Bioethical Threads in the Reflection of Tibetan Refugees in India

Abstract

This article aims to trace and describe the bioethical threads in medical practice and the understanding of medicine among Tibetan refugees living in India. Taking up such a task results mainly from the fact that only traces of bioethical reflection are visible in Tibetan society, but without the awareness that it requires systematic reflection on its essence and changes that accompany modern medicine. I define the state of the discussion on Tibetan bioethics as preparadigmatic, i.e., one that precedes the recognition of the importance of bioethics and the elaboration of its basic concepts. In this paper, I will show how the Tibetan refugees today, in an unconscious way, approach bioethics, using the example of life-related topics, namely beginning and death. To this end, I chose topics such as abortion, fetal sex reassignment, euthanasia, and suicide. On this basis, I will indicate the main reasons that hinder the emergence of bioethics and those that may contribute to systematic discussions in the future. An introduction to Tibetan medicine will precede these considerations. I will show how medical traditions, especially the Rgyud bzhi text, are related to Tibetan Buddhism and opinions of the 14th Dalai Lama.

namo bhagavate bhaiṣajyaguru vaiḍūryaprabharājāya

tathāgatāya arahate samyaksambuddhāya tadyathā:

oṃ bhaiṣajye mahābhaiṣajya-samudgate svāhā.

BhaiṣajyaguruMantra

1. Introduction

The presence of bioethics in contemporary Euroamerican debates on the development of medicine and the human condition seems obvious and requires no special introduction. However, it is worth recalling that a characteristic feature of bioethics is carrying out deep ethical reflections on scientific and technical progress, aimed at protecting the meaning, status, dignity, and value of human life in all its phases (Leźnicki 2017, p. 17). These reflections often relate to issues that trigger numerous disputes regarding moral justifications and adopted decisions. This difficult situation may be indicated by the existence of various theoretical approaches, as well as various bioethical codes and laws adopted by individual states regulating the basic dilemmas concerning the issues of life, health, and death that arise as a result of biological or technological discoveries (cf. Leźnicki 2017, pp. 17–18). It is also worth adding that the legal regulations, political ideologies, and moral and religious convictions in force in a given country are of significant importance for the adoption of specific justifications in bioethical disputes. Trying to explain the complexity of the situation, and at the same time not entering into a detailed description of individual moral decisions and points of contention, I will treat it not as a coherent system but as an area based on an orderly and systematic discussion. Thanks to this, it is possible to have various solutions derived from different philosophical, political, legal, and religious concepts within the situation.

What proves to be of special interest is religion, which often impacts the remaining abovementioned realms, including the influence it exerts on capturing particular points at issue. Simultaneously, religion mobilizes antagonized parties while sometimes influencing the posited law, which should also be borne in mind. The French historian Georges Minois, while describing the interdependencies between religion and medicine, noted that currently, the two domains have diverged, and each of them represents its own distinct area of interest in humanity. However, together with the emergence in the 1960s of numerous bioethical discussions, something extraordinary happened; namely, religion, in Euroamerican societies, was once again appreciated when it came to solving new problems pertaining to artificial insemination, abortion, euthanasia, cloning, genetic manipulation, and the relationship between patient and physician (Minois 2020, p. 9; cf. Jonsen 2006, p. 23; Różyńska and Łuków 2013, p. 15). Additionally, something bizarre happened: considerations of medicine and religion started—depending on particular societies and states—to play a significant role and become identified with morality. This, in turn, has far-reaching consequences for the investigation of bioethics because it is implied that the reflection thereupon should be the domain of religion and, at the same time, should be subordinated to specific theologians rather than to philosophy or other sciences. Hence, the more interesting and important question is how religion plays a role and, normatively, what its role in public bioethics should be (Guinn 2006, p. 4).

This discussion can be found in Euroamerican discussions and in South Asian societies and countries where other ideas and religious traditions are dominant and where important issues related to human life and health are approached differently. Therefore, describing the development of Tibetan medicine is a difficult and fascinating task at the same time. For Tibetan medicine, there are important threads that correspond to medical ethics and content that may open Tibetans to the contemporary bioethical debate. In particular, when we take into account not only the past but also the present state, because there are visible beginnings of serious changes in the approach to such matters as life, health, and death, I would like to add that the transformations taking place in the community of Tibetan refugees result from secularization and the adoption of Indian and Western cultural and social patterns (Bloch 2011, pp. 181–85). Therefore, it is important to show these threads, point out their sources, and describe the approach to their justification. We must also try to identify where changes in moral justifications may occur, bringing Tibetan thinking about medicine and man closer to bioethical debates.

Before I proceed to elaborate on the subject, I must make two important caveats. First of all, I will analyze the two themes that most often appear among Tibetan refugees living in India and are discussed in the literature, consistent with bioethical concepts. However, to reach the most coherent picture, I will reference the present situation of Tibetans inhabiting the Tibet Autonomous Region (Bod rang skyong ljongs; hereinafter referred to as TAR)1. Second of all, I shall use the concept of Tibetan medicine (gso ba rig pa) without discriminating whether it pertains to Tibetans living in the TAR, India, or Nepal. This is because this division would be artificial. After all, their understanding of medicine is very much alike, with medicine at the same time originating from the same sources2.

