. Their focus on social activism to benefit individuals in this world led to the establishment of numerous programs to benefit and provide care for Taiwanese dying patients in clinical settings. Specifically, reforms that have influenced todays Buddhist involvement in death stem from notions advocated by Taixu and Yinshun that took emphasis away from the Buddhist association with funeral practices and monastic guidance through the afterlife experience. Behind these notions is the idea that in order to engage Buddhism more securely in this world, and help individuals here and now, Chinese Buddhism must demonstrate the relevance of compassion within modern society. As a result, within these programs, focus on providing care for this world altered and expanded the role of the Buddhist practitioner in their role delivering the dead to the afterlife. The following chapter elaborates on these ideas through outlining the development of the history of Taiwanese Buddhist reformist movements. What will be extrapolated for later discussion is a consideration of which reformist ideas are most influential in Taiwanese modern Buddhist movements and how these ideas are interpreted to apply in caring for todays Taiwanese Buddhists.

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Buddhist End-of-Life Care in Modern Taiwan In the era before Taixu, late Imperialist China, doctrines and rituals related to death, otherworldly attainments and the afterlife from Chinese Buddhist texts had come to play a significant role in shaping popular beliefs and practices surrounding death. At this time the connection between Buddhist funerary and afterlife practices were so intertwined with death in popular culture that a common euphemism for funeral services was foshi or Buddhist ceremony.1 By the end of the Ming dynasty, Chinese Buddhism became besotted with rituals and funerals. By the Qing, such practices essentially defined Buddhism, and therefore became the cause for its ideological attacks from incoming Western scientific development and technological progress. In around 1919, immediately after the success of the Republican revolution, a movement popularly called The New Culture Movement (Xin Wenhua Yundong) greatly influenced Chinese intellectual thought. This period was a time when concepts of evolution and progress coming from the West spurred Chinese intellectuals, such as Yan Fu (1853-1921) and Chen Duxiu (1879 1942) to stress the necessity of modernization of Chinese

Donald Sutton, Death Rites and Chinese Culture: Standardization and Variation in Ming and Qing Times, p. 135.

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Buddhist End-of-Life Care in Modern Taiwan traditions and engagement in public iconoclastic rhetoric.2 At this time, various political factions and public pressure called for social reform to build a strong and prosperous China. The drive for reform took hold in the late Qing and Republican periods.3 Modernist ideas from Chinese intellectuals, coupled with incoming intellectual and cultural influences from the West, put Chinese cultural traditions, including Buddhist beliefs and practices, under scrutiny. Buddhist institutions were already under threat during the end of the previous Qing dynasty as intellectuals who were weary of the role of Buddhist monastics in China accused them of having little value to the modern world because of lack of education and moral virtue.4 Buddhist practitioners were consequently accused of draining resources from society and not contributing to Chinas social or economic progress. Additionally, those who accepted new rationales coming from the West criticized religious rituals and worship as superstition.5 The influence of these ideas and the dramatic changes that occurred in Chinese society lead to a rise of a Republican Nationalist Government (Guomin Dang), then after a war with the Japanese, the Communist party reigned (Gongchan Dang), followed by a great

2 Donald
3

A. Pittman, Toward a Modern Chinese Buddhism Taixus Reforms, p. 22. Raoul Birnbaum, Buddhist China at the Centurys Turn p. 431. 4 Donald A. Pittman, Toward a Modern Chinese Buddhism Taixus Reforms pp. 28-33. 5 Kenneth, Chen, Buddhism in China, A Historical Survey, pp. 389-408.

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Buddhist End-of-Life Care in Modern Taiwan persecution of Chinese Buddhist institutions and a significant reduction of the influence of Buddhism in China. During this time of Buddhist persecution the government intervened, deciding that property belonging to religious institutions should be redistributed to better serve the public. Orders were thus issued to confiscate any Buddhist property, to be used for government owned schools. Facing persecutions aimed at eliminating Buddhist institutions, a number of revolutionary Buddhist thinkers came to the fore with ideas of how Buddhism should face these challenges. The revolutionary Chinese Buddhist master Taixu became publically known for his ideas to remodel the role of Chinese Buddhists into more active participants in society, in turn becoming the forefather of reformist monks inspiring Buddhist activism in Taiwan. Alternatively, other influential reformist movements at the time took a more conservative approach than Taixu, for instance, Venerable Hongyi (1880- 1942) emphasized personal cultivation, textual study, and retreat from the world. Like Taixu, Hongyi was also known as a Chinese reformist monk, yet his ideas for the reformed direction of Chinese Buddhism were centered on a return to early, conservative Chinese monastic ways of life. Born in the late Qing dynasty, Hongyi was a well-known actor, musician, writer and modern man who famously walked away from his career to renounce as a monastic. Also

27

Buddhist End-of-Life Care in Modern Taiwan heralded as a Chinese Buddhist reformer, Hongyi became best known for his scholarship on the Chinese Vinaya and for his dedication to conservative religious practice. Seeing the world around him as severely troubled, his reformer beliefs led him to be unswayed by worldly conditions and let go of interest in worldly achievements. Interestingly, although Hongyis perspective on how Chinese Buddhism should reform itself in the modern world varied quite dramatically from that of other reformists, he shared in Taixus view that elaborate ceremony and ritual at death were unnecessary as they were often performed merely for economic gain. Hongyi concluded that much simpler and meaningful practices at death were much more beneficial for the dying person.6 Taixu was also dissatisfied with what he saw as the failings of Chinese Buddhism in the final days of the Qing dynasty, but unlike Hongyi, Taixu recognized this time as an opportunity for Chinese Buddhism to grow and to play an active role in a reformed China. Taixu believed that it was the responsibility of Chinese Buddhists to adapt themselves and their practices to the changing era, thereby making more of a positive contribution to the greater society.7 He observed that the threat to Buddhism came from a number of forces acting simultaneously; arguing that the cause of Buddhisms poor public image

6
7

Raoul Birnbaum, The Deathbed Image of Master Hongyi, p. 187. Darui Long, Buddhist Initiatives for Social Well-Being in Chinese History, With Special Reference to Modern Exponents of Humanistic Buddhism, pp. 204-227.

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Buddhist End-of-Life Care in Modern Taiwan did not solely come from outside persecution and instead, their poor reputation could be attributed to the behavior of the Chinese Buddhists themselves. Public scrutiny and the charges brought to the integrity of the institution were formed to a great degree by mainstream Buddhist practices, predominantly the practice of offering funeral services and expertise in otherworldly activities in exchange for monetary gain.8 His advocacy for creating Buddhism for human life (rensheng fojiao) was an attempt to make a distinct change from the public association of Buddhism with Chinese death culture.9 Acting on his dissatisfaction with Chinese Buddhist institutions and persecution from the Nationalist Government, Taixu advocated for a complete Buddhist revolution (fojiao geming) and revival of what he saw as the more important task of Buddhists, the concentration on accumulating merit while still alive instead of waiting for the afterlife.10 Known for his political activism, Taixu urged that all of his monastic and lay followers be adept in political culture and active in addressing social problems. Taixu believed that his goals for Buddhist reform could only be reached if religious communities engaged with socio-political change.11 He

Mark L. Blum, Death, p. 206. Donald A. Pittman, Toward a Modern Chinese Buddhism Taixus Reforms, p. 283. 10 David C. Schak, Community and the New Buddhism in Taiwan, pp. 161-192. 11 Donald A. Pittman, Toward a Modern Chinese Buddhism Taixus Reforms, p. 60.
8 9

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Buddhist End-of-Life Care in Modern Taiwan expressed that China would best make progress toward change through adopting a democratic socialist government because socialism and democracy, although flawed in practice, were similar to Buddhism in advocating for human equality and social welfare.12 Taixu was a strong advocate for education and intellectual exchange, believing that the philosophy and worldviews held within Buddhist doctrine were compatible with modern scientific discoveries and rationalistic worldviews coming from the West. Buddhism for human life involved a reorganization of the Chinese Buddhist institution, particularly reducing the size of the Sangha, instilling modern education, establishing compassionate social action and cooperation with international religious thinkers. He felt the only way to achieve his desired reforms and increase public involvement was to integrate lay Buddhist practitioners with the monastic community in the pursuit of the bodhisattva path through philanthropic activities.13 His intention was to facilitate a transition toward a modern Chinese Buddhist institution that was intellectually on par with the international community and actively attended to the social problems of the Chinese community. In effect, this revolution would keep Buddhism relevant to Chinese modern rationalist thinking and social progress, with which he believed Buddhism was inherently compatible.
12 13

Donald A. Pittman, Toward a Modern Chinese Buddhism Taixus Reforms, p.182. David C. Schak, Community and the New Buddhism in Taiwan, pp. 161-192.

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Buddhist End-of-Life Care in Modern Taiwan Taixus social engagement projects manifested in numerous ways, including spearheading numerous religious societies that engaged in free education, medical care, food distribution and disaster relief among other social services.14 Taixu also had a strong belief that modern Chinese Buddhist groups should engage in international exchange with other religious groups as well as groups from the fields of science and philosophy. He involved himself in numerous international conferences and traveled all over the world to interact and exchange knowledge with the thinkers of his age. Taixu did not characterize his revisions as deviating from traditional Buddhism; instead, he insisted that a return to Mahyna scripture was the inspiration for his ideas to reinvigorate the Buddhist community and relate the Dharma to the needs of the modern world.15 While he was concerned with explicating the Buddhist vision, and devoting considerable attention to reviving interest in the idealistic philosophy offered by the Consciousness-Only School (weishi zong) he insisted that religious actions within the public sphere were central to Mahyna spiritual life. Taixu emphasized that wisdom could not be attained apart from compassionate action in this world, particularly within the

14 15

Donald A. Pittman, Toward a Modern Chinese Buddhism Taixus Reforms, p. 102 Ibid, p. 3-8

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Buddhist End-of-Life Care in Modern Taiwan socio-political sphere, by placing great emphasis on the ethical norms of Buddhist heritage related to social responsibility and human morality. To achieve this objective, he called for a redirection of the Chinese Buddhist religion away from the performance of funeral rituals focusing on other worldly achievements, such as ascending to an otherworldly Pure Land.16 He went so far as to claim that Buddhism for human life required that all religious practice having to do with gods, ghosts and Pure Land devotionalism were counterproductive and should be immediately discontinued. He argued that Buddhist preoccupations with death and assistance with travels to the afterlife were ultimately misguided. Directly combating the association between Buddhism and otherworldly attainment, Taixu argued that Buddhists should focus their efforts on making a favorable contribution to this world whereby making a pure land in this world (renjian jingtu). Regarding his views on Buddhist practices focusing on death and the afterlife he is quoted in the work, An Introduction to a Buddhism for Human Life (Rensheng fojiao kaiti) as stating; So-called death is actually a part of life. Only when we are able to understand life will we be able to understand death. On the

16

Pure Land Buddhism signifies a wide array of practices and traditions within Mahyna Buddhism directed to the Buddha Amitbha and his realm, Sukhvati (Land of Bliss), which came to be referred to in Chinese as the Pure Land. See Daniel A. Getz, Pure Land Buddhism, p. 701.

