The Institute For Zen Studies

Japanese Site

  • Study groups
  • Publications, etc.
  • Scholarly resources
  • Software

Study groups

The Brain Death Discussions: A Summary

Add this entry to Hatena bookmark

The first and second of the Institute for Zen Studies’ series of seven discussions on the question of brain death were concerned with: 1) gathering data to identify in the broadest and most precise terms the issues of greatest importance when considering brain death and organ transplant; 2) organizing and analyzing the various views on these issues.
              Gotō Tenshō (Director, Rinzai School Union of Proselytizers) assembled a comprehensive body of data from on a wide range of sources, including the proceedings of symposia and ethical committee meetings held by groups such as the Japan Medical Association and the various medical school hospitals; the published views of Buddhist organizations such as the Japanese Association of Indian and Buddhist Studies; and even the private opinions of individuals as expressed in op-ed articles in magazines and newspapers. Four fundamental topics for discussion emerged from a study of this data:
 

  1. The problem of brain death
  2. The problem of organ transplant
  3. The problem of brain death as it relates to organ transplant
  4. Determing the perspective of we who discuss these problems
 
Although in practical terms the issues of brain death and organ transplant are closely related, it was decided to discuss them separately at first since they raise quite different ethical questions. Whereas the fundamental issue relating to brain death is the determination of what constitutes death, in the case of organ transplantation questions relating to the meaning of life come to the fore, as in the case of living donor liver transplants.
              Even so, it is indisputable that the movement to accept brain death as the new criterion for human death is motivated by the desire to transplant organs from brain-dead bodies, and that this is the central issue of the brain death controversy as far as the Japanese public is concerned. Thus discussions at the meetings concentrated on the relation between the two, with the central issues closely reflecting those that have emerged in the public           debate on the matter:
  1. To what extent is it possible to determine brain death and to what extent is it possible to perform organ transplants, in view of the present levels of medical knowledge and technique?
  2. How can we determine the trustworthiness of those in charge (e.g., the physician(s) and ethical committee member(s)) as people? Involved in this issue is the determination of standards for medical ethics; for the relationship between doctor, patient, and the patient’s family; and for the makeup of the ethics committee that rules on individual transplants.
  3. How do we deal with the issues of social consensus and legal adaptation with regard to brain death? Related issues are the makeup of the Special Commission on Brain Death, the setting of criteria for brain death and cardiopulmonary death, and the assessment of the situation in the Western world.
  4. How do we establish standards of social ethics for organ transplants? Related issues are the use of imported blood for transfusions, the situation with regard to Japanese who go abroad for transplant surgery, and the legal response to the trade in human organs.
  5. How do the issues of human dignity and feeling relate to such questions as “What is ‘death with dignity’?” “Is any social pressure directed towards people who refuse to become organ donors?” and “What is the social nature of death?”
 
Discussions of the above questions led to the following conclusions:
 