2. The Idiosyncrasies of Tibetan Medicine and the Seedbed for Bioethics

In the Constitution of Tibet (Bod kyi rtsa khrims) promulgated by the 14th Dalai Lama on 10 March 1963 and as a draft constitution for the future State of Tibet, known as Charter of the Tibetans In-Exile (Btsan byol bod mi’i bca’ khrims), there are some chapters dedicated to health-related issues. I hasten to add that the later version, that is, the one of 14 June 1991, differs from the previous document. The differences—in the context of the subject of interest to us—are reduced to the changes in an attitude to medical issues. Namely, in Article 28 of the Constitution of Tibet, we can read what follows3:

“(1) The State shall endeavour to promote adequate health and medical services and to provide that such services would be available free to those sections of the population which are unable to pay for them.

(2) The State shall endeavor to provide necessary facilities and institutions for the care of the aged and the infirm.”

(Constitution of Tibet; Bod kyi rtsa khrims)

On the other hand, Chapter 3 (Article 18) of Charter of the Tibetans In-Exile includes the following:

“(1) The Tibetan Administration shall endeavor to promote adequate health, medical and sanitation services, and provide free medical treatment for the needy. It shall conduct special medical care programs for immunization and chronic illnesses and educate people on environmental issues.

(2) In particular, it shall endeavor to promote the Tibetan pharmacy and the practice of ancient astro-medical sciences, and conduct comparative research in the field of Tibetan and modern astro-medical sciences.

(3) The manufacture and prescription of Tibetan pharmaceutical medicines shall be authorized, regulated and standardized in accordance with the law.”

(Charter of the Tibetans In-Exile; Btsan byol bod mi’i bca’ khrims)

I will skip the remarks related to the inclusion of health-related issues in the Constitution as this inclusion is plainly obvious4. I will also take no heed of the question—which is, incidentally, a very important question indeed—of which State is to take care of Tibetans’ well-being. Instead, I will focus on a later document because what we can spot therein is a change related to the construal of the idiosyncrasies of Tibetan medicine and to the use of another word (over and above the word sman) to refer to medicine. Namely, in Btsan byol bod mi’i bca’ khrims there is some further specification that medicine is not so much sman as (most of all) bod kyi gso ba rig pa, that is, traditional Tibetan medicine. This, at the same time, indicates that religious and cultural issues are still present in debates over medicine and treatment processes as well as in the understanding of what their sources are.

What is a truism is the statement that Tibetan medicine has a long and rich history, and that earlier ideas determine the contemporary conception of what a disease is, a relation between the physician and patient, and what the process of treatment is. I hasten to add that its history is adequately described in the subject-matter literature (cf. Renchung 1973; Gyatso 2015; Fenner 1996; Veith 1962; Sułek 2004; Dashtsev 1988; McGrath 2019; Czaja 2019)5. This is why I will only pay attention to those facts from the rich legacy of Tibetan medicine that will allow for capturing its distinctive features, and especially those facts that yield themselves to bioethical reflection. What merits special attention is one of its sources, that is, more precisely speaking, the treatise originating from the 9th century and bearing the title Rgyud bzhi (Four Medical Tantras, with its fully stated title being: Bdud rtsi snying po yan lag brgyad pa gsang ba mann gag gi rgyud [The Secret Quintessential Instructions on the Eight Branches of the Ambrosia Essence Tantra]), the compilation of which is attributed to Yutok Nyingma Yönten Gönpo (g.yu thog rnying ma yon tan mgon po, 708–833). It is worth indicating in passing that most probably the author of the best-known version of this text or of a commentary thereon was Yuthok Yonten Gonpo the Younger (g.yu thog gsar ma yon tan mgon po, 1126-1202). Rgyud bzhi, apart from the fact that it is an essential relic of Tibetan literature6, should be recognized as an important text subsumable under medical sciences—and not only of local, that is, Tibetan, importance. It consists of four parts dedicated to the demonstration and explanation of the knowledge of the human, his development, and diseases and to the methods of their treatment, respectively7. In line with traditional Tibetan division, the Tibetan text belongs to secular sciences (Cabezón and Jackson 1996, pp. 26–28); however, its content indicates that the abovementioned division is not unambiguous and fails to classify the said text properly. This remark is made—among others—by Todd Fenner, who pointed out that its opening forms bear some resemblance to Buddhist sutras (sūtra) (cf. Fenner 1996, p. 463), thus—already at the level of a form—combining medicine with Buddhism, with Buddhism serving as a justification for medical-healing practices. By way of examples, I can point to sentences from Rtsa rgyud (Root Tantra) in which there are references to Buddha:

“bcom ldan ‘das de bzhin gshegs pa dgra bcom ba yang dag par rodzogs pa’i sangs rgyas sman gyi bla vai du rya ‘ong kyi rgyal po la phyag ‘tshal lo.”

“I prostrate before the blessed Buddha, the Conqueror who achieved full Awakening, Buddha, the teacher of healers, Bhaiṣajyaguru, the King of Aquamarine Light.”