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Buddhist End-of-Life Care in Modern Taiwan contrary, if we only understand death, not only will we not understand life, we will not really understand death17. Here, it is important to note that although Taixus vision for the future of Chinese Buddhism is evident in todays Taiwanese Buddhist movements, during his lifetime there were many who disagreed with his perspectives; for instance, the writings of the previously mentioned conservative monastic Hongyi were highly influential. Also, many of the organizations established by Taixu eventually failed and at the end of his life, even he himself considered his reform movement to be a failure. Taixus student and biographer, Yinshun , effectively brought the reformist movement to Taiwan when he came on the advice of Taixu in 1952. In Taiwan he became the editor of an influential Buddhist journal, mentored many monastics and was a respected scholar monk. Buddhologist Marcus Bingenheimer explains that Yinshun was initially under the influence of Taixus activist reform movement but his real contribution to modern Buddhism was far more scholastic than activist, through his reevaluation of historical Buddhist texts and applying them to the modern world.18 Bingenheimer describes that Yinshun modernized the practice of historical Buddhist studies for scholars and

17 18

Donald A. Pittman, Toward a Modern Chinese Buddhism Taixus Reforms, pp. 175-176. Marcus Bingenheimer, Writing History of Buddhist Thought in the Twentieth Century: Yinshun (19062005) in the context of Chinese Buddhist historiography," pp. 255-290.

33

Buddhist End-of-Life Care in Modern Taiwan used influential Indian Mahyna scholarship, allowing others to look into the roots of Buddhism to support social engagement or Humanistic Buddhism (Renjian Fojiao). In Bingenheimer's analysis, some of Yinshun's hermeneutic devices were well established in the tradition of Chinese Buddhist historical writing. However, it is also noted that Yinshun used selective Buddhist historical perspectives that were more conducive to Buddhist activism in this world. For instance, Yinshun did not emphasize the teaching of the three ages involving the concept of mofa , "the final days of the Dharma."19 The idea that we are now living in the final days of truths decline is at odds with the optimism and reformism of Buddhist modernism, which is based on the possibility of social change for the better. So although mofa was widely emphasized by the Pure Land movements in Japan, it

19

The notion of the final days of the Dharma comes from the idea that while the truth about the nature of reality (dharma) propounded by Sakyamuni and other Buddhas before him is considered to be unchanging, human expressions of that truth and their communities are viewed as conditioned, thus impermanent phenomena. According to this understanding, each Buddha discovers the same truth about reality as that realized by his predecessors, and then he teaches it to a community of followers. After a certain period of time, however (commonly ranging from five hundred to five thousand years), this truth will be forgotten, thus necessitating its rediscovery by another Buddha in the future. See Jan Nattier, Decline of the Dharma, pp. 210-213.

34

Buddhist End-of-Life Care in Modern Taiwan did not go well with his vision of renjian fojiao, aimed at the betterment of the world20. His notions of the role of Buddhism in society are argued as even more centered on improving society than Taixu's, partially because Yinshun was much less politically minded than his teacher and focused instead on local participation and reform through education.21 However, despite being less of a political activist than Taixu, Yinshun did not waiver on certain controversial issues taken up by Taixu, particularly his disdain for Buddhist monastic involvement in funeral and afterlife rituals. In fact, upon first arriving in Taiwan, Yinshun was met with public outcry over criticisms he made regarding Pure Land piety.22 As the government was systematically eliminating Buddhism in China, the impact of the vision of these reformist monks became most evident in Taiwanese Buddhist social movements. In the 1960s, when Yinshun was promoting this world Buddhism, Taiwan was transforming from a politically oppressed society to an independent state that was looking for ways to support the social needs of the people. Although Taiwan was establishing an empowered and independent nation, there was still a cultural need to maintain a connection

Marcus Bingenheimer, Writing History of Buddhist Thought in the Twentieth Century: Yinshun (19062005) in the context of Chinese Buddhist historiography," pp. 255-290. 21 Philip Clart and Charles B. Jones, Religion in Modern Taiwan, p. 172. 22 Marcus Bingenheimer, Writing History of Buddhist Thought in the Twentieth Century: Yinshun (19062005) in the context of Chinese Buddhist historiography," pp. 255-290.
20

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Buddhist End-of-Life Care in Modern Taiwan with Chinese religious roots. At this time, ideas promoted by Taixu and Yinshun of attaining a pure land in this world and building a strong socially active Buddhist community were particularly inspirational. Taixus advocacy for a democratic socialist government and ideas for Buddhist interaction with modern international organizations addressed the Taiwanese desire for government reform and international connections. As Yinshuns views began to take root in Taiwanese society, his scholastic endeavors to educate Taiwanese Buddhists and mentor Buddhist monastic leaders brought the ideas of humanistic Buddhism to the Taiwanese people.

36

Buddhist End-of-Life Care in Modern Taiwan Section 2: Modern Taiwanese Buddhist Groups

Today Buddhist activist movements have developed deep roots in Taiwanese society. Over the years, the founders of the highly successful Taiwanese Buddhist organizations have led their followers to build amazingly successful institutional and outreach programs to serve the public. Among their many social programs and services for the public, these groups have worked to successfully revive a strong discipline of monastic study and practice that was temporarily lost in Mainland China, create the largest movement of fully ordained female monastics in the Buddhist world and at the same time, develop a highly motivated lay membership working together with Buddhist practitioners to provide funding and volunteer services for countless social programs across the country. This chapter will introduce three of these leaders who have made prominent contributions to modern Taiwanese healthcare, namely Venerable Masters Xingyun (1927-present), Zhengyan (1937present), Shengyan (1930 2009). Specific attention will be paid to highlighting their visions for modern Buddhist involvement in healthcare and how the programs initiated by these masters relate to those of their reformist predecessors.

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Buddhist End-of-Life Care in Modern Taiwan The first such leader, Venerable Master Xingyun (1927-present), is a monastic of Chinese descent from Yangzhou near Nanjing in Jiangsu Province. Leaving the mainland for Taiwan at age 23, immediately preceding the Communist takeover, he became the leader of one of Taiwans most popular socially engaged Buddhist groups. Based on his highly successful enterprise Fo Guang Shan Monastery Buddhist organization founded in 1967, and the lay organization Buddha Light International Association founded in 1992. Due to his great accomplishments Xingyun has been called the leader of the most vigorous, innovative, and expansive Chinese Buddhist movement of the post-war generation.1 Claiming that his inspiration comes from Taixu, Xingyun is hailed as the monk who successfully put Buddhism for human life into practice, renaming it Humanistic Buddhism . He advocates for education through building numerous universities, and social outreach programs to benefit the general public. Committed to Taixus vision for the establishment of international humanistic outreach, Xingyun has established over two hundred Fo Guang Shan branch centers and temples internationally.

Donald A. Pittman, Toward a Modern Chinese Buddhism Taixus Reforms, p. 273.

38

Buddhist End-of-Life Care in Modern Taiwan Xingyun focuses on activism that attempts to make a pure land on earth and states that the pure land is within the mind of the individual.2 In discussions on exactly how Buddhists are to practice compassionate behavior toward others, Xingyun shares views closely with Taixu, yet his stance is slightly different on a few specific topics. Although it has caused for mixed response from the public, Xingyun is known for his political participation and considers such activities as part of ones social responsibility. Xingyuns Fo Guang Shan Buddhist groups take responsibility to provide social welfare for the Taiwanese public through establishing orphanages, seniors homes, universities such as Fo Guang University , Nanhua University , museums, etc. Most notably for our purposes Fo Guang Shans healthcare services focus mainly on establishing programs to provide volunteer outreach services. For instance, the Fo Guang Shan Compassion Foundation (Foguangshan cibei shehui fuli jijinhui)3 organizes mobile hospital vans to visit remote areas of the country and provide at home medical care for people who find it difficult to access care. Fo Guang Shan has also established a Buddhist run seniors home, Lanyan Foundation of Seniors

2 3

Ibid, p. 274. Fo Guang Shan Compassion Foundation, Accessed April 24, 2012, http://www.compassion.org.tw/index/index.tpl.htm.

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Buddhist End-of-Life Care in Modern Taiwan Citizens Home in Yilan County (Caituanfaren yilan sili lanyang renai zhijia)4 where monastics, nurses and volunteers work together to care for seniors in a Buddhist temple environment. Additionally, monastics within Fo Guang Shan have acted as leaders in educating the public on life and death and have worked to incorporate the study of life and death into public dialogue and mainstream university curriculums. For instance, Xingyuns disciple Venerable Huei Kai lectures to physicians, nurses and to the general public on life and death, encouraging open discussion on the topic to help individuals come to terms with death and as a result, have a more fulfilling life. To date, Huei Kai he has released two DVDs exploring Buddhist ideas of life and death in the modern world, as well as presented Buddhist views on this topic at numerous international religious and inter-faith conferences. More substantially, Huei Kai has successfully established a Life and Death department at Nanhua University in central Taiwan, securing the once taboo topic into the realm of scholastic study. These substantial contributions reflect a significant change in the role of the Buddhist monk in preparing the public to face death. The work of monks like Huikai has reaffirmed the association of the

Lanyang Foundation of Senior Citizen's Home Ilan R.O.C., Accessed April 24, 2102, http://dharma.fgs.org.tw/shrine/fgsastw8y/01/index.htm.

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Buddhist End-of-Life Care in Modern Taiwan Buddhism with death, but in a modern, intellectual and ultimately beneficial way for the modern world. Although the efforts of Fo Guang Shans Buddhist monastics center on activism in this world, it is still very common for the Taiwanese public to request conventional or otherworldly Buddhist practices to help them as they approach death. As such, Fo Guang Shan monastics will regularly participate in traditional funeral ceremonies, or ritual chanting on behalf of the deceased as needed by the public. Fo Guang Shan temples also hold Pure Land chanting retreats aimed at reinforcing belief in the aspiration for rebirth in an otherworldly Pure Land.5 Our second modern Taiwanese Buddhist leader, Venerable Master Zhengyan, founded the renowned Tzu Chi Foundation (Ciji gongde hui) in 1966. Zhengyan shares her vision and lifes mission with that of her tonsured master Yinshun. Like her predecessors, Zhengyan advocates that Buddhism and modern science share compatible worldviews as they are both based on rational thought. Tzu Chis monastic and lay following are known for their active role in developing compassionate service for society, rather than focusing on religious worship or studying Buddhist doctrine. Zhengyan insists that Buddhisms role in humanity is not passive, and that followers of the Buddha should actively bring positivity to the world around them through good
5

Philip Clart and Charles B. Jones, Religion in Modern Taiwan, p. 172.

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Buddhist End-of-Life Care in Modern Taiwan deeds and social programs to help the needy and establish a pure land in this world.6 The extensive outreach programs of Tzu Chi work to deliver social services not just in Taiwan, but also in many countries around the world. Since 1986 Tzu Chi has made a very special, large-scale contribution to the field of medicine in Taiwan. After tremendous efforts in fundraising and financial assistance from Yinshun himself, Tzu Chi opened the first general hospital in the remote eastern city of Hualian, where locals were suffering from limited access to healthcare. The establishment of this first major Buddhist hospital helped to solidify the transforming role of the Buddhist institution, from a purely religious association concerned with otherworldly attainments to a major authority and provider of medical care in this world. Tzu Chi Buddhist hospitals are at the forefront of Taiwanese biomedical intervention; treatments such as organ and marrow donation are common within these facilities.7 The organization also founded large-scale health educational facilities such as a college of nursing (1989) as well as a college for medicine, Tzu Chi University (1992) and funded numerous medical research endeavors. After the success of this first facility, five subsequent branch hospitals were established across the island.