  1. The determination of physiological death remains the professional responsibility of the medical profession. It is also the responsibility of the medical profession to establish sound criteria for determining brain death and for granting permission to perform organ transplants. The nonspecialist layperson cannot be involved in these decisions. However, as the recipient of medical procedures, the layperson has the right, and moreover the duty, to request the doctor or medical institution to explain the meaning of the criteria and to provide sufficient information on all proposed medical procedures to make informed consent possible. There are at present a number of problems that need to be resolved between the medical profession and the recipients of the medical profession’s care; the possibility of resolving these problems rests on the relationship of trust between the two. With this relationship as a basis, we recognize that the determination of physiological death, whether using the traditional three signs (cessation of heart movement, cessation of breathing, dilation of the pupils) or the criteria of brain death, must be the province of the physician, who possesses the authority and responsibility to do so.
  2. We recognize the importance of developing general principles for the formation of a social consensus regarding the nature of human death and the justifiability of organ transplantation, and of enacting and maintaining laws based on these principles. This is because human death is not simply the death of a single living organism, and the organs of the human body are not merely parts of a machine. The death of a person is, in a sense, the death of the person’s father, mother, and child. The entirety of a person’s body is the body of that person’s father, mother, and child. The human body is born of two people, lives in a society of people, and dies within the thoughts of other people. Human life and human death have a social aspect. With this in mind, issues involving human death and the human body are not matters that can be resolved solely on the basis of judgments pertaining to the physiological criteria of a single organism.
              This is behind the present need for a social consensus regarding brain death and organ transplant. The problem of whether to recognize brain death as the death of the individual is a problem relating to how the individual regards his or her own body and its death, to how the family deals with one of its members’ bodies and its death, and to how society deals with an individual human’s body and its death—in other words, to how the individual establishes his or her identity, to how the family certifies the bonds between its members, and to how society organizes itself. The respective decisions must, of course, be made at the level of the individual and his or her family, but it is necessary to have in place a legal framework to guarantee these decisions and a social consensus to support the legal code. The enactment and maintenance of laws is the province of legislators and lawyers; the formation of the necessary social consensus is our duty as members of society and citizens of a nation acting in accordance with our respective systems of belief.
  3. We are not physicians, lawyers, or politicians. We are ordained members of the clergy, monks of the Zen school who serve the Buddha and practice the Buddha Way. We thus occupy a distinctive place in society and have a special role to fulfill. At present it is part of our role and one of our responsibilities to study the issues of brain death and organ transplantation, and to consider ways to bring into existence the appropriate social consensus.
 
After reaching agreement on the above points during the first and second of the Institute for Zen Studies’ meeting on the question of brain death, the participants decided to invite two scholars with a deep understanding of religion and extended experience with the subjects of brain death and organ transplantation to address the group and share their knowledge. The first speaker was Prof. Ōmine Akira, a priest in the Nishi Hongan-ji school of Pure Land Buddhism who lectures on the philosophy of religion at Osaka University and serves on the medical ethics committee at Osaka University Medical School. The second speaker was Prof. Nagura Michitaka, who graduated with a Ph.D in medicine from Kyoto University Medical School, studied Buddhism at Bukkyō University, and is now on the faculty at the Ryūkoku University Department of Sociology.
 
Prof. Ōmine, who spoke at the third meeting of the discussion group, was of the opinion that “death of the individual must be defined as brain death. Only with this can we truly express respect for the dignity of human life.” Prof. Ōmine continued that some people feel that the issue of organ transplantation preceded that of brain death, but actually it was the issue of brain death that arose first. The concept of brain death, which arose from the desire to save the life of the patient (“the starting point of medicine” and “the foundation of medical ethics”), was a new concept that resulted from advances in modern medical technology. Though in many ways a “troubling concept,” “a kind of karma that the present level of civilization has forced us to bear,” with the fact of brain death we can ascertain that “the cessation of life reflexes is not temporary but irreversible—in other words, that the normal functions of life cannot be recovered.”
      The brain, unlike all other organs, is the integrative center of the body and the seat of consciousness and the mind, the bodily interface of spirit and matter. It is therefore the locus of something that cannot be thought of merely in terms of matter or quantity. The appreciation of human dignity entails the recognition there is in life an essence that cannot be reduced to matter. When it can medically determined that the brain, the locus of this essence, has suffered an irreversible loss of function, then continuing with  artificial respiration and other life-maintaining measures becomes an inhuman violation of the dead patient’s dignity. Only when the dead are free of the living’s attachment to them are they finally able to find peace in the recognition of their new state.
      Humans are social beings, of course, so this recognition cannot come about merely through the opinion of the doctor. A process of accepting death must occur amongst the living. Nevertheless, this acceptance must involve agreement with the informed assessment of a medical professional, since the fact of death cannot be determined through mere discussion or one’s own personal opinion. In other words, the social consensus regarding death must take into account the educated views of the doctor.
      An individual’s life cannot be given to another, nor can it be lived for them. However, an individual’s life is not lived solely within that individual. It transcends that individual—it is born, and gives birth, it floats in the sea of life with all manner of other beings. To be deeply aware of this fact may be seen as the essence of the religious mind. From this awareness arises love for other people and respect for the lives of other people. And from this awareness may arise the concept of donating the organs that are a part of one’s body, an act that in no way will ever constitute a violation of human dignity. Buddhism teaches that the five aggregates are empty, meaning that none of the elements of which we as individuals are constituted can be regarded as our possession. From this point of view, it makes little sense to speak of “my organs” and “your organs.”
      It is not the job of the clergy to concern itself with how to save the lives of those who, if left as they are, would certainly die; this is the job of the medical profession. The job of the clergy is to help people find the true life within them, the life of Dharma, regardless of how long or short their physical lives might be.
 