(Glong gzhi: 1)

And:

“de’i tshe de’i dus na ston pa bcom ldan ‘das ‘tsho mdzad sman gyi bal vai du rya ‘od kyi rgyal po des nad bzhi brgya rtsha bzhi zhi bar byed pa’i sman gyi rgyal po zhes bya ba’i ting te ‘dzin la snyoms par zhugs so.”

“At that moment of that time the Buddha, the Master, the Victorious Conqueror, the Supreme Healer, the King of Aquamarine Light entered into a meditative concentration called ‘the King of Medicine’, in order to alleviate four hundred and four disorders.”

(Glong glong: 1)

Apart from that, as also taken heed of by Fenner (1996, p. 463), what is conspicuous are distinctive features of sutra, especially the Sanskrit opening formula: Evaṃ mayā śrūtaṃ (Pali: Evaṃ me suttaṃ) (cf. Brough 1950)8:

“’di skad bdag gis bshad pa’i dus gcig na. drang srong gi gnas sman gyi grong kher lta na sdug ces bya ba rin po che san lang las grub pa’i gzhal yas khang yod de. khang pa de’i rgyan ni sman gyi nor bu rin po che rnam pa san tshogs pas brgyan pa ste.”

“Thus have I heard, at one time in the abode of the sages, the City of Medicine called Tanaduk, where there is an inconceivable palace made of five different precious substances and is decorated with various types of precious medicinal jewels.”

(Glong gzhi: 2)

I would like to point out that my point is not to make clear whether Rgyud bzhi should be considered a religious or secular text, but to show that, regardless of the Tibetan interest in the human question, Buddhism has a primal status in it. Additionally, this is the state of affairs that we deal with in case of Tibetan medicine, wherein the Buddhist threads are entangled with contemporaneous knowledge on humans’ physiology9. Additionally, it is for this reason that this text—as Fenner points out—is the principal textbook of Tibetan medicine, and it is cited frequently in almost all Tibetan medical literature and is the text Tibetan medical students must master before becoming physicians (Fenner 1996, p. 458; Dolma 2013, p. 106).

An exceptional status of Rgyud bzhi in contemporary Tibetan medical sciences may testify to the fact that the abovementioned realms interpermeate and overlap and to the role of the formation of religious thinking, which plays a role in comprehending the essence of health and illness and, subsequently, in the methods of treatment undertaken. It is also a theoretical basis for purification and healing rituals still conducted in nursing homes as well as in major medical centers in which Tibetan refugees inhabiting India are treated, e.g., Medical School Mentsikhang (Sman rtsis khang; full name: Bod gzhung sman rtsis khang [Tibetan Medical & Astro-science Institute]) and Tibetan Delek Hospital10. As examples of religious practices applied to medical treatment, one can point to, e.g., purification, mo divination, recitation of the Medicine Buddha mantra, and preparing medications (Prost 2008).

Apart from the questions related to references to Buddhism in the text Rgyud bzhi, what is important is its making Tibetan medicine open to bioethical issues. However, in this respect, the content of the Tibetan treatise does not offer anything that could be deemed untypical of medicine as traditionally conceived. Furthermore, the exceptional significance of Rgyud bzhi to contemporary Tibetan physicians (cf. Fenner 1996, p. 458; Sułek 2004, p. 103) is one of the major reasons why for Tibetans bioethical issues do not constitute a vital aspect of their reflection on the condition of medicine as such. We can consider this on the basis of one bioethical thread related to a change in the relation between the physician and patient. In passing, I shall add that the above relation as traditionally conceived refers to a prebioethical order based on a vertical relation between the expert physician and patient. However, with the rise of bioethics, the said relation shifted (or is shifting) into a horizontal one wherein patients cease to consent to be passive subjects subjugated to the experts’ will (Alichniewicz 2004, p. 21; cf. Różyńska and Łuków 2013, pp. 22–23; Gert et al. 2006, p. 289). In case of Tibetan medicine, the relations between the patient and physician were not changed and are still of a vertical type that predominates. The content of the thirty-first chapter of the second Rgyud bzhi Tantra, entitled Sman pa (Physician), in which the characteristics that a physician should have as a specialist should be explained in a fairly detailed way. We read there:

“rgyu ni blo ldan bsam pa dkar ba dang. dan tshig ldan zhing rnam pa bzo ba dang. bya ba la brtson mi chos mkhas dang drug”

“The six qualities of an eminent physician are being intelligent, being compassionate, being committed, having dexterity, being diligent and understanding the dharma.”

(Sman pa)

This can be supplemented by words from the rest of the text:

“dis tshig nad gso lus la phan phyir sman. nang steng dpyad dpa’ ‘gro la pha ltar skyob. rgyal po rnams kyis rje ru ‘khur bar byed.”

“The word physician [sman pa] means the one who cures illness and helps the well-being of the body. He is a hero who heal disease. That one who is like a compassionate father and protector. That one who the king highly appreciates.”