6 7

Donald A. Pittman, Toward a Modern Chinese Buddhism Taixus Reforms, p. 287. Donald A. Pittman, Toward a Modern Chinese Buddhism Taixus Reforms, p. 289

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Buddhist End-of-Life Care in Modern Taiwan Despite her obvious interest in the health and welfare of the Taiwanese people, Zhengyan shares Yinshuns distain for involvement with politics and forbids her disciples from becoming involved in political campaigns.8 Following lead devotees did not publically involve themselves in health policy reform and were not part of the movement to socialize healthcare in Taiwan.9 Although the central aim of the Tzu Chi hospitals is to provide medical care for patients, these facilities each provide space for accommodating traditional Buddhist end-of-life ritual practices. The Tzu Chi hospitals include hospice wards, which have special rooms set aside for religious practices at death. There are cleansing facilities where families can wash their dying loved ones and rooms are prepared with interchangeable religious icons for people to chant with the dying patient for as long as they deem necessary.10 The inclusion of such amenities within Tzu Chi hospitals indicates that the public still requires such practices at death, and that the Buddhist communities in Taiwan provide the means to meet these needs within modern biomedical facilities. The third and last modern Buddhist leader who will be introduced is Venerable Master Shengyan, whose Buddhist activism was highly influenced by his close connection with the charitable and scholarly Venerable Dongchu
David C. Schak, Community and the New Buddhism in Taiwan, pp. 161-192. Philip Clart and Charles B. Jones, Religion in Modern Taiwan, p. 176. 10 This information was obtained through person observation when visiting Tzu Chi hospitals and speaking with Buddhist chaplains in November of 2011.
8 9

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Buddhist End-of-Life Care in Modern Taiwan (19071977), a lesser known monastic who was also studied under Taixu. Born in a rural area near Shanghai, Shengyan became a novice monk at the age of twelve. By 1949, the Chinese Nationalist government was in disarray and being overthrown by the Communist Party. Such political and social strife inspired Shengyan to temporarily leave his monastic pursuits and enlisted in the military, in an attempt to contribute to a positive future for China. Ultimately the Nationalist Party was defeated and retreated to Taiwan, where Shengyan was transferred. In Taiwan, Shengyan left the military to return to monastic pursuits and received tonsure under Dongchu.11 In 1969 he left Taiwan to pursue a doctoral degree in Buddhist literature in Japan, later becoming the first Chinese Buddhist monastic to earn a doctoral degree.12 After this time he traveled to America to educate western scholars about Buddhism and establish Zen meditation centers. However, in 1977 Donchu passed away unexpectedly and in his will was the request that Shengyan take over his Buddhist organizations, prompting Shengyan to return to Taiwan.13 Throughout the rest of his life Shengyan frequented back and forth between America and Taiwan teaching at various universities and establishing Zen meditation centers in America. In 1989

Shi Shengyen, Orthodox Chinese Buddhism: A Contemporary Chan Master's Answers to Common Questions, pp. 19-31. 12 Donald A. Pittman, Toward a Modern Chinese Buddhism Taixus Reforms, p. 280. 13 About, Accessed April 24, 2012, http://www.dharmadrum.org/content/about/about2.aspx?sn=50
11

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Buddhist End-of-Life Care in Modern Taiwan Shengyan founded Dharma Drum Mountain (Fa Gu Shan) in the north of Taiwan, with the goal of uplifting human nature and establishing a pure land on earth.14 In 1994 the National Taiwan University Hospital (NTUH) Department of Family Medicine, established a clinical monastic training program under the sponsorship of the Buddhist Lotus Hospice Care Foundation (Fojiao lianhua jijinhui) at the Palliative Ward of NTUH. In 1998 the dean of Dharma Drum Mountain College of Buddhism, Venerable Huimin , was invited to join the activities of the Lotus Foundation and became a prominent supporter and member of the board. In an attempt to offer non-sectarian training and care to Taiwanese end-of-life patients, Huimin does not play a very public role in the foundation and encourages monastics from various Buddhist groups to study or lecture at the facility. Inspired by the Christian based chaplain groups providing hospice care in Taiwan, the mission of the foundation became to establish a clinically trained Buddhist group of care practitioners to meet the particular spiritual end-of-life care needs of the Taiwanese population. Hence, the first major teaching facility was established to train Buddhist Chaplains to work alongside physicians to

14

Donald A. Pittman, Toward a Modern Chinese Buddhism Taixus Reforms, p. 283.

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Buddhist End-of-Life Care in Modern Taiwan deliver spiritual care to compliment medical care.15 Since its inauguration, the foundation has grown immensely popular and now provides comprehensive training programs for chaplains to actively participate in-patient and family care, focusing on education programs to understand the nature of death and being a prominent member of the clinical team in end-of-life care. What we can observe from the progress in health related outreach activities of these three groups is quite different from the type of services that Chinese Buddhists have historically provided at death. In Taiwan, the Buddhists role at end-of-life is evolving. Buddhists are involved in meeting the ritual, spiritual and now the clinical care needs of individuals, providing a variety of services that benefit patients in life and in death. As advocated by their predecessors, Taiwanese Buddhist groups are actively changing the public image of monastics as being preoccupied solely with funeral ceremonies to having a much more active role in the health and wellbeing of individuals while they are still alive and as they approach death. Through involvement in such activities as facilitating public health services, modern Buddhist groups established themselves as care providers for the health needs of individuals in this world. Fo Guang Shans outreach services effectively brought medical care to remote areas of the country through a mobile hospital vehicle. In addition, the Buddhist

15

Chen Rong-Chi, The Spirit of Humanism in Terminal Care: Taiwan Experience, pp. 7-11.

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Buddhist End-of-Life Care in Modern Taiwan seniors home created a place where elderly Buddhists could spend the end of their life in a religious setting. The efforts of Tzu Chi to create large-scale Buddhist medical facilities and fund modern medical research projects tremendously altered the role of the Buddhist group as the major health service provider in the country and as actively promoting research in modern biomedical technology. The last example provided, the creation of the clinical Buddhist chaplain, exhibits the most significant change in the role of the Buddhist at end-of-life in that Buddhist groups are now actively participating in physician centered care.

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Buddhist End-of-Life Care in Modern Taiwan Chapter 3: Social Changes and Healthcare in Modern Taiwan

Section 1: Prosperity and a Changing Social Demographic

Concurrent with the modern Buddhist movement in Taiwan, over the last few decades the country has experienced tremendous political change and economic growth, creating vast improvements in the standard of living for the country changing the social demographic of the nation. What is referred to as the Taiwan miracle1, the rapid industrialization and economic prosperity of the nation, has meant that Taiwan has opened its doors to foreign influence, leading to rapid social development and modernization. In the past century the country has gone from Japanese rule, to Chinese Republican rule, up until the late 1980s a system of martial law under the retreating Nationalists and in 1996 having the first Taiwanese democratic election. In addition, the Taiwanese government supported tremendous economic growth through a focus on exporting goods to Western countries.2 Along with this trend of political and economic reform, a socially funded National Health Insurance (NHI) program was implemented in Taiwan in 1995, greatly enhancing individual financial protection against unexpected medical expenses and free access to health services for all. Together
Richard Madsen, Democracys Dharma: Religious Renaissance and Political Development in Taiwan, pp. 1-15. 2 Hsin-huang Michael Hsiao, Recapturing Taiwans Democratization Experience, pp. 1-12.
1

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Buddhist End-of-Life Care in Modern Taiwan these changes have brought about major improved standard of living in Taiwan and significantly changing the degree of overall medical care received and life expectancy of the average Taiwanese. Despite high satisfaction ratings, Taiwans reformed healthcare system faces new challenges. As medical technology and access to innovative procedures continue to develop in Taiwan, difficult questions begin to arise such as how the government is to fund medical treatments for citizens who are living longer and becoming more accustomed to healthcare intervention. In a country with socialized healthcare, issues of funding force government policy committees to consider what types of treatments are required to help facilitate good care for patients at end-of-life and to what extent curative treatments are appropriate for the terminally ill.3 Adding to this pressure is the necessity to recognize and prepare for Taiwans growing aging population. Statistically, the demographic transition of birth and death rates in Taiwan from 1960 to the 21st century has brought about dramatic shifts in the age structure of the country.4 In Taiwan, the rate of population aging has increased by an estimated 0.6% every year since 2006 and the growth rate of the elderly segment of the population is among the highest
3

Jui-Fen Rachel Liu and Tung-Liang Chiang, Evolution of Taiwans Healthcare System, pp. 85107. 4 Lin Ming-Hsien, et al., "Population aging and its impacts: Strategies of the health-care system in Taipei," pp. S23-S27.

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Buddhist End-of-Life Care in Modern Taiwan globally.5 The rate of population aging in Taiwan is reported to be so high that by 2050 the elderly population is estimated to exceed 30% of the countrys population, surpassing the United States.6 Taiwan is not alone in this situation as studies are showing that across Asia, and the rest of the world societies are rapidly aging, this change in demographic is attributed to such factors as declining fertility combined with an increased life expectancy. What makes these issues unique in Taiwan is that healthcare providers have strong social and economic support from welldeveloped, highly active humanitarian Buddhist groups. Through programs such as those outlined in the previous chapter, Buddhist groups provide strong complimentary health support to government funded healthcare programs. While the assistance provided through these outreach programs provides much needed service to the Taiwanese, it is interesting to consider how the views and ideals of these Buddhist groups influence the types of care that are provided for dying patients, and alternatively, how biomedicine and the clinical setting has influenced the practices of modern Buddhist end-of-life caretakers. For instance, the outreach programs of some of these Buddhist organizations in Taiwan appear to meet modern bioethical issues head on by embracing modern

Lin Ming-Hsien, et al., "Population aging and its impacts: Strategies of the health-care system in Taipei," pp. S23-S27. 6 Ibid.
5

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Buddhist End-of-Life Care in Modern Taiwan biomedical technologies and providing services in some of the most advanced procedures at end-of-life. For example, the modern procedure of post-mortem organ donation is a highly contentious for some religious groups, and even conflicts with the beliefs of some Buddhist groups, but this treatment is provided through Taiwanese Buddhist healthcare facilities and is considered an appropriate practice for the modern Buddhist individual.7 Although modern biomedical research and procedures are popular in Taiwan, it is important to note that a number of recent biomedical research studies reveal that many terminally ill Taiwanese patients struggle with their religious or culturally based needs being adequately met in modern medical facilities. These studies, that will be discussed in chapter six, indicate the possibility that modern medical and religious reform may be moving more quickly than is appropriate for some Taiwanese individuals when it comes to beliefs and practices that are important at end-of-life.

