M indfully
F acing disease and D eath Compassionate Advice from Early Buddhist Texts
AnÄ layo
MFDAD pages 234x156 v1-38.indd 3
18/04/2016 09:59
Windhorse Publications 169 Mill Road Cambridge CB1 3AN UK info@windhorsepublications.com www.windhorsepublications.com © Anālayo, 2016 The right of Anālayo to be identified as the author of this work has been asserted by him in accordance with the Copyright, Designs and Patents Act 1988. As an act of Dhammadāna, Anālayo has waived royalty payments for this book. Cover design by Dhammarati Typesetting and layout by Ruth Rudd Printed by Bell & Bain Ltd, Glasgow British Library Cataloguing in Publication Data: A catalogue record for this book is available from the British Library. ISBN: 978 1 909314 72 6
MFDAD pages 234x156 v1-38.indd 4
18/04/2016 09:59
4 Q U A L I T I E S O F A PAT I E N T A N D A N U R S E / 3 5
IV
QUALITIES OF A PATIENT AND A NURSE
IV.1 INTRODUCTION
The present chapter approaches the situation of being ill from two complementary perspectives: what are commendable qualities for a patient and for a nurse? These commendable qualities are described in two consecutive discourses from the Ekottarika-āgama, translated below. These show some variations when compared to their two parallels found in the Aṅguttaranikāya.1 One of the commendable qualities for a patient according to the Ekottarika-āgama discourse is mettā, a term often translated as “loving-kindness”, although I think a preferable translation would be “benevolence”. Just as with dukkha, however, it seems best to me to retain the original word in Pāli. This quality of mettā constitutes the first of four divine abodes, brahmavihāra, which are: • mettā,
• compassion, • sympathetic joy, • equanimity.
1 AN 5.123 at AN III 143,19 (translated Bodhi 2012: 741) and AN 5.124 at AN III 144,14 (translated Bodhi 2012: 741); on qualities of a nurse according to the ancient Indian medical treatises Carakasaṃhitā and Suśrutasaṃhitā see Leslie and Wujastyk 1991.
MFDAD pages 234x156 v1-38.indd 35
18/04/2016 09:59
3 6 / M I N D F U L LY F A C I N G D I S E A S E A N D D E A T H
These four divine abodes are the ideal attitudes towards others recommended in early Buddhist thought and mental training.2 The term “divine abode” not only reflects the notion that successful practice will lead to a heavenly rebirth, but can also be interpreted in the sense that dwelling in any of these is akin to experiencing heaven on earth. The first of these four, mettā, refers to an attitude of kindness and well-wishing towards others, which by its nature is directly opposed to aversion, irritation, and ill will. The second, compassion, will be a recurrent theme throughout this book, in particular in the form of the altruistic wish to ease the suffering of others and provide them with guidance in how to face disease and death. By nature compassion is the opposite of the intention to harm others. Sympathetic joy is the opposite of envy, jealousy, and discontent. The fourth divine abode rounds off the whole set, offering the option of equanimity for situations in which the other attitudes would not be appropriate. I will come back to the four brahmavihāras as a meditation practice at the time of passing away in Chapter 15. IV.2 TRANSLATION (1) 3
Thus have I heard. At one time the Buddha was staying at Sāvatthī in Jeta’s Grove, Anāthapiṇḍika’s Park.4 At that time the Blessed One said to the monastics: “A patient who is endowed with five qualities will not gain timely recovery and will remain bedridden.5 What are the five? “Here a patient does not discern what to drink and eat, does not eat at the proper time, does not take the medicine, grieves too much and enjoys being irritable, and does not arouse a mental attitude of mettā towards the nurse.6 Monastics, these are 2 3 4 5
On these four see in more detail Anālayo 2015b: 5–49. The translated discourse is EĀ 32.8 at T II 680b19 to 680c2. AN 5.123 does not mention the location where the Buddha was staying. AN 5.123 at AN III 143,19 instead introduces its set of five qualities in terms of what makes it difficult to take care of such a person. 6 The five qualities listed in AN 5.123 at AN III 143,21 are: 1) doing what is not appropriate, 2) not knowing moderation with what is appropriate, 3) not taking the medicine, 4) not disclosing as it really is if the affliction is becoming worse or better, and 5) being unable to endure painful feelings.
