Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

A Practical Pact for the Pure Land

A Practical Pact for the Pure Land I was perched on the armrest of our family room couch, watching in both awe and bewilderment as my Aunt Janice carefully knelt to the ground, bowed her head three times, paused with her eyes closed, and repeated the head bowing. She did not arise from her position until she had uttered to herself multiple times in a quiet methodical chant, “Nan wu a mi tuo fo,” which I would come to understand as meaning “I entrust in the Amitabha Buddha.” In front of her stood a modest shrine. On a simple white shelf, a framed picture depicted a male figure flanked on each side by a female figure. All three were sheathed in ornate dress and jewels. Also on this shelf were an offering plate with a piece of fruit and a small pot with sand to hold an incense stick upright. Its white wisp of smoke rose in the air, thin and crisp. Once she completed her ritual prayer, I asked, “Aunt Jan, can you help me with a project for medical school? I need to ask you some questions.” “For school? No problem . . . but we eat breakfast first.” “Why don't you go to a temple to practice your Buddhism?” I asked. “Because I don't need to. It's not required for the Pure Land. Amitabha Buddha has allowed his followers to practice in the way they feel best,” she replied, over the sizzle of eggs and tiny salted shrimp in the frying pan. “What's the Pure Land?” “Eat first. You should eat more—how else are you going to care for me when I’m old?” said Aunt Janice, simultaneously pushing a bowl of rice porridge and dumping the steaming contents of her frying pan onto a fresh plate. How do you ask a close relative about the grim and gritty details of her potentially last waking hours, in broken Mandarin Chinese? Poorly, in my case. Armed with my mother, also a practicing Buddhist, as a “qualitative medical interpreter,” I began asking the seemingly simple questions outlined in the advanced care directive (ACD) exercise required for my second-year class in medical ethics and professionalism. At times puzzled and at other times resolutely, she nonetheless answered the seven yes/no questions regarding resuscitation, artificial nutrition, and medical interventions. To my surprise, she agreed to cardiac resuscitation, transfusion of blood products, and administration of antibiotics. In contrast, she refused mechanical respiration, artificial nutrition, invasive procedures, and kidney dialysis. I would read the statement, roughly translate it for my mother who, through her own mental filter, would adapt her understanding of the terms and describe it to my aunt. The process seemed similar to the childhood game Whisper Down the Lane, and I could only hope that what came out of my mouth and into my Aunt Janice's ears was not grossly distorted during the process of interpretation. With gradual resignation Aunt Janice had welcomed Western medicine as she welcomed Western culture, moving in with our family in the United States after her husband had passed away from a difficult but abbreviated battle with renal cell carcinoma. He had just turned 70 years old. He didn't have an ACD but instead relied on his children to make appropriate medical decisions for him. This was to be expected; as in many Asian cultures, the children have the sole responsibility of caring for their elderly parents. And these parents would always agree in silent acceptance; believing that after their lifetime of struggle and hardship to provide a better life and education for their children, their children would know best. Aunt Janice avoided the heated conversations between her children and the physicians about her husband's morphine dosages and opportunities for experimental treatments. Instead she sat at his bedside and spoke to Amitabha Buddha for him. To this day—long after his death—the circumstances surrounding the treatments used for my uncle's cancer still spark disagreements among my cousins. At home in Taiwan, Aunt Janice embraced healthy lifestyle habits, special herb concoctions, and visits to Western-taught physicians on an as-needed basis. It was a rare occurrence for her to become ill with colds or flus; nor did she ever have to grapple with major health conditions or diseases. Many of her lifestyle choices already bore the seal of approval for what Western culture deems healthy practices. Having lived in a farming community, her family had depended on cattle to help cultivate the land, and therefore she does not eat red meat. Growing up, she never had a means for daily transportation other than a bicycle and her two feet and, at 65 years old, would still occasionally walk the two miles to the local grocery store on a nice day. Other practices were more entrenched in Chinese folklore and societal values. At first glance they seemed to lack scientific reasoning, but in actuality they represented thousands of years of meticulous holistic medicine passed down from generation to generation. As children, we would complain that they almost always involved some unusual ingredients boiled into a malodorous slurry. To this day I will never forget Aunt Janice chasing me around the house with a pot of tar-colored broth covering a similarly colored, cooked chicken. “Eat this; it will make your pimples go away! Then you will be pretty and can