(Sman pa: 5)

It is especially important to compare the physician to his father, which strengthens his superior status towards the patient who should submit to his will. In a later part, there is also an important sentence that the doctor is obliged to treat all patients (cf. Sman pa)11. This task is interesting enough as it may mean that the text of Rgyud bzhi was treated selectively by physicians who did not always follow the recommendations contained therein12. This is evidenced by the monuments of Tibetan painting containing rich illustrations showing the actions of doctors and their behavior towards patients. Janet Gyatso in her book Being Human in a Buddhist World included many illustrations of this type in which physicians refuse to conduct medical treatment or choose those individuals that are eligible to become their respective patients (Gyatso 2015, pp. 37–38). What can serve as a contemporary example is the Dalai Lama’s view, for whom this relation is ‘traditionally’ conceived since the physician may decide on a treatment for the patient (Dalai 2001, p. 89). What is of interest is that the Tibetan word nad pa, referring to a patient, only slightly differs from the Latin patior, with the latter being an etymon of ‘patient’, the meaning of which is: ‘to experience’, ‘to sustain’, and—most of all—‘to suffer’ (Plezia 2007, p. 48). On the other hand, Tibetan nad signifies ‘illness’ (cf. Goldstein and Narkyid 1999, p. 146; nad pa). The distinctness can also be spotted in different connotations. That is, whereas the meaning of the Latin word may be approximated as ‘suffering person’, in the Tibetan language the meaning of the scrutinized word is narrowed down and who counts as a patient is an ‘ill person’13. It is worthwhile to add that in the contemporary medical Jargon, in Tibet, there is the phrase nad sman ‘brel ba (doctor-patient relationship)14. However, on the basis of, say, the reminiscences of Tibetan refugees and my own research15, it should not be assumed that the phrase could imply a qualitative change and thus the emergence of a horizonal type of the relation under consideration.

3. The Ban on Abortion and the Status of Human Fetus in Tibetan Medicine

One of the oft-discussed topics in contemporary bioethics is birth control (cf. Szewczyk 2009, p. 37). I hasten to add that this issue is one of the few which appear in Tibetan ruminations and is confined to the problem of abortion16. Before I proceed to consider the crux of the matter, let me note that abortion is regarded as impermissible not only by Tibetan Buddhism but also in the Buddhist doctrine at large. Ngawang Jampa Thaye17, while adducing Vinaya-Pitaka [Vinaya-Piṭaka] as well as later Tibetan theologians such as: Jetsun Dragpa Gyaltsen (rje btsun grags pa rgyal mtshan, 1147–1216) and Ngorchen Kunga Zangpo (ngor chen kun dga’ bzang po, 1382–1456), which claims that terminating life from the moment of conception up to the moment of death is impermissible (Thaye 2007, p. 3; cf. McDermott 1998, p. 157; Keown 2001, p. 92). Similar pronouncements—albeit less categorical—are presented by the 14th Dalai Lama, who has it that from the Buddhist point of view, each life is exceptionally valuable (Dalai 1999, p. 15). These discrepancies in unambiguous condemnation of abortion may be bolstered by references to the text Rgyud bzhi, which contains some views pertaining to the human fetus, with the views being both of utmost interest and at variance—what should be underlined—with commonly shared Buddhist beliefs. This may demonstrate that although bioethics among Tibetans is not consciously and systematically elaborated, some rudimentary forms of its existence—as evinced by the case under consideration—do obtain.

However, to reach a reliable picture of the situation we must take into account the circumstances under which Tibetans found themselves after the division into TAR and the refugees living in India and submitting to the authority of the Central Tibetan Administration (Bod mi’i sgrig ‘dzugs; hereinafter referred to as CTA). However, the difficulties do not end at this point since Tibetans must comply with the law which is effective in the State they reside in; that is, either in China, Nepal, or India (cf. Rigton 1996; Rogers et al. 2019). Additionally, in both countries, abortion is legal. Furthermore, it is not without significance is that this may contribute in the future to the liberalization of the ban of terminating pregnancies (cf. Hughes 1998, p. 183)18. The changes taking place in the way of reproduction among Tibetans are also significant. There is also a noticeable departure from the pronatalism promoted by CTR, still in the 1970s, which results in a clear decline in fertility (Childs 2008, pp. 132, 158). Researchers have repeatedly drawn attention to the transformation of the Tibetan refugee community, in which traditional rules and patterns are replaced by new ones coming from influences, such as Indian and Western ones. It is not without significance that the emergence of new ideas, including the approach to reproduction, is influenced by the education of the young generation and the limited influence of older generations, including those who understand the cultural and religious ‘tradition’ differently (Childs 2008, p. 139; Bloch 2011, p. 181)19. Moreover, we must be aware that presenting a more or less consistent abortion regime does not necessarily mean that it is in line with what individual Tibetans believe. This holds especially true in the light of the fact that Tibetans may often falsely believe that their own interpretations are in line with, say, a religious doctrine20.