In Japan, for instance, organ donation has not been accepted within the culture. See Margaret M. Lock, Twice Dead: Organ Transplants and the Reinvention of Death, pp. 1-14. 51

Buddhist End-of-Life Care in Modern Taiwan Section 2: Taiwan Healthcare Reform For The Aging

The massive healthcare reforms that have taken place in 20th century in Taiwan, establishing it as an international competitor as far as public access to medical care, marks the first time the countrys government has played a significant role in health care delivery and financing.1 Western medicine first started to be practiced in Taiwan by missionaries coming from the UK in the late 1860s. Before this time Chinese doctors dominated mainstream health care delivery but there was no formal system of licensing in the country. The prominence of Chinese medicine began to diminish soon after Japan took over Taiwan and the colonial government increased the supply of Western-style providers by establishing the first school of Western medicine and constructing a number of public hospitals staffed by licensed doctors trained in Western medicine. After World War II, as the government changed hands back from Japanese back to Chinese rule, Western medicine continued to flourish and dominate Taiwanese healthcare, while at the same time there was also strong public demand for Chinese medicine.2 With the establishment of the Department of Health (DOH) under the national cabinet in 1971, Taiwans healthcare system moved into a new era

Jui-Fen Rachel Liu and Tung-Liang Chiang, Evolution of Taiwans Healthcare System, pp. 85107. 2 Ibid.
1

52

Buddhist End-of-Life Care in Modern Taiwan characterized by the governments active involvement in health care reform. Since then, Taiwans healthcare system has undergone two important periods of development: first the pursuit of health care for all, from 19711995 and second, the moving toward a high performing health system from 1995 to the present. After much planning and consideration beginning in the early 70s, Premier Yu Kuo-hwa made a policy announcement calling for health insurance for all by 2000, thereby making healthcare reform recommendations a chapter of the Long-term Economic Perspectives in Taiwan, 19862000, which eventually formed Executive Yuans policy guidelines for Taiwans economic development.3 At the same time, as was mentioned earlier, Taiwans political environment and climate was undergoing major transitional changes. In the process of democratization, Taiwans first opposition party, the Democratic Progressive Party was officially formed on 28 September 1986, and in 1987 the government lifted the Emergency Decree Law (martial law). On 28 February 1989, Premier Yu announced the plan to advance the new target year for implementing the NHI program to 1995.4 The accelerated implementation timeline of NHI, five years ahead of its original schedule, was largely a product of increasing public demand for universal health coverage. The

Jui-Fen Rachel Liu and Tung-Liang Chiang, Evolution of Taiwans Healthcare System, pp. 85107. 4 Ibid.
3

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Buddhist End-of-Life Care in Modern Taiwan current NHI program was also updated to include providing a comprehensive benefits package covering preventive and medical services, prescription drugs, dental services, Chinese medicine and home nurse visits.

Section 3: Biomedical Research On End-Of-Life Needs Of Taiwanese Patients

In this next section, a number recent biomedical studies will be introduced that address various challenges faced by Taiwanese end-of-life patients within the reformed system of care. In order to highlight the specific care needs that would involve Buddhist caretakers, the information presented from the studies will be limited to non-physical needs, ones that were categorized as religious, spiritual or cultural. The intention is to highlight Taiwanese end-of-life needs as identified within the new structure of socialized health care in order to later compare these needs with programs that are provided by Buddhist chaplains and Buddhist end-of-life care programs. The accelerated implementation of socialized healthcare and the introduction of specialized policy for terminally ill patients has brought Taiwanese health policy rapidly into the modern age of biomedicine. However, recent Taiwan based biomedical studies that will be examined within this chapter show that many patients indicate fear of not having their religious or cultural end-of-life needs met in medical facilities. It is possible that even though
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Buddhist End-of-Life Care in Modern Taiwan reformed government health policy has dramatically improved Taiwans standards in providing access to medical care, this transition has perhaps overlooked the needs of many Taiwanese end-of-life patients. These studies suggest that modern ways of caring for terminally ill patients that do not accommodate for patients beliefs in reincarnation and the afterlife experience will not adequately meet their needs as they approach death. So, while modern Buddhist end-of-life caretakers may focus on helping the individual in this world, a number of Taiwanese patients still require religious guidance and assistance with their otherworldly beliefs. These studies indicate that cultural and religious beliefs of individuals are not necessarily always compatible with modern medical practices, suggesting that there is room for improvement in accommodation of the otherworldly needs of Taiwanese terminally ill patients. A 1997 study from Wang et al. on medical care for AIDS patients in Taiwan showed that while physical discomfort was being treated, patients indicated that end-of-life care was not adequately addressing the psychological needs of its patients.5 The study found that a number of the psychological issues were unique to Taiwans specific religious and cultural beliefs. For instance, patients expressed a desire to return to their home to die, as expressed as a belief that if one does not die at home, the spirit would become a restless ghost and
5

Shirley S.L. Wang et al., "The Health Care Needs of Hospitalized Patients with AIDS in Taiwan," pp. 179-188.

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Buddhist End-of-Life Care in Modern Taiwan harm members of the remaining family. Additionally, a number of patients communicated a desire to be cleaned and dressed in appropriate attire before they die, as they believed that a person who dies in non-formal clothing would be a beggar in their next life. A third issue was that patients found it undesirable and even against their cultural values to speak about death, either with their doctors or with family members. Patients claimed that to speak about death directly was a social taboo in traditional Chinese culture, instead preferring to use the phrase "go home" as opposed to death. A 2006 study of Taiwanese terminal cancer patients from Shih and her research team indicated similar evidence to Wangs study. In this study 86% of the participants expressed a wish to die at home, believing that without this the soul of the dead cannot be reunited with his or her family and become lost in the underworld. Results from this later study also revealed that patients regarded discussion around death and dying to be culturally taboo and were uncomfortable discussing such issues with family members and physicians. What was interesting about this study was that although talking about illness, death and dying were considered cultural taboos and bad luck to the patients, many older patients who were participating in the research study admitted that

56

Buddhist End-of-Life Care in Modern Taiwan they appreciated the opportunity to discuss their health status and their preparations for a peaceful death.6 A later study from Shih and her team published in 2009 aimed to identify the spiritual needs of Taiwanese end-of-life patients and evaluate the various measures of care provided to meet these needs in a healthcare environment7. This study noted tremendous difficulties in even determining a common definition of spirituality or religion that suited all of the patient participants. Despite these difficulties, the study revealed the common theme that fulfillment of patient needs during the final phase of life involved a process that involved pursuing an afterlife as a transcendental spiritual being. Similar to the two previous studies discussed, many of the participants were concerned with their bodily appearance at death and expressed a desire to take their last breath at home, as these factors had relevance to their beliefs and preconceptions about afterlife experience and rebirth. This study also noted that although patients generally feared their own death and were not generally comfortable discussing it, they found it helpful and important to open up to discussions on life and death. A fourth study from Chao et al. looked at a cross section of Taiwanese terminally ill patients from various age groups to see if end-of-life needs were

6 7

Shih Fu-Jin et al., Death and Help Expected from Nurses when Dying, pp. 360-375. Shih Fu-Jin et al., Spiritual Needs of Taiwans Older Patients With Terminal Cancer, pp. 31-38.

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Buddhist End-of-Life Care in Modern Taiwan common to specific age brackets.8 The study found that across all age groups fear of death was a common characteristic among palliative care patients, and this fear increased as the patient approached their last days of life. Based on these findings the research team concluded that comprehensive care in the palliative care unit should include a focus on the relief of the death fear in cancer patients, consequently revealing a need for psychological and spiritual care in care facilities for the terminally ill. The findings of these studies reveal an interesting pattern consisting of distinct themes in end-of-life desires of Taiwanese patients: wanting to die in the home to assist their spirit in reconnecting with the family, a desire to be properly washed and dressed upon death as it affected the afterlife experience, and a general fear of death combined with a cultural taboo of speaking about it whatsoever. Based on how these specific end-of-life needs were described by the patients, it is clear that beliefs from traditional Chinese death culture, as described in chapter one, are still prevalent in modern Taiwan.

Nevertheless, the findings from these studies suggest that terminally ill patients in Taiwan generally fear death and would benefit from more open discussion regarding life and death. Also, terminally ill patients indicate having

Tsai Jaw-Shiun et al., Fear of Death and Good Death Among the Young and Elderly with Terminal Cancers in Taiwan, pp. 343-351.

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Buddhist End-of-Life Care in Modern Taiwan specific hopes for end-of-life scenarios that include assistance in preparing for an otherworldly afterlife experience. The findings of these studies suggest that the terminally ill population in Taiwan would benefit from the care of a religious chaplain to instigate open discussions on death to help alleviate fear surrounding the experience. Additionally, patients appear to require assistance in preparation for otherworldly activities, which was a large part of Buddhist end-of-life care in the past and is still part of care services today. Post-mortem rituals including chanting with a body for a number of hours after death is still practiced, and facilities are provided to accommodate such practices in Tzu Chi hospitals, National Taiwan University Hospital and many hospice units, but such ideas are generally not compatible with the clinical understanding of what happens after death.

In Taiwanese hospitals, hospices that care for the needs of dying patients are modeled after the Christian hospices; however, these Buddhist facilities have altered their services to meet the specific end-of-life needs of the Taiwanese population. To gain a better understanding of how traditional Buddhist care for the dying is incorporated into the clinical setting to provide spiritual care to suit the specific needs of the Taiwanese population, the following two chapters will provide information on the hospice movement in Taiwan and investigate the role of the Buddhist chaplain.

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Buddhist End-of-Life Care in Modern Taiwan Chapter 4: The Hospice Movement In Taiwan And Buddhist Chaplaincy

Section 1: Hospice and Palliative Care in Taiwan

Presently, Buddhist chaplains and lay Buddhists belonging to the modern socially engaged Buddhist denominations outlined earlier provide clinical spiritual care in Taiwan. However, as was also outlined earlier, in the clinical setting these groups focus centrally on caring for the needs of this world and do not focus on otherworldly attainments. Considering the findings of studies on Taiwanese terminally ill patients, it would appear that not all Taiwanese adhere to the reformed Buddhist teachings regarding the rejection of otherworldly attainments. In fact, it seems as though otherworldly attainments and afterlife experiences are very important to Taiwanese individuals, especially as they approach death. Such findings evoke questions as to the type of care that is provided by modern Buddhist groups and how these groups care for individuals who do not adhere to modern religious beliefs. Additionally, policy that looks to provide appropriate care for Taiwanese end-of-life patients needs to be evaluated to analyze whether or not the types of treatments that are provided can accommodate what the public deems as necessary for a good death physically and spiritually.

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Buddhist End-of-Life Care in Modern Taiwan This chapter will explore more closely end-of-life care as it is provided by government funded healthcare and religious organizations in an attempt to better understand exactly what measures are provided for individuals as they approach death. Central to this discussion will be an analysis of the evolvement of publically funded hospice and palliative care in Taiwan, followed by an indepth exploration of the types of services provided by caregivers at these facilities. Spiritual care is highlighted as one of the central care services provided within these facilities. Although Taiwanese hospice services and spiritual care are inspired by Christian based hospices, today Buddhist chaplains provide the majority of hospice care in Taiwan and so for the purposes of this study special attention will be paid to outlining Buddhist involvement in these services. The hospice movement in Taiwan began as part of a larger Asia Pacific hospice movement that spread very rapidly in the 1990s. The Asia Pacific Hospice Network was founded in 1995 and by 1998 it had delegates from 13 countries.1 Taiwan's first hospice ward was established in 1990 as a religiously Christian based facility as part of the Mackay Memorial Hospital in Taipei County. The Taiwan Department of Health established a Task Force for Hospice Care in 1995 as there was public concern regarding the nature of care for terminally ill patients. At that time a palliative ward was established at the
1

Joan C. Lo, The impact of hospices on health care expenditures - the case of Taiwan, pp. 981991.