bear many sons for this family!” “Pure Land is where you can go when everything is done,” Aunt Janice said while she and my mother watched Chinese television programs. “It's like that heaven for Americans but different in that you don't just stop there. You become special and then help others get to the Pure Land too,” my mother added. “Mm hmm, and it's easier to get into as well,” said Aunt Janice with a sly wink. My mother frowned at my aunt, who chuckled, although I couldn't tell if she was laughing at my mother or at the stunts on the Chinese variety show. Aunt Janice became serious again. “I only say that because Buddha only wants your devotion, directly from you. There is no church, no priest or minister. You speak to him yourself; you tell him that you want to reach the Pure Land. And if you do it many times, and believe in it completely, you will go.” Pure Land Buddhism is a type of Mahayana Buddhism practiced widely throughout China and Japan. Its popularity grew as a result of its simplicity in veneration, particularly among social outcasts such as criminals or prostitutes, who were barred access to public areas of worship. It relies on a single devotion to Amitabha Buddha through the utterance of a single phrase. According to the Larger Sutra of Immeasurable Life, the primary text of Pure Land Buddhism, the Amitabha Buddha makes 48 vows to save the beings of this world, of which the 18th vow states “Shi nian bi sheng yuan” or that at minimum ten recitations of His name will bring forth rebirth into the Pure Land. Once one enters the Pure Land, she becomes enlightened but necessarily forgoes attaining nirvana. Instead she emerges as a bodhisattva, one who is devoted to helping lead others down the same path to enlightenment. “So, no tube down your throat to help you breathe, no tubes to help you eat or drink, and no tubes to help clean your blood. Do you just not like tubes?” I asked. Aunt Janice chuckled again. “It's not about tubes, though you doctors definitely like to use them. Your uncle had all sorts of them going in and out of his body. “It is what happens to you after you put that tube in. Do they put the tube in and it fixes you right away? No. You may have that tube for a long time, even forever. It may keep me alive, but to what end? If I am about to enter the Pure Land, after having finished this life, in whatever way, would this tube now prevent that fate from happening?” she said. She went on to discuss that it was not a matter of not fearing death, but rather knowing there was a place and purpose beyond the present. Entering the Pure Land is in some respects similar to the Western concept of heaven, in that there is much joy and contentment upon reaching it. But unlike the finality of reaching heaven, the enlightenment achieved in Pure Land begets a continued purpose, helping others reach the same state. A bit perplexed, I looked down at the checklist sheet again. She had agreed to cardiac resuscitation, blood and blood products, and antibiotics. “Well, if you don't want something that may block your intended fate, why accept any of these treatments? If you were meant to leave this world, you will want it to happen naturally, yes?” I asked. “That is true. But life is not perfect. The Pure Land is not perfect. A Buddhist should want to reach nirvana, the highest place in Buddhism. But it requires a lot of time and sacrifice. It requires a lifetime of strict worship. Amitabha Buddha realized this would be difficult, and he made the Pure Land to save our world. To help all kinds of people, good and bad, if they will devote themselves to Him. It's not perfect, but it's practical . . . for people who aren't perfect but are still devoted to his teachings. “Besides, I am not ready to go yet. I still want to see you finish school, your younger brother finish school. I want to see you both get married. If I become sick and need a little push to keep me in this life, then I will take it. But if it seems like it's preventing what is expected to happen, I will not. “So are we done? I’m going to clean up the dishes in the kitchen.” Aunt Janice jumped up from the family room couch and proceeded to the kitchen. My mother followed, leaving me to sit there and ponder all that I had just heard. As a medical student, I am overwhelmed at times, attempting to learn and become proficient in the complex array of knowledge and skills that contribute to my development as a physician. Even in the most abbreviated interactions between physician and patient, elements of medicine, ethics, and culture must be delicately interwoven to provide the best patient care. I was grateful to my Aunt Janice for sharing these intimate thoughts with me. They may be simple logical ideas to her, but they have dramatically changed my views on medicine and faith. I am certain that I will never be proficient in every aspect of every culture, religion, and faith that intersect with medicine. But in the least, I can prepare myself to learn and embrace its presence. Back to top Article Information Additional Contributions: I thank my Aunt Janice, whose name and relationship to me have been changed, and my mother for their insightful participation, including their contributions to this essay; and Peter R. Lewis, MD, for editing assistance and encouragement. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