To put it succinctly, in Tibetan Buddhism, the debates over abortion are comparable to Western disputes, and they resemble the position assumed by the Roman Catholic Church and the argumentation expressed by antiabortion movements (or prolife movements). The position in question consists in the contention that the fetus becomes a human being already at the moment of conception21. According to the Buddhist view, conception is an event that requires the confluence, in the same moment, of three factors: reproductive substances emitted by a man and woman and a transmigrating consciousness, which is impelled by its own karma to that particular copulating couple (Garrett 2008, p. 8). This view may be elaborated upon in greater detail, while adducing the pronouncements by Thaye to the effect that the appearance of a new human person is conditioned upon the combination of three elements: semen (khu), ovum (khrang), and the consciousness of an entity existing in the state between death and rebirth (las) (Thaye 2007, p. 3; Polnop 2017, p. 38; Kania 2001, p. 5)22. Similar descriptions also appear among Tibetan physicians, for example:

“To make a child you need two things. First, the child comes through the karma of parents, this brings the wind humour into the womb. Then, at a certain time, the substances of man and woman must come together. For the woman, she must have enough red element in her seminal vesicle to make a child. If the red element does not arise, then you cannot have a child.” (Prost 2008, pp. 20–21)

Whereas the pronouncements of Thaye do not induce much reflection since they express a commonly shared belief of practicing Buddhists, the pronouncements of the Mentsikhang physician clearly demonstrate that religion plays a significant role in understanding the foundations of biology and medicine. In addition to all of this, we may have an impression that the views emerging among Tibetans, while not taking heed of the Dalai Lama’s stance, present a clear position with explicit premises justifying the ban on abortion.

While searching for the sources of the above-cited views characterizing Tibetan thought, we should turn to not only particular Buddhist sutras but also the text Rgyud bzhi. It transpires that they are in line with the version represented by Renchung Rinpoche in Tibetan Medicine, which is, more specifically speaking, evidenced by the following statement: “From the moment of conception, through karma, the embryo’s mind spreads the srog-lung (breath of life)” (Renchung 1973, p. 33). At this point, I must emphasize that the above sentence diverges from the content of the Tibetan original23, which is, as we remember, a source text for Tibetan medicine and for knowledge on human physiology. This is important as it may testify to the act of interpretation, which is, after all, aligned with the predominant view of the 20th century related to the origins of life rather than to the strict adherence to the content of the text of the Tibetan treatise. A difference lies in the use of the concept ‘rlung’, not understood literally as ‘wind’ but rather as ‘life force’ or ‘breath of life’24, with the latter understanding not appearing at this point in the original text. On conception in Rgyud bzhi, we can read in the first chapter of the second part under the title Embriology (Chags tshol) as little as the statement that what is necessary to bring into existence a new human person is: semen, menstrual blood, karma, and kleshas (kleśā). Namely:

“dang po pha ma’i khu khrag skyon med pa. rnam shes las dang nyon mongs kyis bskul nas. ‘byung lang dzogs pa mngal du chags pa’i rgyu. dper na gtsubs shing dag las me ‘byung mtshungs.”

“The causes of conception are the union of non-defective semen [khu] and [menstrual—M. L.] blood [khrag] of parents [pha ma’i], and the consciousness of the being, imprint of past karma [les] with kleshas [nyon mongs] and the assemblage of the five elements. It resembles the fire produced by the friction of two sticks.”

(Chags tshol: 1)

In the context of bioethics, Rgyud bzhi preserves a religious belief to the effect that the emergence of karma at the moment of conception turns a fetus into a human person, thus strengthening the ban on abortion.

Let us now pay attention to one more sentence of this chapter which is not in accordance with the above-presented interpretation, and which thus makes room for the appearance of typically bioethical issues. The sentence runs as follows:

“les ma ‘dzom na rnam shes mi ‘jug set.”

“If karma [les] does not arise, consciousness [rnam shes] will not enter the mother [ma].”

(Chags tshol: 2)

First of all, what appears here is the concept of ‘consciousness’ supplanting ‘conception’. Additionally, second of all, the essence of conception and the status of the emerging human fetus appear. Let me recall at this point that in an earlier fragment, what was necessary for the appearance of the fetus was the combination of semen and blood, whereas in later versions it was ovum and karma. The cited words may be understood in such a way that semen and blood (ovum) are supposed to constitute a material basis for karma to penetrate. If so, it may transpire that karma is not indispensable for conception, but it is indeed necessary for the recognition of fetus as a human person, with the latter being allegedly marked with consciousness. It follows therefrom that karma can penetrate the human embryo at a later stage, which would thus undermine the view to the effect that a human person emerges already at the moment of conception. In other words, a zygote is not identical with a human person. Instead, the former becomes the latter when the former is penetrated by karma. Incidentally, this view is shared by the 14th Dalai Lama, who claims that consciousness enters an already conceived ovum in the woman’s uterus (Dalai and Hopkins 2004, p. 75). Let me add that this interpretation may unleash Tibetan debates over abortion which would bear close resemblance to Western bioethical debates over the moral status of the human fetus (cf. Wasserstrom 1975; Steinbock 2006; Różańska 2008, pp. 1–19). This would also imply a transition from an extremely conservative standpoint to a moderately conservative one (cf. Galewicz 2010, pp. 12–13). Let me add that it is in this spirit that the words of the Dalai Lama are expressed, with the said words being to the effect that a moral assessment of the termination of pregnancy should be adjusted to a specific event and an individual situation of each family (Dalai and Hopkins 2004, p. 95; Dalai 1999, p. 15)25.