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Buddhist End-of-Life Care in Modern Taiwan National Taiwan University Hospital in Taipei City, and comprehensive home hospice care was started to become popular in 1996. The movement in Taiwan was spurred by concern over the growing medical cost to treat the rising population of terminally ill cancer patients in Taiwan. Cancer has been the leading cause of death in Taiwan since 1982 and the huge amount of money being spent in the acute care setting for terminally ill cancer patients was not proving to increase their wellbeing2. Home-care nursing institutes providing home-based, long-term nursing care had become the most popular model of long-term care services and were reimbursed by NHI. However, the home-care model, which provided mainly nursing treatments, did not meet the many and complex needs of those receiving care, particularly the elderly. In 1996 NHI policy was amended to include hospice home care as part of general comprehensive coverage and after much lobbying and public debate, in 2000 a Hospice Palliative Care Act (HPCA) was passed. It was the first time in the world that government social policy had used the terms Hospice Palliative Care in the name of a legal act, defining it as palliative or supportive care for decreasing or relieving pain and suffering of the terminal patients. What is also known as the Natural Death Act, legally enacted under the HPCA, effectively legalized and made standard a number of modern, potentially contentious

Joan C. Lo, The impact of hospices on health care expenditures - the case of Taiwan, pp. 981-991.

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Buddhist End-of-Life Care in Modern Taiwan medical practices that were not practiced previously in Taiwan, such as Do No Resuscitate (DNR) orders, Advanced Care Directives (ACDs) and the option of organ donation for terminally ill patients.3 The intention behind the Natural Death Act was to provoke discussion of end-of-life healthcare wishes and to avoid unnecessary pressure from physicians for terminally ill patients to undergo medical treatments, instead allowing patients to focus on non-curative treatments for physical or psychological pain. Publically funded hospice care was an important part of healthcare for Taiwanese as it emphasized more on the various non-physical needs of patients as opposed to purely medical care at endof-life. Terminally ill patients were thus considered to be a unique patient population with unique medical and psychological care needs. Additionally, international studies showed that overall costs of hospice care for patients in their last months of life are far less than conventional care.4 The benefits of the HPCA as outlined under NHI specifically for terminally ill patients include inpatient and outpatient services, home care, home hospice care services, preventive medicines including Chinese medicine, and pharmaceutical drugs. The beginnings of hospice care treatment came from religious organizations that created the foundations for promotion of this movement, namely, the Catholic Sanipax Socio-Medical Service & Education Foundation
3 4

Chen Rong-Chi, The Spirit of Humanism in Terminal Care: Taiwan Experience, pp. 7-11. Joan C. Lo, The impact of hospices on health care expenditures - the case of Taiwan, pp. 981-991.

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Buddhist End-of-Life Care in Modern Taiwan (1983), the Christian based Taiwan Hospice Foundation (1990) and the Buddhist Lotus Hospice Care Foundation (1994), which is backed by numerous Buddhist groups, as noted earlier. As the hospice movement became more recognized for providing important care measures for terminally ill patients, other health professionals became involved. For instance, the Taiwan Hospice Organization was founded in 1995 to unite all care providers and personnel involved and in 1999, physicians desiring formal involvement in the hospice palliative movement established the Taiwan Academy of Hospice Palliative Medicine.5 In 2004, the National Health Research Institute launched the first geriatrics fellowship training program in Taiwan with assistance from Mt. Sinai Medical School of New York. The pilot program ended in 2006 due to budget limitations. However, in 2006 Taipei Veterans General Hospital also started its own geriatrics fellowship training program through a collaboration with the British Geriatrics Society. Today, many professional home-care services targeted to serve the needs of end-of-life patients such as, nursing services, home-based physical therapy, occupational therapy, nutritional therapy and respiratory therapy, meal delivery services, day services, respite care services, transportation services, and many other social services are all reimbursed under the NHI program. To avoid over-

Chen Rong-Chi, et al., The Development of Hospice Palliative Care in Taiwan, pp. 2108-2110.

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Buddhist End-of-Life Care in Modern Taiwan hospitalization of end-of-life care, a pilot program to step-up care within homes and to provide end-of-life care in communities was launched in 2010.6 Additionally, to cope with the rapidly increasing elderly population and longterm care needs a new National Long-Term Care Insurance, set to be launched in 2012, to provide seamless care for older people, from health-care to social welfare. The pending National Long-Term Care Insurance program plans to partially reimburse the institutional care of severely disabled older people.7 An in-patient Palliative Care Ward was successfully founded at the National Taiwan University Hospital (NTUH) in 1995. During the period from 1998 to 2006, due to the growing demands for spiritual guidance for terminally ill patients in hospice/palliative care and their families, the NTUH Palliative Ward, along with the Buddhist Lotus Hospice Care Foundation and Yi-Ju Sanctuary Hospice Care Association, developed a spiritual care model for terminal patients that included clinically trained Buddhist chaplains to provide spiritual care.

Section 2: The Taiwan Association of Clinical Buddhist Studies

In 2000, the first facility for Buddhist monastics was founded to train Buddhist chaplains to participate in medical care. The Taiwan Association of

Lin Ming-Hsien, "Population aging and its impacts: Strategies of the health-care system in Taipei," pp. S23-S27. 7 Ibid.
6

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Buddhist End-of-Life Care in Modern Taiwan Clinical Buddhist Studies (TACBS) training center was created at the Palliative Ward of NTUH. The stated mission of the TACBS is to integrate modern medicine with Buddhist studies, develop a spiritual care model indigenous to the culture of Taiwan and to enhance the quality of palliative care for terminally ill patients. These proposed ends are met through research activities, education programs, and training courses with a focus on clinical Buddhist studies and work for the incorporation of palliative care training and life education as components of health promotion activities and courses.8 Today clinical Buddhist chaplains can be seen providing spiritual care for terminal cancer patients in nearly 30 hospitals throughout Taiwan. Chen writes that the future plans for the foundation include promoting the incorporation of a clinical Buddhist monastic training program within the curriculum of Buddhism colleges in Taiwan universities.9 In the TACBS mission statement written by Chen, he addresses the need for spiritual care in clinical facilities for the terminally ill to help relieve what he calls spiritual unrests suffered by the patients. He writes, these spiritual unrests are caused by, as well as causing, loss of self-respect, self-abandonment, attachment (e.g., reluctance, worries, ties and regrets), fear of death, and

Taiwan Association of Clinical Buddhist Studies, Accessed April 24, 2012, http://www.tacbs.org/xms/. 9 Chen Rong-Chi, The Spirit of Humanism in Terminal Care: Taiwan Experience, pp. 7-11.
8

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Buddhist End-of-Life Care in Modern Taiwan unfulfilled wishes.10 TACBS aims to provide spiritual care for terminally ill patients through the integration of core Buddhist wisdom into contemporary medical care, helping thereby to render Buddhist spiritual care an essential aspect in providing modern healthcare. He writes that based on their unique religious and spiritual learning background, clinical Buddhist chaplains are able to better interact with terminal patients and guide them on their journey to a peaceful death. The establishment of the TACBS is a prime example of modern Buddhist social outreach with the aim of maintaining a lasting connection between modern Buddhist monastics and physicians so they can work together to care for the various needs of a dying patient. Thinking back to the studies that described Taiwanese end-of-life needs, the TACBS mission statement directly addresses the need to alleviate patient fear of death and to fulfill end-of-life wishes. What is perhaps more interesting is in describing the various needs of hospice patients Chen does not mention anything regarding funeral preparations or assistance in the journey into the afterlife. In fact, he says quite the opposite stating that the Buddhist chaplain is to guide terminal patients in their journey toward death. He addresses a number of specific spiritual unrests experienced by patients, but is not explicitly clear exactly what is meant by this term.
10

Taiwan Association of Clinical Buddhist Studies, Accessed April 4, 2012, http://www.tacbs.org/xms/.

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Buddhist End-of-Life Care in Modern Taiwan From what was discussed earlier with regards to the changing perspectives of modern Buddhist groups regarding end-of-life, it seems possible that Buddhist chaplains working in a clinical setting are not trained by the TACBS to handle otherworldly matters. However, since ceremonies and rituals involving the afterlife are commonplace in Taiwan, we know that Buddhist monastic training already includes education on how to assist individuals with these matters. This leaves the question, what exactly is taught in the Buddhist chaplaincy programs offered though the TACBS? What is offered as far as Buddhist doctrine, how does it relate to issues of afterlife attainment and how is such training applicable to the clinical setting? As we have seen so far in this paper, Taiwans recent implementation of socialized healthcare has had great support from modern Buddhist outreach programs that have undergone equally proportionate restructuring. Through their extensive outreach activities, such groups have alleviated some of the pressure on government agencies by providing programs to care for the sick and dying. The wide range of services offered by these groups includes providing mobile medical care to remote areas of the country, establishing modern hospitals, providing in-hospital or outreach spiritual care for sick patients, and centers to train spiritual chaplains to care for patients in hospitals. The success of these services indicates that there is a thriving relationship between Taiwanese

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Buddhist End-of-Life Care in Modern Taiwan modern Buddhist activities and the interests of modern medical facilities, negating questions of the incompatibility of the two social entities. Care is provided in the clinical setting, while Buddhist connections with supernatural or otherworldly attainments are still recognized and accommodated in modern Taiwan regardless of whether or not they fit within the reformed Buddhist view. Considering what has been established thus far, what has yet been discussed is exactly what Taiwanese clinical Buddhist end-of-life care is. Does the influence of the clinical setting dictate the types of religious care that can be provided? How are otherworldly practices still carried out and modified within the medical arena? Which Buddhist tenants or doctrine is considered appropriate for modern terminally ill patients? If Taiwanese Buddhist groups regard their beliefs as compatible with biomedicine, how are new procedures and technologies negotiated when they conflict with traditional practice? These questions will be addressed in the eighth and final chapter of this research paper through an examination of nine different articles on Buddhist chaplaincy written by Taiwanese physicians.

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Buddhist End-of-Life Care in Modern Taiwan Chapter 5: Articles From The Taiwan Association For Buddhist Studies

In an attempt to answer some of these questions and to gain a clearer understanding of how the care provided by Buddhist chaplains relates to both Buddhist doctrine and modern medicine, the following chapter will review a number of recent articles written by Taiwanese physicians directly addressing the specific role and practices of Buddhist chaplains, as trained by the Taiwan Association for Buddhist Studies (TACBS). Although these articles were written and published in Chinese, their abstracts have been translated into English and posted on the TACBS website. The website does not indicate in which scholarly journals these articles were published in their original Chinese format, but each of them was written by Taiwanese physicians working in NTUH. The following sections of this final chapter will draw upon and discuss the various Buddhist practices and beliefs outlined as beneficial to palliative patients, and how they relate to the objectives of modern medical care. The studies also provide insight into how modern bioethical issues regarding death and dying are contextualized for the clinical Buddhist audience. In an attempt to organize these abstracts, they will be grouped together and analyzed in terms of basic themes of discussion. The first group of studies provides a basic outline of the role of Buddhist chaplains in providing end-of-life care. The second group focuses on educational
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Buddhist End-of-Life Care in Modern Taiwan role of the chaplain to teach patients and their families about the nature of life and death and guide them to accept their inevitable fate. The third groups of studies outlines specifically which Buddhist doctrine is recommended for caring for terminally ill patients and their families and the last article discusses the role of the clinical Buddhist chaplain in participating in end-of-life ceremonies.