A Practical Pact for the Pure Land

JAMA , Volume 299 (12) – Mar 26, 2008

Loading next page...
 
/lp/american-medical-association/a-practical-pact-for-the-pure-land-h9TNSNvaf5

References (0)

References for this paper are not available at this time. We will be adding them shortly, thank you for your patience.

Publisher
American Medical Association
Copyright
Copyright © 2008 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.299.12.1405
Publisher site
See Article on Publisher Site

Abstract

I was perched on the armrest of our family room couch, watching in both awe and bewilderment as my Aunt Janice carefully knelt to the ground, bowed her head three times, paused with her eyes closed, and repeated the head bowing. She did not arise from her position until she had uttered to herself multiple times in a quiet methodical chant, “Nan wu a mi tuo fo,” which I would come to understand as meaning “I entrust in the Amitabha Buddha.” In front of her stood a modest shrine. On a simple white shelf, a framed picture depicted a male figure flanked on each side by a female figure. All three were sheathed in ornate dress and jewels. Also on this shelf were an offering plate with a piece of fruit and a small pot with sand to hold an incense stick upright. Its white wisp of smoke rose in the air, thin and crisp. Once she completed her ritual prayer, I asked, “Aunt Jan, can you help me with a project for medical school? I need to ask you some questions.” “For school? No problem . . . but we eat breakfast first.” “Why don't you go to a temple to practice your Buddhism?” I asked. “Because I don't need to. It's not required for the Pure Land. Amitabha Buddha has allowed his followers to practice in the way they feel best,” she replied, over the sizzle of eggs and tiny salted shrimp in the frying pan. “What's the Pure Land?” “Eat first. You should eat more—how else are you going to care for me when I’m old?” said Aunt Janice, simultaneously pushing a bowl of rice porridge and dumping the steaming contents of her frying pan onto a fresh plate. How do you ask a close relative about the grim and gritty details of her potentially last waking hours, in broken Mandarin Chinese? Poorly, in my case. Armed with my mother, also a practicing Buddhist, as a “qualitative medical interpreter,” I began asking the seemingly simple questions outlined in the advanced care directive (ACD) exercise required for my second-year class in medical ethics and professionalism. At times puzzled and at other times resolutely, she nonetheless answered the seven yes/no questions regarding resuscitation, artificial nutrition, and medical interventions. To my surprise, she agreed to cardiac resuscitation, transfusion of blood products, and administration of antibiotics. In contrast, she refused mechanical respiration, artificial nutrition, invasive procedures, and kidney dialysis. I would read the statement, roughly translate it for my mother who, through her own mental filter, would adapt her understanding of the terms and describe it to my aunt. The process seemed similar to the childhood game Whisper Down the Lane, and I could only hope that what came out of my mouth and into my Aunt Janice's ears was not grossly distorted during the process of interpretation. With gradual resignation Aunt Janice had welcomed Western medicine as she welcomed Western culture, moving in with our family in the United States after her husband had passed away from a difficult but abbreviated battle with renal cell carcinoma. He had just turned 70 years old. He didn't have an ACD but instead relied on his children to make appropriate medical decisions for him. This was to be expected; as in many Asian cultures, the children have the sole responsibility of caring for their elderly parents. And these parents would always agree in silent acceptance; believing that after their lifetime of struggle and hardship to provide a better life and education for their children, their children would know best. Aunt Janice avoided the heated conversations between her children and the physicians about her husband's morphine dosages and opportunities for experimental treatments. Instead she sat at his bedside and spoke to Amitabha Buddha for him. To this day—long after his death—the circumstances surrounding the treatments used for my uncle's cancer still spark disagreements among my cousins. At home in Taiwan, Aunt Janice embraced healthy lifestyle habits, special herb concoctions, and visits to Western-taught physicians on an as-needed basis. It was a rare occurrence for her to become ill with colds or flus; nor did she ever have to grapple with major health conditions or diseases. Many of her lifestyle choices already bore the seal of approval for what Western culture deems healthy practices. Having lived in a farming community, her family had depended on cattle to help cultivate the land, and therefore she does not eat red meat. Growing up, she never had a means for daily transportation other than a bicycle and her two feet and, at 65 years old, would still occasionally walk the two miles to the local grocery store on a nice day. Other practices were more entrenched in Chinese folklore and societal values. At first glance they seemed to lack scientific reasoning, but in actuality they represented thousands of years of meticulous holistic medicine passed down from generation to generation. As children, we would complain that they almost always involved some unusual ingredients boiled into a malodorous slurry. To this day I will never forget Aunt Janice chasing me around the