Prof. Nagura, who spoke at the fourth meeting of the discussion group, stressed the need for modern medicine to transform itself from a form of therapy that sees the human being as a kind of living mechanism to one that respects the patient as a subject blessed with the gifts of life and an autonomous identity. The stance of the clergy, said Prof. Nagura, must be reverence for the subjective significance of life, and thus the Buddhist clergy’s role in medical ethics is certain to become more important as medical technology advances.
      Prof. Nagura was of the opinion that brain death is a “clinical concept” that sees the cessation of brain activity as marking the point where the imminent death of the organism can be confidently predicted even if life functions continue in most of the body’s cells. Thus Prof. Nagura does not regard brain death as comprising the death of the organism, as Prof. Ōmine does, but sees it instead as predictive of the death of the organism.
      Regarding why the concept of brain has been advanced by the medical profession, Prof. Nagura offered the following explanations:
  1. Brain death makes it possible for the medical profession to harvest organs from still-living bodies.
  2. Brain death makes it possible to terminate treatment of brain-dead patients.
Both of these, according to Prof. Nagura, are utilitarian views, means of “controlling” death in which, he fears, the possibility of a natural end to life is lost. Moreover, the death of an individual is not simply the cessation of that individual’s life activity but also involves a transformation in his or her relationship with everyone with whom he or she was connected. Only when this relational transformation is accepted by these people is the process of death complete. Central to this acceptance of death, Prof. Nagura pointed out, are the experiences of observing the traditional three signs of death, of noticing the loss of bodily temperature and facial color, and of performing such traditional rituals as the wake and funeral.
 