There is one more issue connected with the human fetus, and although it constitutes an important and separate thread, it rarely appears in contemporary discussions. What is thereby meant are the practices which are supposed to influence the deliberate formation of fetus gender, with these attempts making Tibetan practices approximate contemporary genetic engineering. Similar to the previous case, the source of these ideas is the text Rgyud bzhi, in which there is a fairly accurate—as for contemporary times—description of the factors contributing to the formation of fetus gender. Namely:

“mngal kha bye nas zhag ni bcu gnyis bar. dang bo’i zhag gsum bcu gcig bu mi len. gcig gsum lang bdun dgu la bur ‘gyur te. gnyis dang bzhi drug brgyad pa bu mor ‘gyur. nyi ma nub pas pad ma’i kha zum bzhin. bcu gnyis ‘das nas khu ba mngal mi sdod.

khu ba mang ba bu ru skye ‘kyur gyi. zal mtshan mang ba bu mor skye bar ‘kyur. ca mnyam ma ning bye las mthse mar skye. skye gnas mi mthun pa dang gjugs mi sdug. ‘di dig gnod pa’i dri mas skye bar ‘khyur.”

“The entrance to the uterus is open for twelve days. In the first three days and after the eleventh conception does not occur. If conception occurred on the first, third, fifth, seventh or ninth day, then there will be a boy; if in the second, fourth, sixth or eighth, then a girl. Similar to how the lotus closes at sunset, after twelve days sperm does not penetrate there.

If there is more sperm, a boy will be born, if there is menstrual blood, a girl, if equally will be a hermaphrodite [mtshan mang ba], and if the seed splits twins [mthse ma] will be born. The birth of a non-human being or an unattractive child is due to negative influences.”

(Chags tshol: 4)

However, Tibetan embryology, contained in Rgyud bzhi, apart from the distinction between genders and the determination of causes of their formation, does not introduce anything important for the specification of a possibility of influencing a sex change26. Still, this thread is to be found in Kyempa Tsewang (skyem pa tshe dbang)—a 15th-century Tibetan physician commenting on Rgyud bzhi. In his view, it is possible to undertake deliberate actions aiming at a sex change, or, speaking more precisely, at the formation of a male fetus (Garrett 2008, p. 8). It is worthwhile to turn one’s attention to a more detailed description of the scrutinized practice, as presented by Kyempa Tsewang:

“On the astrologically auspicious day when the Victory star and the moon are aligned, he explains, a blacksmith should create the form of a male child out of three, five or seven types of metal. The form should be heated in a coal fire until it glows red, and then soaked in the milk of an animal who has given birth to male offspring, measuring an amount of milk that corresponds to however many types of metal were used. Two handfuls of cooled milk should be given to the woman. Alternatively, he continues, to achieve the same effect a medicinal concoction, a mixture of Seaberry, grape and molasses, could be administered to the pregnant woman. Finally, if these procedures are ineffective or impractical, the woman could try wearing an amulet.”

(Garrett 2008, p. 1)

The first issue—an important one from the bioethical standpoint, albeit not explicitly stated—is a positive attitude towards this sort of practice, which is exactly what may in the future open Tibetan medical reflection to genetic engineering. Additionally, what can make Tibetan medicine reflect on genetic engineering? The second thread is related to the idiosyncrasies of Tibetan medicine and is connected with the demonstration of how deeply embryology is connected with religious and cultural content. More precisely speaking, what is thereby meant is the connection of embryology with magical rituals alluding to sympathetic magic and with the faith of positive influence of amulets as well as with astrology and pharmacology based on herbal medicine and the use of metals (cf. Liu et al. 2019). What is also meant are such magical rituals that also make reference to sympathetic magic and the faith in the positive workings of amulets, with the magical rituals in question occurring also in the medical practice of contemporary Tibetan physicians, in the actions undertaken by patients, and in Buddhist monks’ religious service in hospitals treating Tibetans (cf. Prost 2008, p. 49). Let me add that this thread appears in liberalized forms in the pronouncements of the Dalai Lama, who does not straightforwardly criticize such practices but instead commends adjusting a moral assessment to particular circumstances (Dalai 1997, p. 79).

4. The Termination of Life from the Tibetan Medical and Religious Perspective

According to Damien Keown, the moral issues which arise at the end of life are no less complex than those surrounding its beginning (Keown 2001, p. 138). Additionally, although each life is inextricably intertwined with death, the latter assumes (with our focus being Buddhism alone) multifarious—depending on a doctrine, country, or culture—faces and shades. It transpires that in the case of Tibetan culture (including religion and medicine), more attention was paid to death than to the issues of procreation and of the legal and moral status of the human fetus. What testifies to this is the significance Tibetans attach to the text Bar do thos grol (Liberation Through Hearing During the Intermediate State), known as The Tibetan Book of Dead, as well as many treatises and commentaries pertaining to the analysis of death from the perspective of Tibetan Buddhism. It also transpires that death and the proper preparation therefor play an important role in a religious practice, the aim of which is to attain a ‘good’ rebirth in one’s future life. The Dalai Lama goes as far as to say that the awareness of the fact that we will die is favorable to spiritual practice (Dalai and Hopkins 2003, p. 33). Apart from a religious dimension, death has also a biological and a medical one, with the medical dimension being of special interest to me, which is why I will pay attention thereto. Let me add that similar to the case of conception to that of the fetus, we can only point to some rudimentary remarks which resemble bioethical reflection. Additionally, they may merely seem to be at variance with Buddhism. However, once one probes them more deeply, it turns out that in Tibet, religious schemes are deeply rooted in biological sciences of the human. In the Tibetan language, the concept of ‘death’ is expressed by ’chi, the understanding of which is to be found in the text Rgyud bzhi, wherein we can read the following:

“lus kyi ‘jig ltas rnam pa bzhi yin ti. ring dang nye ba ma nges pa’o.”