MFDAD pages 234x156 v1-38.indd 36
18/04/2016 09:59
4 Q U A L I T I E S O F A PAT I E N T A N D A N U R S E / 3 7
reckoned to be the five qualities, endowed with which a patient will not gain timely recovery. “Again, if a patient is endowed with five qualities, [the patient] will gain timely recovery. What are the five? “Here a patient discerns what to [drink and] eat, eats at the proper time, takes the medicine, does not cherish grieving, and fully arouses a mental attitude of mettā towards the nurse. Monastics, these are reckoned to be the five qualities, endowed with which a patient will gain timely recovery in turn. “Monastics, in this way you should mindfully discard the former five qualities, and you should together respectfully uphold the latter five qualities. Monastics, you should train in this way.”7 At that time, hearing what the Buddha had said, the monastics were delighted and received it respectfully. IV.3 TRANSLATION (2) 8
Thus have I heard. At one time the Buddha was staying at Sāvatthī in Jeta’s Grove, Anāthapiṇḍika’s Park.9 At that time the Blessed One said to the monastics: “If a nurse is endowed with five qualities, [the patient] will not gain timely recovery and remain bedridden.10 What are the five? “Here a nurse does not discern when administering medicine, is negligent and has a mental attitude that lacks energy, regularly enjoys getting irritated and is exceedingly drowsy, nurses the patient out of greed for food, not because of reverence for the Dharma, and does not come back to converse with the patient.11 7 AN 5.123 records no injunction addressed to the monastics. 8 The translated discourse is EĀ 32.9 at T II 680c3 to 680c17. 9 AN 5.124 does not mention the location where the Buddha was staying. 10 AN 5.124 at AN III 144,14 instead introduces its set of five qualities as what disqualifies a nurse from taking care of a patient. 11 The five qualities listed in AN 5.124 at AN III 144,16 are: 1) the nurse is unable to prepare medicine, 2) due to not knowing what is appropriate and what is not appropriate, the nurse gives the patient what is not appropriate and withholds what is appropriate, 3) the nurse looks after the patient for the sake of worldly gains, not out of mettā, 4) the nurse feels disgusted when having to remove faeces, urine, vomit, and spittle, 5) the nurse is unable to instruct and gladden the patient from time to time with a talk on the Dharma.
MFDAD pages 234x156 v1-38.indd 37
18/04/2016 09:59
3 8 / M I N D F U L LY F A C I N G D I S E A S E A N D D E A T H
Monastics, these are reckoned to be the five qualities; if a nurse is endowed with them, [the patient] will not gain timely recovery. “Again, monastics, if a nurse is endowed with five qualities, [the patient] will gain timely recovery in turn and will not remain bedridden. What are the five? “Here a nurse discerns when administering medicine, is not negligent, being the first to rise and the last to lie down, constantly enjoys conversing and has little drowsiness, [nurses] out of reverence for the Dharma and not out of greed for food and drink, and is capable of teaching the Dharma to the patient. Monastics, these are reckoned to be the five qualities; [if] a nurse is endowed with them, [the patient] will gain timely recovery. “Therefore, monastics, when you are nursing, you should [mindfully] discard the former five qualities, and undertake the latter five qualities. Monastics, you should train in this way.”12 At that time, hearing what the Buddha had said, the monastics were delighted and received it respectfully. IV.4 DISCUSSION
According to the first Ekottarika-āgama discourse, a patient who does not discern in regard to the appropriate type of food and drinks and the proper time for consuming these will deteriorate, and the same holds if the patient does not take their medicine. The Aṅguttara-nikāya presentation formulates the same basic advice in a more general way. The sickness will become worse if the patient does not do what is appropriate and, in relation to what is appropriate, knows no moderation. Here, too, the same holds if the patient does not take their medicine. Other qualities that prevent a patient’s recovery in the Ekottarika-āgama discourse are being irritable and lacking mettā towards the nurse. The Aṅguttara-nikāya version instead describes a patient who does not disclose a worsening or improvement of the condition and who is unable to endure pain. The Ekottarika-āgama discourse and its Aṅguttara-nikāya parallel agree in continuing their presentation by listing 12 AN 5.124 records no injunction addressed to the monastics.
MFDAD pages 234x156 v1-38.indd 38
18/04/2016 09:59
4 Q U A L I T I E S O F A PAT I E N T A N D A N U R S E / 3 9
the opposite five qualities as the means for quick recovery. Combining the two versions and presenting the result in a summary fashion, the qualities that will enable a patient’s speedy recovery are: • to take only the appropriate food and drink, • to take these at the right time and in moderation, • to take the prescribed medicine, • to disclose one’s condition truthfully and not get irritated, • to cultivate mettā towards the nurse and patiently endure pain. Regarding the qualities of a nurse in the second Ekottarikaāgama discourse translated above, both versions take up a nurse’s lack of ability or powers of judgement when administering medicine. The Aṅguttara-nikāya discourse presents this problem in terms of two qualities, where a nurse lacks ability to prepare the medicine and lacks judgement as to when something should be administered and when it should better be withheld. The second quality in the Ekottarika-āgama version is instead negligence, which would also adversely affect the providing of adequate medication and health care. A quality only mentioned in the Ekottarika-āgama version combines the enjoyment a nurse may find in displaying irritation with becoming exceedingly drowsy. The next quality in the Ekottarika-āgama discourse and its counterpart in the Pāli parallel turns to the issue of nursing for the sake of material gains. In the ancient Indian setting monastics had to look after each other, as a result of which some of them took up the office of nursing those who were sick and in need of care. Once provisions offered by the laity for the sick and those who looked after them became abundant, undertaking the task of caring for those who were ill could be motivated by the wish for material gains, and for an easy supply of food. Instead, as pointed out explicitly in the Aṅguttara-nikāya version, one should care for the sick out of altruism, being motivated by mettā. A quality found only in the Aṅguttara-nikāya discourse is the disgust a nurse might feel when having to remove faeces, urine, vomit, and spittle. The last quality in both versions
MFDAD pages 234x156 v1-38.indd 39
18/04/2016 09:59
4 0 / M I N D F U L LY F A C I N G D I S E A S E A N D D E A T H
highlights the importance of conversing with the patient. The Ekottarika-āgama version makes it clear that, if a nurse does not come back to converse with the patient, this will run counter to the patient’s recovery. The Aṅguttara-nikāya parallel more specifically speaks of a nurse’s inability to instruct and gladden the patient with a talk on the Dharma. The need to take care of the mental condition of a patient and provide a source of comfort through conversation and instruction will be a recurrent topic in the next chapters, which regularly show the Buddha and his disciples compassionately visiting the sick and dying to offer support by teaching the Dharma. As explained by de Silva in relation to the present discourse:13 It is noteworthy that the nurse [is] expected to be efficient not only in taking care of the body by giving proper food and medicine, but ... is also expected to take care of the patient’s mental condition. It is well known that the kindness of doctors and nurses is almost as efficient as medicine for the patient’s morale and recovery. When one is desperately ill or helpless, a kind word or a gentle act becomes the source of comfort and hope.