Section 1: The Role of the Buddhist Chaplain

The first abstract from the TACBS website entitled, The Role of Clinical Buddhist Chaplains in the Hospice/Palliative Care1, written by Tsung-Tueng Bhikkhuni and her research team, delineates various aspects to the role of the Buddhist chaplain in caring for the terminally ill. The first aspect is the importance of guiding patients to accept their death as a natural course in life. Symptom control is listed as the second priority of the chaplain including physical discomfort, mental, social, or spiritual stress. The third is the necessity for clear communication in an effort to acknowledge and understand specific physical and mental needs as well as any spiritual needs of the patients. The final aspect of the role of the chaplain is to work as part of a professional team

Tsung-Tueng Bhikkhuni, et al., The Role of Clinical Buddhist Chaplains in the Hospice/Palliative Care.

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Buddhist End-of-Life Care in Modern Taiwan consisting of doctors, nurses, psychiatrists, chaplains, social workers, volunteers, etc. to provide patient-centered family-focus total care. A second abstract entitled, The Spiritual Care for End-stage Cancer Patients in Taiwan2, written by Chen, shares similar aspects to the first article in asserting that providing care to Taiwanese palliative patients requires an understanding of the unique needs of this population. To realize and satisfy these needs, role of the caretakers is to work as part of the clinical team to alleviate psychological issues associated with coming to terms with death, address physical discomfort, accommodate the essential social relationships involved and provide appropriate spiritual guidance. Before unpacking the asserted role of Buddhist chaplains in providing this care, it is important to discuss the distinct definition of spirit provided in this study. As was mentioned in chapter one, chapter four and chapter six, addressing the spiritual needs of an individual at end-of-life is not a simple task, Taiwanese patients participating in research found it difficult to even describe define spirituality as a concept. However in Dr. Chen Ching-Yus study, the term is clearly defined. He writes, for end-stage patients, the term spirit was defined as the personal capability to recall, enlight (sic) and understand the

Ching-Yu Chen, The Spiritual Care for End-stage Cancer Patients in Taiwan.

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Buddhist End-of-Life Care in Modern Taiwan Buddhas teachings.3 This is quite a distinct definition of the term with explicit implications, if indeed this notion of spirit adequately reflects the sentiment of Taiwanese Buddhist chaplains. Using the information again revealed in previous research on end-of-life Taiwanese patients, needs that were identified as nonphysical or otherworldly reflected specific desires that were both Buddhist and non-Buddhist in nature. To assume that the spiritual needs of a patient necessarily entail understanding the Buddhas teachings could lead to inappropriately impose specific religious beliefs to a highly vulnerable population who might not wholly subscribe to this set of beliefs. Patients nearing their death could become convinced that their own beliefs are thereby incorrect, potentially causing mental anguish and undue stress. At this time it is unclear how this assumption, if it is indeed true, that spirituality is necessarily Buddhist in nature affects Taiwanese chaplain care; however, more information will be revealed as these studies are further examined. Chen Ching-Yus study asserts that the Buddhist chaplain essentially works to compliment or upgrade purely medical care as an essential aspect of a system of complete care for mind, body, society and spirit of the patient. The role of the Buddhist chaplain in clinical care is described as providing the four major elements of hospice care to improve patient experience at end-of-life.

Ching-Yu Chen, The Spiritual Care for End-stage Cancer Patients in Taiwan.

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Buddhist End-of-Life Care in Modern Taiwan These elements are: (1) helping the patient to accept death, (2) providing humanistic care, (3) ensuring good communication, and (4) offering team care. The framework of spiritual care in Taiwan is stated as consisting of informing patients of their conditions and guiding them to accept death, helping the patient experience and feel the existence of their spirit, and assist the patient in abiding by and upholding the Buddhist Dharma as they approach death. Although these two articles vary in their description of the role of the Buddhist chaplain, they both emphasize the same basic elements in providing complete care for dying patients and together they appear to satisfy a variety of the needs identified by Taiwanese end-of-life patients in chapter six. The elements as outlined in the first article unmistakably affirm the goals of modern Taiwanese Buddhist movements and emphasize the importance of meeting the unique needs that the terminally ill population may have; whereas the second article draws a much clearer association with Buddhist doctrine and provides more cause for thought. When it comes to the administration of Buddhist care that emphasizes a focus on upholding Buddhist Dharma, it is important to consider what aspects of Buddhist Dharma are being emphasized as appropriate for end-of-life patients and how the Dharma is being administered to the public. At the forefront, the role of the chaplain emphasized in these two articles is to guide the patient to come to terms with and accept death. Not only does this

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Buddhist End-of-Life Care in Modern Taiwan highlighted aspect of Buddhist chaplaincy directly address the predominant issue of fear of death by asserting that, Patients should be informed of their illnesses and guided to accept death and be prepared for it4, but it also synchronizes the clinical objective with the role of the chaplain. The chaplains responsibility toward this goal is asserted as clarifying that death is a natural part of life, a concept that easily associated with early Buddhist and Daoist doctrine, as was shown in chapter one. Although outlining the role of the Buddhist chaplain as one who helps to alleviate fear of death by promoting the acceptance and understanding, which is a manner of thinking in keeping with Buddhist concepts, conceiving of life and death in this way has generated interesting outcomes in the clinical setting in Taiwan. The importance for Taiwanese Buddhist chaplains to guide terminally ill patients to accept death has directly affected trends in Taiwanese bioethical decisions regarding the implementation and perspectives toward such biomedical notions as Do Not Resuscitate Orders (DNRs). A DNR is an advanced care directive that indicates a patients wishes not to be resuscitated when their heart or breathing stops and they are unable to communicate their wishes5. Advocates from the Buddhist Lotus Hospice Care Foundation and the TACBS were at the forefront of the promotion of legalizing the Natural Death
4 5

Ching-Yu Chen, The Spiritual Care for End-stage Cancer Patients in Taiwan. Chen Rong-Chi, The Spirit of Humanism in Terminal Care: Taiwan Experience, pp. 7-11.

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Buddhist End-of-Life Care in Modern Taiwan Act in Taiwan. In a 2009 article published by Chen Rongh-Chi, he endorses the DNR as a means for bringing a peaceful ending for patients and giving the patient and the family a form of gracious closure of a difficult life. He urges medical professionals: Do not neglect your solemn duty of helping [the] patient [die] a good death. Please help the patient to make DNR planning in due time and offer hospice care to the patient in need to ensure peaceful dying for each patient.6 Chen Rong-Chi ultimately states that maintaining a religious and holistic spirit of removing suffering of patients and providing happiness includes promoting patients to sign a DNR living will and training Buddhist monastics as chaplains to serve in hospice care. The idea that Buddhist chaplains should advocate that a DNR is associated with a good death and that it is a way to show acceptance of death clearly reinforces religious reformist ideas that Buddhist doctrine is compatible with modern medical thinking. What is also evident from this example is that Buddhist religious beliefs are being used to encourage public opinion on biomedical decisions. Further, the fact that it was Buddhist groups that joined the groups advocating for DNRs to be legalized in Taiwan shows the influence that these groups have on public health policy.

Chen Rong-Chi, The Spirit of Humanism in Terminal Care: Taiwan Experience, pp. 7-11.

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Buddhist End-of-Life Care in Modern Taiwan Proceeding from this first example comparing the articles by TsungTueng Bhikkhuni and Chen Ching-Yu, the subsequent elements outlined as central to the role of the Buddhist chaplain can also be understood in relation to reformed Buddhist thought. The specified aspect of Buddhists organizations providing humanistic care to patients and their families while they are still alive, and not simply assisting them in death, directly aligns with the Buddhist reform movement as advocated by Taixu and Yinshun, therefore suggesting a lineage in this matter. The role of generating communication with patients and their families, specified in both of the articles, simultaneously promotes social bonds and addresses the issue of cultural taboos when discussing death. To advocate for proper communication within the care team and with the patient and their family directly addresses what numerous research studies have outlined as a major bioethical issue for Asian end-of-life patients in modern medical facilities. The issue of lack of communication between physicians, families and patients is commonly associated with ideas of taboos around speaking of death, as discussed in chapter one, and is currently regarded as not beneficial to patients in terms of decision-making and overall psychological experience as they approach death. While the topic of good communication was not specifically associated with Buddhist ways of thinking in these articles, it is clear that the

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Buddhist End-of-Life Care in Modern Taiwan Buddhist chaplain is responsible for promoting open discussion regarding the issue. The final aspect of care expressed in the article by Tsung-Tueng Bhikkhuni, upholding the Buddhist Dharma as patients approach death, identifies that chaplains should assist patients by employing a specific set of ascribed beliefs that could prove problematic in end-of-life patients, as was mentioned earlier. This is problematic for patients who do not subscribe to a Buddhist worldview, and also to patients professes to subscribe to a Buddhist worldview that does not necessarily correspond perfectly to the spiritual one being advocated in this program. It appears as though the Buddhist doctrine that is being advocated in the training of Buddhist chaplains is greatly influenced by the teachings of the Chinese reformer Buddhists outlined earlier. As we have already discussed, since the beginning of the reform movement in Taiwan, guidance has come from masters who advocate for the greater importance of assisting people in this world and downplay Buddhist association with otherworldly beliefs. This system of thought is clearly identified in chaplaincy training and the defined clinical role of the Buddhist in end-of-life care in Taiwan.

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Buddhist End-of-Life Care in Modern Taiwan Section 2: Buddhist Life and Death Education in the Clinical Setting

The next few articles posted by the TACBS discuss the important role of education in the work of Taiwanese Buddhist chaplains. These articles specify that the role of the chaplain is to integrate Buddhist teachings into education for patients regarding the nature of life and death and to council families emotionally through grieving the death of their loved one. What is perhaps most interesting about these studies is that they all specify the importance of using Buddhist doctrine to guide modern Taiwanese patients and their families, but no explicit mention is made of the afterlife. Although reference to Buddhist doctrine, specifically doctrine that related to death, implies an afterlife experience, these articles outlining the role of the clinical Buddhist chaplain focus on how to use Buddhism to help individuals in this world. One article written by Der-Chia Bhikkhuni and her colleagues entitled, The Application of Buddhas Teaching in the Life and Death Education of Terminal Cancer Patients Families7 provides an overview of the reasoning behind using Buddhist doctrine to prepare and educate family members of end-of-life patients and specifies more clearly the various actions that the chaplain role entails. Due to the emotional anxiety felt by many family members, it is stated that one of the

Der-Chia Bhikkhuni, et al., The Application of Buddhas Teaching in the Life and Death Education of Terminal Cancer Patients Families.

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Buddhist End-of-Life Care in Modern Taiwan goals of Buddhist chaplains is to provide life and death education that will prepare families for the death of their loved one. For instance, the study advocates the use of Buddhist teachings to guide families in understanding the essence of impermanence and to break through the difficulties of life and death. Also the role of the chaplain includes educating families on near death symptoms so they can prepare for the experiences they will encounter with their family member. Chanting Buddhist dharma at the time of death is specified as important for many patients, as well as funeral consultation, and grief guidance. The article emphasizes that providing these services lessens the familys anxiety while creating an acceptance of the illness. It is noted that if the family can be lead to accept the death of their loved one then they can begin to consider various consent orders, specifically DNRs, and finally help to participate in creating a peaceful death for the patient. While this article provides a better understanding of the activities that are associated with the work of the Buddhist chaplain, and the practice of chanting with the dying patient is mentioned, a more detailed account of what these activities entail and which Buddhist teachings and practices are used in end-of-life care are discussed in the following subsequent articles.