         Prof. Nagura next took up the problem of organ transplantation as it relates to the way we think of life. He identified the following points as representative of the view of life according to medical science:
  1. The body is not something to be understood in mechanistic terms, but as something that strives to protect the identity of the self (as in the physiological phenomenon of rejection).
  2. Life is an integrated dynamic in which the body and mind of the individual work together in the context of the surrounding environment, spontaneously adapting in the direction of overall harmony. It is, truly, an interdependent phenomenon.
  3. When life willingly takes in another life form (as in the acceptance of sperm during fertilization, the symbiotic hosting of microorganisms in the intestine, the regeneration of blood corpuscles following blood transfusions, etc.), the assimilation of that life form involves change in both life forms and the start of a new life process.
Prof. Nagura also emphasized the quality of “initiative” in life forms as central to medical science’s view of life.
          With regard to how transplantation therapy affects the relationship between the patient and the medical profession, Prof. Nagura pointed out that this form of therapy operates on a fundamentally different principle from traditional “curative therapy.” In contrast to curative therapy, which operates through measures to strengthen or support the body’s natural healing functions, transplantation therapy depresses those very functions in order to prevent rejection of the transplanted organ, resulting in a substantial weakening of the body’s defenses against pathogens and cancers, and obliging the patient to live with a constant sense of danger. It is a therapy solely designed to postpone the time of death.
          Regarding the issues that the spread of transplantation therapy will present Buddhists with, Prof. Nagura commented as follows:
  1. Shortages of organs suitable for transplantation might result in the application a sorting process to patients in need of a transplant, and a consequent commodification of organs. In order to help prevent this it will be important to stress that life must not be judged by utilitarian standards alone, but esteemed as something of equal value in each individual.
  2. A system will have to be in place to safeguard the will of the patient, the free choice of the donor, and the values of society. In order to do so, it is important that religious people who value the subjective interests of the individual patient be involved not only as members of medical ethics committees but also as participants in the patient’s actual medical care.
  3. Progress in life-prolonging technology will of course raise people’s expectations for extended lifespans, but since it is impossible for technology to fulfill all such expectation much dissatisfaction may result. It is important that religion works for a broadening in society’s sense of values so that people realize that even a short life can be lived to the full.
Prof. Nagura’s views differed considerably in nuance from those of Prof. Ōmine. Whereas Prof. Ōmine took a positive stance regarding the recognition of brain death and acceptance of organ transplantation, Prof. Nagura urged that we keep in mind the various problems that have accompanied the inexorable advance of medical technology in these areas. Both speakers agreed, however, that now is the time to awaken to the fundamental value of life, and that Buddhism and the Buddhist clergy have an important role to play in this awakening.
          Following the talks by Prof. Ōmine and Prof. Nagura, Rev. Hirata Seikō, Director and Chairman of the Board of the Institute for Zen Studies, was invited to present his candid views on the topics of brain death and organ transplantation to the fifth gathering of the discussion group. Rev. Hirata, referring to Pope John Paul II’s published view that brain death constitutes the death of the individual, was of the opinion that we have little choice other than to leave the determination of biological death to the medical profession. However, he added, there is a fundamental problem with understanding human life as a sort of substance. In Zen the ordinary Japanese word for “life,” seimei 生命, does not exist. Zen refers instead to emyō 慧命, “the wisdom [of the Dharmakaya] as life” or shōmyō 性命, “Buddha-nature as life. This concept of the life of the Buddha as constituting human life, or of wisdom as life, is, Rev. Hirata believes, the true Buddhist way of regarding life.
          He continued that no fundamental resolution to the issues of brain death and organ transplantation is possible as long as they are judged on the level of individual phenomena. What is needed is a more global approach in which the background or foundation from which these issues emerged—that is, modern science, technology, ethics, and religion—is taken into consideration.
          Rev. Hirata then commented on the presentations of the earlier speakers. Rev Hirata warned that Prof. Ōmine’s fundamental position, based on the Buddhist teaching that “the five aggregates are empty,” risks falling into nihilism, while Prof. Nagura’s views, which take the teaching of dependent origination as a kind of golden rule, may veer toward onesidedness. We must seek the realm of existence in which principle and phenomena interact in unimpeded freedom, in which both extremes of being and nonbeing are cut with a single stroke. When, for example, the medical profession asks Buddhism to recognize brain death, saying that death is what Buddhism deals with, and in this way seeks a kind of indulgence for the profession’s position, it is missing the point. What Buddhism does is ask what is this “self” that is asking the question. Regarding the various positions advanced by Buddhist academics based on their interpretations of scriptural passages, Rev. Hirata agreed with Prof. Ōmine’s view that such efforts are meaningless for the modern world, consisting of superficial readings of the sacred texts that lack any practical application.
          Noting that difficult discussions regarding the pros and cons of organ transplantation and the concept of brain death continue within the medical profession itself, Rev. Hirata asked of the profession that any conclusions reached by these discussions be presented in a forthright manner and in terms understandable to the layperson. Although Rev. Hirata is resigned to the fact that brain death will eventually receive legal approval, he commented that as long as the pertinent arguments were not presented to the public in clear and understandable form then he for one would remain fundamentally opposed to organ transplantation and the concept of brain death. In his view a social consensus on these issues will form only when there is an honest presentation of all the medical information and data.
          Rev. Hirata voiced his agreement with Prof. Nagura’s statement that ‘human cravings can never be satisfied through technology’.” Rev. Hirata commented that how to integrate science, technology, ethics, and religion is a fundamental problem for society. He pointed out that this problem of integration has been with us since ancient times, citing a passage from the “Heaven and Earth” chapter of the Zhuang zi:

Where there are machines there are inevitably machine concerns, and where there are machine concerns there are inevitably machine thoughts. When your breast is full of machine thoughts it cannot be home to the pure and simple. If it cannot be home to the pure and simple then the spirit is unsettled. If the spirit is unsettled it cannot know the Dao.
Rev. Hirata noted that the issue of integration is addressed in, for example, the Tiangong Kaiwu 天工開物 (The utilization of the works of nature), by the Chinese scientist and encyclopedist Song Yingxing 宋應星 (1587-1666). Song, who believed that humanity’s works must function in accordance with nature’s works, recognized the dominance of nature, while the Ming-dynasty literatus Fang Yizhi 方以智 (1611-1671) stressed the union of nature and humanity. In Japan, the scientist Sakuma Shōzan 佐久間 象山 (1811–1864) felt that Western technology, which he held in high regard, should be utilized in accord with Eastern ethics, that is, with the Way of Heaven.
          For all of these figures, the Way of Heaven was the context in which integration of science and technology must occur. This approach to integration, however, is unworkable in the technologically advanced modern world. The relationship between science and ethics (or religion) must be rethought from its very foundation and the integration between the two sides must be reconstructed.
 
The views expressed by the three speakers confirmed the original three conclusions reached by the brain-death discussion group, namely:

  1. The determination of physiological death is the professional responsibility of the medical profession.
  2. A proper legal framework must be established so that the various questions that inevitably arise with regard to brain death and organ transplantation may be effectively addressed. In order for this to occur the formation of a social consensus on these issues is essential.
  3. In order to bring this social consensus into being it is important that the clergy develop a living message appropriate for the world today. This is important not only for the sake of society but, more importantly, for maintaining the true vitality of religion.
During the sixth meeting the participants considered how members of the Zen clergy might best approach the issues under discussion. It was about this time that the report of the government’s Special Commission on Brain Death was published, so the meeting focused on the conclusions presented in this report. The following opinions on the report were expressed by the members of the discussion group:
  1. It is commendable that minority opinions also found a place in the Special Commission’s report.
  2. Along with recognizing brain death as the death of the individual, the Special Commission also recognized the traditional criterion of cardiopulmonary death, so that two standards for determining death exist.
  3. The fact that minority opinions were included in the report suggests that a social consensus regarding the issue of brain death has yet to be established.
  4. Even the minority positions contained in the report accept the principle that if the individuals involved give their consent, organ transplants may proceed following brain death.
With regard to the position of the discussion group, the members offered the following views:
  1. Although the issues of brain death and organ transplantation penetrate to the core of Zen doctrine and demand from Zen doctrine an appropriate response, the Zen clergy’s consciousness of the issues remains low and misunderstandings abound.  This situation must be remedied.
  2. Although the Special Commission’s report does not discuss the recipient of the donated organ, the question of the recipient’s egoism is an important one. Proper attention must be paid to the attitude of the one involved in the establishment of ethical standards.
  3. From the spiritual perspective, is it not the task of the Zen monk to encourage a way of being in which inevitable aspects of life, such as illness and death, can be accepted without feeling the need to resort to such extraordinary measures as organ transplantation?
  4. The creation of a new outlook on life will inevitably involve a new approach to integrating science/technology and ethics/religion. The worldview that offers the greatest potential for such an integration is that of Buddhism, particularly Zen Buddhism, rather than Christianity.
  5. It is impossible to declare oneself “for” or “against” organ transplantation when faced, on the one hand, with the suffering of the donor, and, on the other, with the yearning of the recipient for life. The same can be said when facing the agonized surgeon who stands between the two.
  6. It is because people are caught in the inexhaustible passions and are unable to “drop off body and mind” that they suffer. When developing teachings for the modern age Zen should take this into consideration; simply telling people to “meditate” or “wake up” does not solve the problem.
  7. The standpoint of the truly religious person, including the Christian, is not fundamentally that of the activist who proclaims himself for or against something, nor is it that of the teacher who directs people to do this or do that. Rather, he or she prays together with those who are suffering, or sits with them with body and mind oriented in the same direction. In doing so, however, the religious person must be thoroughly aware of the “place” in which he or she prays or sits.
During the seventh and final gathering of the brain-death discussion group these and other points were discussed and possibilities for putting the various suggestions into practice were considered. Proposals were made for further meetings, including the inclusion of representatives from other religious traditions, and for training programs directed toward the young priests who will comprise the future leadership of the Rinzai school.