Letter to Siriraj Doctors

This letter was probably the most influential I have ever written. In the midst of the controversy, deceptions, and confusion around Tan Ajahn's body being taken up to Bangkok's leading government hospital and weeks of front-page headlines, Dr. Prawase Wasi (a senior doctor, respected social commentator and activist, and long-time student of Tan Ajahn) was raising issues within the medical establishment. My letter also contributed. It was well-received, subsequently reprinted in a number of places, and used in medical ethics courses. I still meet doctors who say it changed their thinking on their relationship to patients, technology, ethics, and Dhamma.

R.C.U., Atsadang Building
Siriraj Hospital, Bangkok
Thursday July 1, 1993

Dear Doctors,

Because I have difficulty expressing myself in Thai, I have decided to send you this letter. In it, I would like to discuss Nature, its role in the treatment of Venerable Buddhadasa Bhikkhu, and related issues. Perhaps you will find something useful here.

But first, please allow me to thank you for the time, effort, and concern you have given to the Venerable Ajahn’s care. Nobody doubts that you have done anything but your best and provided the most up-to-date medical technology available in this country. Whatever the final outcome, your sincere efforts will be appreciated. May your good intentions bring you satisfaction and peace.

In the book Dhammanusati (page 11) Venerable Buddhadasa Bhikkhu is quoted as telling his good friend Panyananda Bhikkhu, Dr. Prawase Wasi, and Dr. Wicharn Panich, a blood relative, that

I’ve held to the principle for who knows how long of letting Nature treat me, letting Dhamma care for me. You doctors can help preserve life and keep the body going, so that it doesn’t die, then Nature will treat the different diseases by itself. We’ll take what we can get; we don’t want any more than that. Actually, one shouldn’t live longer than the Lord Buddha.

People who are unfamiliar with the Venerable Ajahn’s teaching may interpret these words in a way that fits with their own views, views that may differ quite a bit from the speaker’s understanding. Earlier, certain doctors expressed their interpretations of this and other passages to the press. Some of us, however, who have been living and studying with the Venerable Ajahn for many years, have other perspectives on these words. I would like to share some of them with you. Please try to understand.

Let’s begin with the word “Nature” or “Dhamma.” What is this Nature or Dhamma which is to treat him? Venerable Buddhadasa Bhikkhu frequently reminds us that the Dhamma is the thing honored and worshipped by all Buddhas. Because Buddhas are the highest level of humanity, it would be inappropriate for them to worship other people. There is something, however, which is even higher than them and which is worthy of their deepest respect, namely, the Dhamma. The Venerable Ajahn has tried to follow the Lord Buddha’s example by worshipping the Dhamma to the best of his ability. He invites each of us to do the same.

Nature is a common theme in Venerable Buddhadasa Bhikkhu’s teaching. Foremost, it is a synonym of Dhamma, which encompasses everything. Dhamma or Nature includes all mental and physical phenomena. It includes everything around us and inside us; we are Nature. There is nothing which is not Nature. Human thoughts, feelings, and actions are all part of Nature. The lowest, most ugly things are also Nature. Even the highest, most exalted thing — Nibbana — is Nature. Everything is Nature and Nature is much more than physical, material things. Can you feel this truth deep in your hearts?

There is more to Nature than mere “things” or “phenomena.” Nature includes and is governed by Truth, that is, the Law of Nature. Everything happens according to Natural Law, which is the fact that everything happens according to causes and conditions, depends on causes and conditions, changes when the causes and conditions change, and ends when the causes and conditions end. This principle encompasses the discoveries of modern science and goes beyond them to include all mental and spiritual realities as well. It is the only true power in this universe.

When everything is under the power of this Law, each thing has a Duty to perform in each and every circumstance. The Duty to be done is determined by outer and inner conditions, that is, environmental and personal realities. When this Natural Duty is done correctly in accordance with Natural Law, its Natural Fruit is peace, coolness, Nibbana, which is the highest Dhamma of all. “Law,” “Duty,” and “Fruit” are further meanings of Dhamma or Nature. Nature, Natural Law, Natural Duty, and Natural Fruit are the essential dimensions of Dhamma.