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Buddhist End-of-Life Care in Modern Taiwan Section 3: The Use of Buddhist Doctrine in End-of-Life Care

The next group of studies from the TACBS elaborates on exactly which Buddhist doctrines and stras are used by chaplains and explains the particular benefit that these teachings have for terminal patients and their families. In particular, teachings from Bodhidharma, chanting the Buddhas name at death, specifically Amitabuddha or Amitabha Buddha, the Heart Stra, Stra of Impermanence are described as specifically addressing the needs of end-of-life patients and for their grieving families. Themes that are drawn upon from these teachings are letting go of attachments, realizing that all things are impermanent and more generally, using these teachings allows the Buddhist chaplain to open up discussion on life and death. The first of these studies, written by Hui-zhe Bhikkhuni et al., explains that Buddhist chaplains are trained to guide patients through what is called clinical dharma talks8. Clinical dharma talks are described as involving a therapeutic review of ones life with the guidance of the clinical Buddhist chaplain. Reviewing ones life entails affirming the meaning and value of life, attaining end-of-life aspirations and moving towards spiritual growth. The use of Buddhist dharma is stated as necessary for the patient as the means for the patient to obtain liberation from suffering associated with death. The Buddhist
8

Hui-zhe Bhikkhuni, et al. Clinical Dharma Talks During Life Review.

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Buddhist End-of-Life Care in Modern Taiwan dharma specifically mentioned as useful for the clinical dharma talk is a teaching from the recently rediscovered text from Dun Huang , which the study calls the Bodhidharma four-line concept , (Damo sixing guan).9 What this study is referring to is a teaching ascribed to the Indian sage Bodhidharma, who is credited for bringing Chan to China. An English translation of this teaching delineates how to follow the Buddhist path of practice, which is coupled with the path of reason. The path of practice has four aspects, suffering injustice, adapting to conditions, seeking nothing and practicing the dharma.10 The four aspects outlined in Bodhidharmas teaching are seen as important and appropriate concepts to discuss with terminally ill patients, as such they can lead to discussions on what it means to suffer, coming to terms with ones current condition and ultimately letting go of this life. The second article from this group, written by Tsung-Tueng Bhikkhuni and her colleagues, examines the practice of reciting the Buddhas name at and before death as a way to assist end-of-life patients in letting go and to assist to comfort the family.11 In Chinese Buddhism, the practice of chanting the Buddhas

Hui-zhe Bhikkhuni, et al. Clinical Dharma Talks During Life Review. Red Pine, The Zen Teaching of Bodhidharma, pp. 3-8. 11 Tsung-Tueng Bhikkhuni, et al., The Clinical Application of End-of-life Dharma Speech and reciting Buddhas name to Dying Patients.
10

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Buddhist End-of-Life Care in Modern Taiwan name at the end of life is a popular Pure Land practice called nianfo 12. Most commonly throughout Chinese Buddhist death practices, the practice of chanting the Buddhas name has the particular purpose of assisting a dying person to be reborn in the blissful Pure Land of Amitbha Buddha. However, in the study from the TACBS the practice is only references as a method for alleviating suffering in this world and there is no mention of attaining otherworldly rebirths whatsoever. The practice of chanting the Buddhas name is described as a way for the clinical Buddhist chaplain to teach the patient to let go of their fear of death, which was earlier outlined as a central cause for suffering in terminally ill patients. Also, the chaplain is encouraged to invite patients' family members to recite Buddhas name for the deceased as a means of comfort them through the process of grieving. This new way of conceiving of the practice is certainly a shift in meaning from popular Pure Land practices that are focused around obtaining an afterlife in Amitbhas Pure Land. What is perhaps most interesting about the use of this practice in clinical settings is that the purpose and meaning of the popular practice of chanting the Buddhas name at death would be very clearly associated with otherworldly attainments by both the Buddhist chaplain and those participating in the ritual chanting. It is probable that when writing this

12

Charles B. Jones, Foundations of Ethics and Practice in Chinese Pure Land Buddhism, pp. 220.

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Buddhist End-of-Life Care in Modern Taiwan study those who are training chaplains highlight the worldly benefits of the practice as a means to open the practice to a wider audience who do not necessarily believe in an otherworldly Pure Land. It could also be argued that the practice is being described in this manner to make it appear more compatible with the clinical setting, where rebirth and Pure Lands are not recognized. Tsung-Tueng Bhikkhuni and her colleagues authored the third study in this group, which promotes the practice of applying the major principles of the Buddhist Heart Stra as the simplest and most practical doctrine by which to guide terminal cancer patients.13 The four major principles of the stra as outlined by this study are dependent arising, suffering and the cessation of suffering, contemplations on phenomena, and emptiness of all phenomena. Based on the psychological needs of the patient, these four principles are highlighted as particularly practical for helping people to accept their condition and let go of this life. The final article in this group by Tien-Lin Bhikkhuni et al. promotes the Stra of Impermanence as beneficial in caring for terminally ill patients.14 In the study it is emphasized that the teachings from this text help to transform fears of death due to fear of loss, separation and hopelessness; indicating that patients

Tsung-Tueng Bhikkhuni, et al., Implementation of Heart Stra in Spiritual Care of Terminal Cancer Patients. 14 Tien-Lin Bhikkhuni et al. Clinical Application of the Stra of Impermanence in Life and Death Education.
13

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Buddhist End-of-Life Care in Modern Taiwan who hold onto this life tend to suffer more emotional pain. The chaplain is encouraged to use doctrine such as what is found in the Stra of Impermanence to help patients let go and accept death as a natural as aspect of the life course, thereby giving the patient more psychological strength and understanding to break away from emotional pain.15 These four articles introduce some concepts from Buddhist teachings deemed suitable for addressing the specific needs of todays terminally ill clinical patients. On a deeper level, an in-depth look at any of the suggested teachings and practices might reveal notions of otherworldly attainments or notions of past lives and reincarnation. However, the way that these Buddhist concepts were described in these articles de-emphasizes specific concepts and instead stresses their ability to timelessly correspond to anxiety about death in general. The next study from the TACBS website that will be introduced presents a very different approach to interpreting Buddhist text to assist todays dying patients. Similar to the previously discussed scenario where the Buddhist idea of letting go of this life was used to promote DNRs in the clinical setting, this next study employs the

15

The Stra of Impermanence is actually the text recommended by Daoxuan in his commentary to the Chinese Vinaya for assisting the final thoughts of the dying. Additionally, it is lectured on in the Buddhist Colleague, which was established by Yinshun and was the principle text chanted at his funeral. See Koichi Shinohara, The Moment of Death in Daoxuans Vinaya Commentary, p. 126.

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Buddhist End-of-Life Care in Modern Taiwan Buddhist doctrine of the Lotus Stra to promote another socially and politically contentious medical procedure, organ transplantation.

Included on the TACBS website is a study by Heng-Chu Bhikkhuni et al. that supports clinical Buddhist chaplains to use the Universal Gate Chapter of the Lotus Stra as a way to help patients overcome their fear of death.16 This study relays that the importance of giving is emphasized in the Universal Gate Chapter of the Lotus Stra and the Six Perfections is that they emphasize, giving fearlessness (Shi wuwei ) which teaches individuals not to fear death. The article proceeds to explicitly designate organ donation as a highly noble type of giving fearlessly at death, tying the concept of overcoming fear of death with specific notions of the very modern medical procedure of donating ones organs at death to someone else in need. In the Universal Gate Chapter of the Lotus Stra the bodhisattva Guanyin is described as the one who gives courage and bestows fearlessness in times of fearful calamity. For this reason everybody in this sah world calls him Abhayadada (Giver of Fearlessness)17. The stra states that with true faith in the bodhisattva, all pain and suffering in death will dispel, The pure seer

Heng-Chu Bhikkhuni et al., The Clinical Application of the Universal Door Chapter in Lotus Stra to Overcome Fear of Death in Terminal cancer Patients. 17 Tsugunari Kubo and Akira Yuyama, https://www.bdkamerica.org/default.aspx?MPID=81, p. 298.
16

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Buddhist End-of-Life Care in Modern Taiwan Avalokitevara will be a refuge when suffering distress or the misery of death18. However, within the chapter there is no mention of personal giving, or even a broader teaching on giving up ones body to serve another. On the contrary, the text is focused on calling upon the power of the Bodhisattva Avalokitevara in times of need. The second doctrinal selection suggested in this study for promoting organ transplantation, the Six Perfections, seems much more applicable. The Six Perfections, giving in charity, keeping the precepts, tolerating insults, diligence, meditation, and wisdom, and ultimately gain the wisdom that transcends death19 emphasize the individuals role in alleviating suffering. More specifically, the first perfection of giving in charity or the perfection of giving dna-pramit is described as being of significant benefit to both oneself and to others.20 This first perfection can be directly related to the notion of organ donation, as the giving of ones organs could potentially save the life of another. In fact, the act of giving ones body to benefit another is a fairly common theme in Buddhist literature throughout its history. Within Indian Buddhist literature

Ibid. Heng-Chu Bhikkhuni et al., The Clinical Application of the Universal Door Chapter in Lotus Stra to Overcome Fear of Death in Terminal cancer Patients. 20 For an elaboration on the extensive benefits of the six perfections to oneself and to others see Shi Xingyun, Of Benefit To Oneself And Others: A Critique Of The Six Perfections, pp. 7-21.
18 19

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Buddhist End-of-Life Care in Modern Taiwan and tales of the Buddhas previous lives, there are numerous examples of the Buddha as a human being or an animal selflessly giving his eyes, flesh, blood or entire body on behalf of someone in need.21 These stories are exemplary of the Buddhas utmost compassion for others and complete detachment from the physical self. In the modern world, the practice of organ donation is a complicated bioethical concept in terms of Buddhist belief and still no consensus has been reached as to how a Buddhist should understand such a situation. Buddhist bioethics scholar Damien Keown addresses this very issue in depth in his 2010 paper, Buddhism, Brain Death and Organ Transplantation22. He notes that organ donation can be considered a valuable opportunity on several levels, as a way to sever attachment to ones own body, to place another persons welfare above ones own, etc. However, he states his serious reservations concerning the current medical practice for Buddhists, writing, This is not because Buddhism is opposed to organ donation per se, but because it rejects the concept of brain death, which is typically used to determine death prior to the harvesting of organs23. What Keown is referring to is the fact that the issue of organ donation sits between two sets of prominent Buddhist based beliefs. On one hand there is
Reiko Ohnuma, Head, Eyes, Flesh, And Blood: Giving Away the Body in Indian Buddhist Literature, pp. 199-241. 22 Damien Keown, Buddhism, Brain Death and Organ Transplantation, pp. 1-36. 23 Ibid.
21

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Buddhist End-of-Life Care in Modern Taiwan the aspiration to become detached from the physical body as one approaches death, coupled with a desire to compassionately help others in need. On the other hand Buddhist practices surrounding death, which are both traditional and advocated in modern days24, are not compatible with organ donation because of requirements that the physical body not being touched for a set period of time, usually for eight hours. Not touching the physical body is born the notion that death is a transitional process rather than occurring in a singular moment and so the individual needs time to allow the dying process to occur. Keown cites early Buddhist sources emphasizing the subtle body made up of elements within the body that take various amounts of time to dissipate. However, the biomedical standard for determining the death of a person is based on the internationally recognized neurological death that is determined as a single point in time.25 Organ transplantation is very time sensitive and in some cases, as in the heart transplant, the organ needs to be fully functioning as it is taken from the body. The standardized neurological death defines the moment of death to be based solely on the functionality of the brain, allowing for other organs to be removed from the patient while they are still functioning.26 Consequently, if the patient does not subscribe to the notion of the neurological death, he is inclined to

Raoul Birnbaum, The Deathbed Image of Master Honyi, pp. 175-207. Martin Smith, Brain death: time for an international consensus, pp. 6-9. 26 Martin Smith, Brain death: time for an international consensus, pp. 6-9.
24 25

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Buddhist End-of-Life Care in Modern Taiwan believe that an individual is not yet dead when organs are being removed, which would cause great pain and suffering. Keown argues that cutting up the body while the subtle elements of the body are still present is equivalent to cutting up a living person. The perspectives of Buddhist groups in Taiwan vary regarding this issue, in that some groups advocate that the compassion involved in organ donation supersedes any negativity that might be involved, and there are others that adhere to practices from traditional doctrine. The highly regarded Chinese monk Hongyi, whose conservative ideas for Buddhist reform were introduced in chapter two, gave a highly influential public lecture in 1933 on how to create a positive end-of-life scenario.27 Hongyis public discourse on death was so widely revered that it was quickly published and disseminated widely, the instruction of which still resonates with Buddhists today. Hongyi stresses that the body should not be handled under any circumstance for at least eight hours after the person has died as the dying process lasts for numerous hours after the last breath has been taken and intense pain is felt if the physical body is touched which will distract the dying person as they transcend into another existence. Contrary to this view, the Taiwanese Tzu Chi Buddhist group promotes organ donation as

27

Raoul Birnbaum, The Deathbed Image of Master Honyi, pp. 175-207.