“There are four types of signs of destruction [‘jig]: distant, near, indefinite and definite.”

(‘jig ltas: 1)

As we can see, ‘death’ signifies disintegration and destruction, which are referred to in Tibetan as ’jig, and which is not negatively perceived in either a Buddhist doctrine or in the text Bar do thos grol. What also characterizes a typically Buddhist construal of death are signs—extensively described in Rgyud bzhi—presaging the end of person’s life such as dreams, omens, or a characteristic pulse (cf. ‘jig ltas: 1; Varela 2001, p. 175). It should be added that in the Buddhist view, which also characterizes Tibetans, death differs from the Western view27, for death is understood as a process that should lead to a ‘good’ reincarnation (cf. Patrul 1998, p. 85)28.

Searching for the information related to bioethical aspects of death, we are doomed to working our way through numerous texts pertaining to religious practices wherein what rather rarely appears are references to euthanasia or suicide among Tibetan refugees. When it comes to euthanasia, there appears only some vague criticism reducible to the position that euthanasia—from the Buddhist perspective—does not really solve the problem since sooner or later, that is, in the process of successive rebirths, one will have to go through all this painful experience anyway. Therefore, as the Dalai Lama points out, it is better to pay off karmic debt while in a human body (Dalai 1999, p. 105). The general level of reflection is also reduced to the fact that in individual cases, what is possible is the liberalization of that position and the approval of euthanasia as the only way out of a predicament; for example, consider the case of a terminally ill patient or a person in a coma (Dalai 1999, p. 106). I may at this point venture a statement that the lack of serious debates over euthanasia stems from the difficulties that Tibetans living in India are burdened with and which determine the reflection they entertain and medical actions they undertake. To put it briefly, the situation is connected with the growing unemployment rate, drug addiction among a young generation, and health issues as well as the low quality of health care in hospitals and smaller medical facilities in which Tibetans are treated (Bloch 2011, pp. 294–95; Prost 2008, p. 17; Patrul 1998, pp. 85, 164–65). That is why euthanasia should be regarded as a problem that might figure in the future in medical and religious debates. On the other hand, when it comes to suicide, there is a commonly shared belief to the effect that suicide constitutes an impermissible action (cf. Keown 1998–1999). In the pronouncements by the Dalai Lama, a very general criticism of suicide is to be found (cf. Dalai 1999, pp. 107–10), with the criticism being accompanied—as he noted in his book Ethics for the New Millennium—with the contention that the problem under scrutiny does not really apply to Tibetans (Dalai 2001, p. 15)29.

One of the few instances of the debate over the relation between medicine and death which appears in the Dalai Lama’s texts is about the nonapplication of painkillers by dying persons. The significance of this case consists in the relations between medicine coupled with palliative care and religious practice coupled with the care for ‘good’ reincarnation. In his view:

“While in the process of dying, what is important is that we should not be given by medications that distort our clear-mindedness. The person involved in her spiritual practice should not be administered stupefying medications because the consciousness should be as lucid as possible. An injection causing a ‘peaceful death’ might deprive one’s mind of the possibility of manifesting itself in positive ways such as, for example, the contemplation of flimsiness, the inducement of faith, the experience of sympathy or the meditation over selflessness. However, if a non-stupefying painkiller were to be invented, its influence might be even favorable because one’s mind could then normally function, while remaining free of distortions caused by pain.”

(Dalai and Hopkins 2003, pp. 72–73)

This position taken by the Dalai Lama is important for two reasons. First, the process of dying is in Tibetan Buddhism connected with religious practice. It also refers to the content of bar do thos grol, in which there are precise descriptions of the process of dying and the religious significance thereof, e.g.,:

“Recognizing the voidness of thine own intellect to the Buddhahood, and looking upon it as being thine own consciousness, is to keep thyself in the (state of the) divine mind of the Buddha.”

(Evans-Wentz 1957, p. 96)

From a medical—but not from the Buddhist—point of view, Dalai Lama’s position is seemingly clear, especially given the fact that he does not prohibit the use of pharmacological substances as such but rather turns our attention to the consequences of applying them. Additionally, at this point, the second issue emerges. This time the issue is related to the vagueness related to pain and/or suffering occurring while dying: for example, in people suffering from oncological illnesses, renal colic, or labor pain. Does pain in such cases contribute to the distortions in the attainment of clear mindedness? Additionally, in connection with the previous question, another emerges: how is, from the perspective of Tibetan Buddhism, proper death possible? It is worthwhile to add that the Dalai Lama, while writing (or speaking) about pain, identifies it with psychological—but not physical—suffering (Dalai and Cutler 1998, p. 110)30. That is why—as in the case of euthanasia—one is warranted in saying that the issue of pharmacological support of dying persons is a task for the future in the medical, pharmaceutic, and bioethical sense.