To let Nature or Dhamma care for us we must understand what Nature is and see its Law in action. Only then can the Duty be done correctly and its rightful Fruit experienced. To understand this, we must go deeper than mere intellectual exercises. We must be very attentive, reflect carefully, open our hearts, and personally experience how the Law of Nature is about interrelatedness and interdependence. When all things depend on other things, none of them is primary and all are partners or friends. When our reality is one of interdependence, our response should be one of cooperation and harmony. It is our Duty to cooperate with others and with Nature itself.

Venerable Buddhadasa Bhikkhu’s understanding of Nature is that there is nothing “unnatural” in itself. When we truly and deeply see this truth, we are one with Nature. Unfortunately, few of us are able to see this truth consistently, so we spend most of our time fighting Nature, especially in the modern materialistic society. The consumer culture encourages us to live by and for our desires. It debases everything in the most crudely sensual and possessive terms. For many, Nature is merely something to be conquered and exploited. This attitude is profoundly “unnatural,” that is, non-Dhammic, for it puts us in conflict with life and with ourselves.

To live “naturally,” we must recognize that Dhamma or Natural Law is the true power in life, not us. Only when deluded by our petty little egos do we think that we ourselves are powerful. When we see with wisdom that Nature is the real power, we honor it and stop trying to control it. To force things, including other people, is to fight Nature and the way things are. This creates conflicts and separates us from our deepest Nature, which is freedom and peace.

Venerable Buddhadasa Bhikkhu has tried always to let Dhamma take charge. While doing everything he can to control himself, he has never tried to control other people or force them to do things. Although he may give orders to those of us who have offered our service to him, we are always welcome to refuse. What a shame when other people force things on him!

In a democratic country, one of the worst things anyone can do is to force a person to do something or endure something that he does not want or choose. When we violate a person’s wishes we are taking his life into our control. To do so is a tremendous responsibility. Do we have the necessary wisdom? And when the person is one of the most important Buddhist teachers of this century, can we be sure our wisdom is superior to his?

There are two kinds of power or force. We have been talking about Dhamma Power; the other is Worldly Power. Worldly Power is rooted in ego and selfishness, in our attachments and obsessions, and in our desires. All of these arise from our likes and dislikes, or as the Venerable Ajahn puts it, from the positive and the negative. These in turn are products of ignorance, of not understanding life as it really is. Whenever ignorance reigns in our hearts, there will always be desire, attachment, ego, and selfishness. Through them we try to manipulate, control, and dominate Nature.

Worldly Power seeks to manipulate and dominate others in order to get what it wants. It always tries to run the show. It is inherently violent, although few have the sensitivity to see it as such. Any actions carried out by and for Worldly Power, as well as the beliefs and attitudes which justify them, are the meaning of “unnatural.” Venerable Buddhadasa Bhikkhu has tried his best to abandon such Worldly Power in order to be “natural” and serve Dhamma.

To experience in our every breath that we are nothing but Nature and that Natural Law runs the show is wisdom. With this wisdom we can respond to life peacefully and with the deepest love. We no longer fight things, but find out where, when, and how we can aid and support the natural development of things. We don’t give any self-importance to this help because we know that what little intelligence and ability we have comes from Dhamma.

I can only guess whether these words have any meaning for you or not. I suspect that they may conflict with the theories you learned in medical school. My own upbringing and education in the West taught me perspectives and ways of thinking which don’t fit very well with the Dhamma principles discussed above. From what I have seen, the medical science practiced here is based on those same Western perspectives and ways of thinking, that is, those which are Cartesian, dualistic, materialistic, mechanistic, and reductionistic. Nonetheless, I know that you are intelligent, decent people. Thus, I have faith that you can understand some of what I am trying to explain. Anyway, it’s right in front of our noses, plain and clear for all those who would “see”.