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Buddhist End-of-Life Care in Modern Taiwan one of the greatest gifts of life one can give28, and Venerable Zhengyan has spoken out publically in support of the procedure. The article referencing the Lotus Stra interprets a Buddhist text to meet a potentially contentious modern biomedical situation, even though conceiving of the text in this way is contrary to traditional ritual behavior surrounding death. This tactic appears to reflect the reformist spirit of Taixu who promoted that Buddhisms main concern is caring for people in this life. He believed that there was a deep connection between Buddhist thinking and rationalistic science and so promoted re-visiting Mahyna scripture and conceptualizing it in a way to meet the needs of the modern world. Thus, taking the stance that it is more important to donate organs in order to save someone in this world than to adhere to traditional timelines for post-mortem practices also reflects the values of a reformist Buddhist view. However, the promotion of organ donation in modern Taiwan does not mean that all dying patients adhere to modern interpretations of end-of-life, nor does it indicate that Tzu Chi hospitals or Buddhist chaplains do not facilitate traditional Buddhist practices of leaving a body untouched at death. Postmortem rituals including chanting with a body for a number of hours after death

28

http://www.tw.tzuchi.org/en/index.php?option=com_content&view= article&id=387%3Apass-on-the-love-organ-donation

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Buddhist End-of-Life Care in Modern Taiwan is still practiced, and facilities are provided to accommodate such practices in Tzu Chi hospitals and many other hospice settings.

Section 4: The Role of the Chaplain in Rituals at Death

The final article that will be examined from the TACBS website deals specifically with the Buddhist chaplains role in the dying process. As far as the discussion and questions that have been raised so far in this paper, regarding modern Buddhist beliefs and practices at end-of-life, this last article will ultimately shine some light on the role of the Buddhist chaplain at death. Specifically, what is most important for this study is that it presents exactly how the work of the chaplain differentiates from other monastics who may be administering more traditional ritual care to the patient at this time. This last article outlines the Buddhist chaplains role in delivering the dead through Buddhist ceremonies and how to assist the family members of the deceased.29 The study first indicates that there are two purposes of holding Buddhist services to deliver the dead. The first one is to deliver the deceased to the otherworldly Pure Land and the second one is to comfort the families of the

29

Man-Shyang Bhikkhuni et al., Delivering the Dead with Buddhist Ceremonies and Guiding the Family Members of the Dead.

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Buddhist End-of-Life Care in Modern Taiwan dead with Buddhist teachings. It is stated that the role of the clinical Buddhist chaplain at the time of death is to alleviate the grief of the family using Buddhist teachings, rather than to perform Buddhist service for the deceased. The study states that if it is necessary, Buddhist chaplains trained by the TACBS do in fact administer services to assist family members to spiritually connect with the deceased within 49 days after their loved ones passed away, but this is regarded as more of a service for the living as opposed to a service for the dead. In accordance with the desire of the family members of the deceased, the clinical Buddhist chaplains are taught to use various Buddhist doctrines to guide the family members suffering from various issues. For example, for those who feel worried or even sorry because they did not provide enough care for the dead, the Repentance Liturgy of Emperor Liang or Water Repentance Liturgy are recommended. For those who have a closer relationship with the deceased and therefore have difficulties letting go, the Diamond Stra and the Heart Stra are explained to be better choices. For those who believe in the Pure Land or those who accept death and hope for a better future for the deceased, Amitbha Stra and the Discourse on Samantabhadra Bodhisattvas Beneficence Aspiration are said to be usually selected. For the dead who had been sick for a long time or died an untimely death, Amitbha Stra and the Medicine Buddha Stra and the Medicine Buddha Repentance are often chanted.

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Buddhist End-of-Life Care in Modern Taiwan A proper Buddhist ceremony for the deceased is considered beneficial for the dead, but more importantly for the role of the chaplain, such ceremonies are deemed as helping the surviving family members cope with their grief. In Buddhist deliverance ceremonies, the most important role of the Buddhist chaplain is not in performing the rite itself, but in guidance for the living. From the clinical care perspective, Buddhist deliverance ceremonies extend the patients spiritual growth before dying, promote the proper frame of mind during death, and provide guidance for the surviving family members. This final aspect of clinical Buddhist chaplaincy offers a compelling perspective of how modern Taiwanese Buddhist groups understand their role in the end-of-life experience. The article clearly addresses the fact that Taiwanese end-of-life patients would like Buddhist otherworldly ceremonies for the dying and deceased and that modern Buddhist practitioners participate in such rituals as chanting Amitbha Buddhas name. However, the article explicitly explains that these rituals are performed at the request of the family and are meant more importantly for the benefit of those remaining in this world as opposed to assisting the deceased in otherworldly experiences.

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Buddhist End-of-Life Care in Modern Taiwan Conclusion

The country of Taiwan has a thriving Buddhist population that is highly influential in the social arena as outreach groups provide tremendous social relief and public support programs. The vision of the predecessors of Taiwans Buddhist movement was of a reformed Chinese Buddhism that would prove itself relevant in modern society through actively contributing to the welfare of the public. To realize this vision, reformist monks sought to change the public image of Buddhism from a religion preoccupied with the afterlife and otherworldly experiences to the neglect of the present life and society, to a Buddhism that actively contributed to the wellbeing of people in this world. This reformist vision took root in Taiwan through the leadership of numerous influential activist monastics who brought ideas for a reformed and prosperous Chinese Buddhism to life. Modern Taiwanese reform and prosperity did not only come in the form of religious movements, in recent years Taiwan has undergone a complete political, economic and social revolution launching the country into modernity. Along with modernist thinking, deemed as rationalistic and liberal-minded, one might assume that Taiwanese ties to religious faith-based belief would dwindle, but on the contrary the peoples affiliation with religious groups has only continued to grow. Buddhist groups have developed into an essential part of
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Buddhist End-of-Life Care in Modern Taiwan Taiwanese culture. Activist groups work to directly support the needs of the public and in the case of healthcare needs, Taiwanese Buddhist groups engaged in large-scale social relief far earlier and to a much greater degree than government groups could initially provide. The central focus of this paper was to examine the interaction between modern Taiwanese Buddhist groups and their extensive support to bring medical support to individuals as they approach death. The specific intrigue behind this topic is that the public service of caring for the dead through end-oflife and afterlife rituals has been the part of Chinese Buddhist tradition that has been most prominent over the centuries. Yet this very service was the one treated with the most distain by reformist Buddhist monks for their preoccupation with funeral culture and lack of significant contributions to alleviate social problems. Of all of the modern outreach services, it would appear as though Buddhist and medical care for the dying would be completely incompatible. To better understand exactly how Buddhist groups are providing support to people as they die, this research paper surveyed the types of Buddhist end-oflife care programs that have been established in Taiwan and how theyve developed in light of modern views of death and advances in biomedicine. Findings showed that the Taiwanese medical community and Buddhist organizations have made great efforts to work harmoniously in providing end-

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Buddhist End-of-Life Care in Modern Taiwan of-life care that supports various patient needs at this time. Buddhist activist groups facilitate the widespread provision of medical care, establish large-scale modern medical hospitals and fund medical research. In turn, the medical community embraces the religious beliefs of the Taiwanese population through accepting Buddhist chaplains onto the medical team to provide spiritual support for dying patients, and allowing for ritual end-of-life ceremonies to be performed within the medical facility. As far as medical public health policy, large-scale programs and infrastructure, it appears as though there is a symbiotic relationship between modern Buddhist groups and medical care in Taiwan. However after examining a number of research studies surveying the expressed needs of Taiwanese terminally ill patients, it became apparent that not all Taiwanese adhere to the modernist Buddhist beliefs and still rely heavily on traditional Chinese views of death and the afterlife. In fact, studies revealed that there is still a strong need for religious ritual practices and guidance for afterlife experiences. Based on these findings it would seem that Buddhist end-of-life care for the terminally ill that was solely based on modern reformist beliefs would be inadequate for a great number of patients. As such, this study looked at the specific services provided by modern Taiwanese Buddhist groups that work within the medical arena,

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Buddhist End-of-Life Care in Modern Taiwan comparing the objectives of these programs with the needs specified by Taiwanese end-of-life patients. What was essentially found was that modern Buddhist groups genuinely embrace modernist perspectives in the medical arena and use traditional Chinese Buddhist doctrine as inspiration to overcome modern challenges. In all of the documentation found explaining the role of the Buddhist chaplain or the Buddhist doctrine that was useful for end-of-life care, the main focus was on helping the patient and their families deal with experiences in this life. Even doctrine that is contextualized in otherworldly attainments was interpreted to promote modern perspectives on death and referenced as broadly supporting Buddhist notions of non-attachment to the physical body and the impermanence of life. In some extreme examples Buddhist doctrine was even used to support modern, bioethically contentious practices such as DNRs and organ transplantation. Throughout this research paper, initial skepticism of how religious doctrine and practices regarding death could work inside a modern medical facility were met with rational, practical solutions. For instance, the modern medical facilities offering reformed Buddhist style care also facilitate ritual endof-life and afterlife ceremonies. And Buddhist doctrine is promoted as helpful for the terminally ill population, but it is only advocated in reference to broad issues

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Buddhist End-of-Life Care in Modern Taiwan of fear of death and learning to let go of this life. In one way, it could be argued that todays Taiwanese Buddhist groups are in fact preserving the most important aspect of caring for the dying and that is affecting the final thoughts of the patients. Through alleviating the anxiety and fear related with death and reciting sutras, todays Buddhist chaplains are indeed adhering to the main criteria outlined in early texts written on the subject. Final thoughts of this paper turn to new questions that have arisen and will remain unanswered in this research paper. Essentially, evidence shows that Buddhist ritual end-of-life and afterlife ceremonies are desired by the public and are still widely practiced within Buddhist community. Since these practices are downplayed in the reformed Buddhist movement in Taiwan they are also largely ignored in public discourse on the topic and in the literature on activities of Buddhist outreach groups. Investigation into the modern use of these practices would make for fascinating future research.

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