house with a pot of tar-colored broth covering a similarly colored, cooked chicken. “Eat this; it will make your pimples go away! Then you will be pretty and can bear many sons for this family!” “Pure Land is where you can go when everything is done,” Aunt Janice said while she and my mother watched Chinese television programs. “It's like that heaven for Americans but different in that you don't just stop there. You become special and then help others get to the Pure Land too,” my mother added. “Mm hmm, and it's easier to get into as well,” said Aunt Janice with a sly wink. My mother frowned at my aunt, who chuckled, although I couldn't tell if she was laughing at my mother or at the stunts on the Chinese variety show. Aunt Janice became serious again. “I only say that because Buddha only wants your devotion, directly from you. There is no church, no priest or minister. You speak to him yourself; you tell him that you want to reach the Pure Land. And if you do it many times, and believe in it completely, you will go.” Pure Land Buddhism is a type of Mahayana Buddhism practiced widely throughout China and Japan. Its popularity grew as a result of its simplicity in veneration, particularly among social outcasts such as criminals or prostitutes, who were barred access to public areas of worship. It relies on a single devotion to Amitabha Buddha through the utterance of a single phrase. According to the Larger Sutra of Immeasurable Life, the primary text of Pure Land Buddhism, the Amitabha Buddha makes 48 vows to save the beings of this world, of which the 18th vow states “Shi nian bi sheng yuan” or that at minimum ten recitations of His name will bring forth rebirth into the Pure Land. Once one enters the Pure Land, she becomes enlightened but necessarily forgoes attaining nirvana. Instead she emerges as a bodhisattva, one who is devoted to helping lead others down the same path to enlightenment. “So, no tube down your throat to help you breathe, no tubes to help you eat or drink, and no tubes to help clean your blood. Do you just not like tubes?” I asked. Aunt Janice chuckled again. “It's not about tubes, though you doctors definitely like to use them. Your uncle had all sorts of them going in and out of his body. “It is what happens to you after you put that tube in. Do they put the tube in and it fixes you right away? No. You may have that tube for a long time, even forever. It may keep me alive, but to what end? If I am about to enter the Pure Land, after having finished this life, in whatever way, would this tube now prevent that fate from happening?” she said. She went on to discuss that it was not a matter of not fearing death, but rather knowing there was a place and purpose beyond the present. Entering the Pure Land is in some respects similar to the Western concept of heaven, in that there is much joy and contentment upon reaching it. But unlike the finality of reaching heaven, the enlightenment achieved in Pure Land begets a continued purpose, helping others reach the same state. A bit perplexed, I looked down at the checklist sheet again. She had agreed to cardiac resuscitation, blood and blood products, and antibiotics. “Well, if you don't want something that may block your intended fate, why accept any of these treatments? If you were meant to leave this world, you will want it to happen naturally, yes?” I asked. “That is true. But life is not perfect. The Pure Land is not perfect. A Buddhist should want to reach nirvana, the highest place in Buddhism. But it requires a lot of time and sacrifice. It requires a lifetime of strict worship. Amitabha Buddha realized this would be difficult, and he made the Pure Land to save our world. To help all kinds of people, good and bad, if they will devote themselves to Him. It's not perfect, but it's practical . . . for people who aren't perfect but are still devoted to his teachings. “Besides, I am not ready to go yet. I still want to see you finish school, your younger brother finish school. I want to see you both get married. If I become sick and need a little push to keep me in this life, then I will take it. But if it seems like it's preventing what is expected to happen, I will not. “So are we done? I’m going to clean up the dishes in the kitchen.” Aunt Janice jumped up from the family room couch and proceeded to the kitchen. My mother followed, leaving me to sit there and ponder all that I had just heard. As a medical student, I am overwhelmed at times, attempting to learn and become proficient in the complex array of knowledge and skills that contribute to my development as a physician. Even in the most abbreviated interactions between physician and patient, elements of medicine, ethics, and culture must be delicately interwoven to provide the best patient care. I was grateful to my Aunt Janice for sharing these intimate thoughts with me. They may be simple logical ideas to her, but they have dramatically changed my views on medicine and faith. I am certain that I will never be proficient in every aspect of every culture, religion, and faith that intersect with medicine. But in the least, I can prepare myself to learn and embrace its presence. Back to top Article Information Additional Contributions: I thank my Aunt Janice, whose name and relationship to me have been changed, and my mother for their insightful participation, including their contributions to this essay; and Peter R. Lewis, MD, for editing assistance and encouragement.

Journal

JAMAAmerican Medical Association

Published: Mar 26, 2008

There are no references for this article.