To make myself more clear, please allow me to apply these principles more directly to our situation here. Any action which seeks to overpower or control Nature is unnatural. Medical science which tries to control bodily functions and conditions through drugs and technology is unnatural. A mentality that speaks of “fighting disease,” “controlling vital signs,” and “winning” is unnatural. Yet these are common in the modern medical world. Even Venerable Buddhadasa Bhikkhu has been subjected to them. I do not claim that these things are “wrong,” but they don’t fit very well with Venerable Buddhadasa Bhikkhu’s understanding and teaching concerning Dhamma and Nature.

On the other hand, it is possible that modern medical science can adapt its knowledge, experience, skills, and technology to work with Nature rather than fight it. In fact, there are increasing attempts to do so, attempts which appreciate the role of the mind in all forms of illness and healing, which see life holistically and organically. Some medical fields are more in harmony with Nature and Dhamma than others. Others, especially the most invasive and hi-tech dependent, have a way to go before they can harmonize with Dhamma.

The Venerable Ajahn’s advice is that doctors learn to adjust to Nature and its Law. This requires that doctors discover that nature is not primarily materialistic, which means they must unlearn the basic philosophy underlying their profession. Your words and actions reveal a belief that matter is more fundamental than mind; I have yet to hear any serious discussion of the mind’s role in healing. In Buddhism, however, mind is first, foremost, and most fundamental. Further, doctors must shift from a paradigm of control and domination to one of cooperation, partnership, harmony, and balance. They must stop thinking mechanistically and learn to think organically. Most important, they must put their egos aside and see life unselfishly, that is, without concern for profits, status, and power. As with the rest of us, these adjustments can be difficult. But they are necessary if we are to heal ourselves of our many wounds and assist others in their own process of healing.

I wonder if the doctors, he spoke to that day, have realized that the Venerable Ajahn was trying to help them find Nibbana. (Nibbana, as he understands it, has nothing to do with death.) Can you understand him this way? The words I quoted above weren’t so much about himself and what they should do for him, but what they should do for their own salvation. Are doctors interested in saving themselves from the endless torment of ego? I hope so, otherwise the rest of us may suffer with them. For each of us, salvation requires wisdom, especially the understanding that allows one to live without desire, attachment, ego, and selfishness.

Venerable Buddhadasa Bhikkhu’s concept of letting Nature heal includes natural abilities such as the healing powers of a mind that is samadhi. The characteristics of the samādhi mind are purity, stability, and activity; it is calm, concentrated, and integrated. With mindfulness, wisdom, and samadhi, the heart is clean, clear, calm, and cool. These qualities allow the mind to be pakati (normal, natural). When the mind is pakati, the body can return to pakati. Ultimately, the highest pakati is another name for Nibbana. Without pakati, in the Dhammic sense, there is no healing. The purity, calmness, and coolness of a mind that is pakati is a very powerful medicine. What can doctors do to assist this spiritual medicine without interfering? What must they do within themselves to be able to help others?

Physical accidents and diseases can harm the body. When physical illness occurs, some physical treatment may be needed to prevent further harm and to stabilize the condition. Thus, there is a role for medicines and other therapies. Nonetheless, these physical approaches are not the real cure, for the body is not the most important aspect of life. Medical treatment is merely a support to the natural healing described above and should never interfere with it. If too many drugs or too much hi-tech equipment is used, or if too strong invasion of the body is allowed, then wisdom and samādhi will not be able to heal the whole person.

Venerable Buddhadasa Bhikkhu has dedicated more than sixty years to the study of Dhamma. While he has never claimed total mastery of Dhamma, is there anyone among you who can claim better understanding than him? Regarding his own judgments, ideals, and wishes, there is no one qualified to overrule him. Further, he has practiced and investigated anapanasati (mindfulness with breathing, the Lord Buddha’s favorite form of meditation) extensively, which gives him excellent means for maintaining mental and physical health. In the past we have seen him deal with a series of illnesses – including gout, stroke, and heart attack – in his own way. We sincerely wish that he will be allowed to do so again.