5. Conclusions

In the literature on the subject, bioethics in Asia are a relatively new and not yet systematized issue (cf. Florida 1998, p. 11). Based on the above considerations, we can assume that this matter is not so unequivocal because there have been issues in traditional Tibetan medicine that we can define as bioethical for many centuries. These include, as we recall, issues related to the beginning of life and abortion, as well as death. However, a more accurate diagnosis of the situation makes it difficult to understand the basic concepts properly. In addition, there is also a lack of a clear distinction between ethics and morality, concepts that are often used as synonyms and, as a result, make it difficult to reflect on Tibetan bioethics systematically. Without going into the doctrinal details, let us pay attention only to the plane of the Tibetan language, whose users use the term ‘medical ethics’ as compatible, as we recall, with Chinese yīdé. The meaning of Tibetan sman pa’i kun spyod fully overlaps with the Chinese word, but they are not in accord with the English translation. Namely, kun spyod and dé mean morality and not ethics, which, in the Tibetan language, is defined by the word khrims, meaning not only ethics but also the law (Goldstein and Narkyid 1999, p. 171). In addition, there is also the term tshul khrims, which can be translated as ethical system or legal system and is closely related to good conduct (Gethin 1998, p. 83; cf. Powers 2007, p. 68)31. The significance of these discrepancies consists in the fact that ‘ethics’ is not synonymous with ‘morality’ but refers to something else. The Polish ethicist Jacek Hołówka differentiates between the two in such a way that he attributes to ethics the status of a normative system which must be independent of anybody’s opinions or beliefs about norms and moral values (Hołówka 1996, p. xiv). On the other hand, ‘morality’ refers to views, opinions, beliefs, attitudes, and resolutions, and it occurs as something personal and common at the same time (Hołówka 1996, p. xiii). In line with this distinction, what instantiates ethics, that is, what instantiates a coherent system, is tshul khrims, whereas what exemplifies morality is kun spyod. That is why the expression sman pa’i kun spyod ought to be rendered as ‘medical morality’. However, the situation is not so simple because ethical reflection on medicine—also as bioethics, which after all belongs to the groups of professional ethics—induces us to pose novel questions about the relation and differences between ethics and morality. The authors of the book Bioethics: A Systematic Approach capture the issue in a much more confrontational manner, while claiming that ethics delineates the general framework of one fundamental and universal structure of morality, which in turn can assume various forms under different contexts but always strives to avoid the same sort of harms and to attain the same goals (Gert et al. 2006, p. 28). Note that such a construal does not release us from attempting to reach systematicity of our train of thought and from searching for some justification for views, attitudes, or values adopted. This in turn corresponds with the views inhering in Tibetan Buddhism to the effect that a reflection on morality should be conducted on the basis of reasoning and not on the basis of blind faith (Thaye). This is also important in the case of bioethics, which emerged in the second half of the 20th century in connection with the changes that occurred in medicine and which gave rise to new challenges and problems. Moreover, it is to be underlined that bioethics required some systematic reflection and rational justifications, which especially applies to such issues as abortion or euthanasia (cf. Galewicz 2010, p. 10).

The case of Tibetans and the medical issues considered by them proves to be an interesting topic since Tibetans put forward solutions that differ from Western ones. What is thereby meant is, first and foremost, Buddhist soteriology and eschatology. The case of Tibetans also reveals, importantly enough, the process of the formation and shaping of bioethical reflection and, more precisely, its causes, course, and discrepancies in the justifications of the disputed issues. However, despite the differences in ethical understanding and the changes taking place in the Tibetan community in India, the traditional approach to issues related to medical care and treatment of patients still prevails. Moreover, it testifies to the occurrences of the attitude bearing close resemblance to common morality, as formulated by the authors of Bioethics: A Systematic Approach. More precisely speaking, what is meant by common morality is one that is based on a feeling of self-evidence stemming from, in our case, the Buddhist doctrine and from such values as respect for life, compassion, etc., but without precisely specifying the terms used (Gert et al. 2006, p. 35). What is interesting are the particular pronouncements by the Dalai Lama which simultaneously uncover references to Buddhism and to the emergent—if I may put it like this—bioethical awareness. What is conspicuous in them is the liberalization of authoritative attitudes towards abortion and euthanasia. Namely, the Dalai Lama commends an individualized approach to each situation and the selection of the optimal solution, which may imply the termination of pregnancy or not sustaining life of a terminally ill person (Dalai 1999, p. 106; Dalai and Hopkins 2004, p. 95). Even if we could regard the said liberalization as a significant step towards a change in the attitude to typical bioethical issues, it still turns out to be barely useful on the moral plane because it is not founded on any coherent principles. As in the case of common morality, the above-considered morality is of little use when it comes to deciding how to act in a specific situation (Gert et al. 2006, p. 13). This is extremely important for the contemporary challenges of medical practice, which require considering various contexts in which dilemmas32 may arise and the importance of more precise treatments justifying their moral acceptability.