The Ekottarika-āgama discourse and its Aṅguttara-nikāya parallel continue their exposition by listing the opposite five qualities of a nurse that will lead to a patient’s quick recovery. Combining their presentation in a summary fashion and focusing on what seem to be the essential points, the following are the main qualities of a nurse that will facilitate a patient’s recovery: • to give proper medication, • to be attentive to the needs of the patient, • to cope with one’s own disgust, • to be willing to converse with the patient, • to maintain an altruistic motivation and avoid getting irritated. The coverage given to these sets of qualities shows that the early Buddhist teachings related to disease are not only concerned with what falls directly within the domain of 13 This and the next quote below are both from de Silva 1993: 29.
MFDAD pages 234x156 v1-38.indd 40
18/04/2016 09:59
4 Q U A L I T I E S O F A PAT I E N T A N D A N U R S E / 4 1
progress to awakening. Although this is clearly a prominent concern, alongside this overall orientation towards awakening proper room is given to ordinary aspects of the situation of someone who is sick. Such giving of room appears to have been not merely a question of verbal teachings: in fact in the Vinaya the Buddha himself is on record for setting an inspiring example for the willingness to nurse those who are sick. The episode in question is directly related to the lists of qualities in the two discourses translated above, since the account of this event in the Pāli Vinaya continues by listing the same five qualities of a patient and of a nurse as found in the Aṅguttara-nikāya, thereby setting a narrative context for the teachings discussed in this chapter. Other Vinayas similarly relate this episode to comparable listings of qualities. According to this narrative context, in the way it has been recorded in the Pāli Vinaya, the Buddha had chanced upon a sick monastic left lying in his own excrement by his companions. Aided by his personal attendant Ānanda, the Buddha is on record for himself washing the monastic. Afterwards he admonished the other monastics, explaining that it was their duty to look after a sick fellow monastic, which they should consider to be just as if they were looking after the Buddha himself.14 As noted by de Silva: The Buddha not only advocated the importance of looking after the sick, he also set a noble example by himself administering to the helplessly sick.
Besides throwing into relief the Buddha’s compassion, even to the extent that he becomes personally involved in cleaning one of his disciples, another remarkable aspect of the same event is the lack of concern of the other monastics. The episode gives the impression that to take care of one’s companions in the monastic life was not necessarily seen as a self-evident duty, otherwise the monastics would not have needed to be told that they should look after the sick. The Buddha apparently had to set an example to inspire in his monastic disciples the 14 Vin I 302,3 (translated Horner 1951/1982: 431); for a study of the parallel versions see Demiéville 1974: 236–8.
MFDAD pages 234x156 v1-38.indd 41
18/04/2016 09:59
4 2 / M I N D F U L LY F A C I N G D I S E A S E A N D D E A T H
compassionate attitude that makes it natural to be willing to nurse another, independent of whether the patient will be able to recompense in some way the care received. This makes such a compassionate attitude in nursing an integral and even characteristic aspect of the Buddha’s teaching. The importance of compassion also emerges from the listings of qualities of a nurse and a patient, where due room is given to the beneficial repercussions of an attitude of mettā and empathy, free from irritability and carelessness. This is perhaps the most salient aspect to be taken away from this chapter, in that a sincere attitude of altruism and benevolence aids speedy recovery, an attitude to be cultivated by both patient and nurse. The two sets of qualities that are detrimental or beneficial for a patient’s recovery have a counterpart in two sets of qualities that are detrimental or beneficial for a meditator’s progress on the path to mental health, the path to awakening. These two sets of qualities are the hindrances and the awakening factors, which are the theme of the next chapter.
MFDAD pages 234x156 v1-38.indd 42
18/04/2016 09:59