Ideally, this will happen at Suan Mokkh, the location of most of Venerable Buddhadasa Bhikkhu’s spiritual study, practice, and work. Suan Mokkh has an atmosphere to which his body-mind is well adjusted. The air is pure, many trees supply a rich source of oxygen, life is peaceful, and everyone respects his teaching and wishes. It is interesting to note that the Venerable Ajahn deteriorated while at the Surat Thani Hospital, but began to improve once he returned to Suan Mokkh. Since he was brought to Bangkok, there has not been any overall sustained improvement in his condition. Does he know something that the doctors don’t?

You will be meeting regularly to discuss the progress of Venerable Buddhadasa Bhikkhu’s condition and to decide on what treatment to give him. Since you have taken things into your own hands, the responsibility is now yours. Nonetheless, we the attending monks still have some duties to perform. One of the most important of these is to bear witness to the Venerable Ajahn’s teachings and wishes, which is what I have tried to do in this letter. It is our hope that they will not be ignored.

Because we try to follow Venerable Buddhadasa Bhikkhu’s example, we have had no intention to force you to do anything and hope you have not mistaken us in this respect. In your positions, you may wield worldly power, but we as monks must avoid it. We should seek only the power of Dhamma, of righteousness, of egolessness, to the best of our abilities. It is always possible that worldly power will willingly cooperate with Dhamma power and we sincerely hope that it will happen in this case.

Dr. Prawase Wasi implores doctors to treat the person, not the disease. Many of you have been his students; I hope you have taken his advice. This letter has been my attempt to help you understand the person you are treating. Venerable Buddhadasa Bhikkhu has dedicated his life to understanding, practicing, and disseminating Dhamma. To know him, you must know what he has lived for.

In fact, I am not so much concerned for Venerable Buddhadasa Bhikkhu or we the attending monks as I am for you the doctors and Thai society in general. I don’t want you to go so far in treating diseases, symptoms, and numbers that you fail to treat the person. You cannot know him from the body lying silent and still in the hospital bed with tubes going in and out. The numbers on the monitors cannot help you either. Maybe we who have lived with him many years can introduce him to you. The more you see the Dhamma, the more you will see him.

Please don’t overlook the ambivalence toward living longer which he expresses by saying, “Actually, one shouldn’t live longer than the Lord Buddha”. He is willing to live longer when it genuinely serves a Dhammic purpose, but has no interest in hanging on just so superstitious people can cling to his physical form. The quality of life necessary for him to feel useful requires the ability to speak without tiring too quickly, to have some independence, to not be totally dependent on nursing care, to be able to write, and to have the energy to think creatively about Dhamma.

You have shown great skill in preventing death, but do you really understand what you are preventing? Death is a great mystery which each of us must honor. May you face it with courage and wisdom. May you come to understand when a person is ready to die and know how to let them do their final Duty. I believe that the highest merit for a doctor is to help a person die in peace and with mindfulness. If that person is able to realize Nibbana thereby, the merit will be inestimable.

Finally, let me remind you that the views expressed here are merely the attempt of one person to convey some relevant aspects of Venerable Buddhadasa Bhikkhu’s teaching. While I may be better qualified than most to attempt this, my understanding of Dhamma is not perfect. Still, I am confident there are no serious mistakes in the principles discussed above. Anyway, it is your duty to examine the reasoning yourself and find out whether it accurately reflects the truth or not.

We have patiently listened to your theories and opinions, although we know that so-called medical science has its fair share of limitations. Its body of knowledge keeps changing and growing, which means that some of the things you have told us may be later discredited. Thus, I think it is only fair to invite you to listen to the perspectives of Buddha-Dhamma as taught by the Venerable Ajahn. Of course, my explanations also have their limitations. Still, they are as valid as yours. Don’t you think?

I had hoped to keep this letter short, as I know you are all busy people, but it has turned out rather long. Still, issues are not explained as deeply as they should be and many details have been left out. Perhaps it is a start. Perhaps it will help you to adjust your treatment to the person you now have in your hands.

All of Thailand is watching and people around the world will hear of Venerable Buddhadasa Bhikkhu’s last illness. I sincerely hope that nobody has done any harm to him or themselves.

May the merits of your good intentions bring you happiness and good health.

Dhamma Metta Santi

Santikaro Bhikkhu