helen craigie - buddhist end-of-life care in modern taiwan

Buddhist Influence on End-of-Life Care in Modern Taiwan

Helen Craigie

June, 2012

Buddhist End-of-Life Care in Modern Taiwan

ii

Abstract

In recent history, Taiwan has exhibited some fascinating social trends in

the development of both Buddhist outreach programs and socially funded

medical care. Specifically, modern Taiwan presents an interesting case study for

the interaction between religious practice and modern medicine in that newly

socialized government health programs must meet the needs Taiwan’s

population which has a basic Chinese culture combined with a strong modern,

secular culture influenced by both the west and Japan. Remarkably, government

health agencies are given immense support in their mission to provide

appropriate healthcare through the numerous health related service projects

organized and developed by Buddhist organizations. For instance, outreach

volunteer services provide health services for individuals through free medical

care from doctors and educational seminars lecturing on how to cope

psychologically with life and death issues. Massive projects have been enacted

such as the construction and staffing of large-scale hospitals in areas without

convenient access to health services, the funding of biomedical research studies

and the creation of medical universities to train future healthcare providers.

End-of-life care for the elderly and terminally ill is provided through volunteer

outreach home care for elderly and sick individuals, and Buddhist chaplaincy

programs train monastics to provide spiritual care in religious and secular


iii

hospitals. Outreach services also provide end-of-life ritual chanting and funeral

arrangement as well as grievance counseling for the remaining family members.

As Taiwanese government health agencies and Buddhist outreach

programs become increasingly intertwined in providing care services for the sick

and dying, it is important to consider how the two groups influence one another

and the effects of their close relationship on the types of care that are provided.

On one hand, the religious body has great potential for influence over public

health policy and program decisions as they build large-scale medical hospitals,

train medical staff and fund medical research. On the other hand, the field of

modern medicine could affect the development of modern Buddhism as

traditional practices and beliefs are incorporated into the clinical setting.

Understanding how these two entities interact with one another to provide care

for the modern Taiwanese patient will reveal compelling information on how

modern liberal-minded social health programs interact with the thriving

religious beliefs associated with Taiwanese Buddhism.


iv

Contents

Abstract ....................................................................................................................................................... ii

Acknowledgements ........................................................................... Error! Bookmark not defined.

Contents ..................................................................................................................................................... iv

Introduction .............................................................................................................................................. 1

Methodology .............................................................................................................................................. 6

Chapter 1: Spirituality and Death Culture Throughout Chinese History ........................... 9 Section 1: Defining Spirituality ........................................................................................................................... 9 Section 2: Death and Funeral Culture Throughout Chinese History ............................................... 11

Chapter 2: Taiwanese Reformist Buddhist Movement .......................................................... 23 Section 1: Chinese History of Taiwanese Buddhist Reform .................................................................. 23 Section 2: Modern Taiwanese Buddhist Groups ........................................................................................ 37

Chapter 3: Social Changes and Healthcare in Modern Taiwan............................................ 48 Section 1: Prosperity and a Changing Social Demographic ................................................................ 48 Section 2: Taiwan Healthcare Reform For The Aging ............................................................................ 52 Section 3: Biomedical Research On End-Of-Life Needs Of Taiwanese Patients .......................... 54

Chapter 4: The Hospice Movement In Taiwan And Buddhist Chaplaincy ....................... 60 Section 1: Hospice and Palliative Care in Taiwan .................................................................................... 60 Section 2: The Taiwan Association of Clinical Buddhist Studies ....................................................... 65

Chapter 5: Articles From The Taiwan Association For Buddhist Studies ....................... 70 Section 1: The Role of the Buddhist Chaplain ............................................................................................. 71 Section 2: Buddhist Life and Death Education in the Clinical Setting ............................................ 79 Section 3: The Use of Buddhist Doctrine in End-of-Life Care .............................................................. 81 Section 4: The Role of the Chaplain in Rituals at Death ........................................................................ 92

Conclusion ............................................................................................................................................... 95

Bibliography ......................................................................................................................................... 100

Primary Sources.................................................................................................................................. 100

Secondary Sources ............................................................................................................................. 100


1

Introduction

In recent history, Taiwan has exhibited some fascinating social trends in

the development of both Buddhist social outreach and socially funded medical

care. Specifically, modern Taiwan presents an interesting case study for the

interaction between religious practice and modern medicine in that newly

socialized government health programs must meet the needs Taiwan’s

population which has a basic Chinese culture combined with a strong modern,

secular culture influenced by both the west and Japan. Remarkably, government

health agencies are given immense support in their mission to provide

appropriate healthcare through the numerous health related service projects

organized and developed by Buddhist organizations. For instance, outreach

volunteer services provide health services for individuals through free medical

care from doctors and educational seminars lecturing on how to cope

psychologically with life and death issues. Massive projects have been enacted

such as the construction and staffing of large-scale hospitals in areas without

convenient access to health services, the funding of biomedical research studies

and the creation of medical universities to train future healthcare providers. End-

of-life care for the elderly and terminally ill is provided through volunteer

outreach home care for elderly and sick individuals, Buddhist chaplaincy

programs train monastics to provide spiritual care in religious and secular


2

hospitals. Outreach services also provide end-of-life ritual chanting and funeral

arrangement as well as grievance counseling for the remaining family members.

As Taiwanese government health agencies and Buddhist outreach

programs become increasingly intertwined in providing care services for the sick

and dying, it is important to consider how the two groups influence one another

and the effects of their close relationship on the types of care that are provided.

On one hand, the religious body has great potential for influence over public

health policy and program decisions as they build large-scale medical hospitals,

train medical staff and fund medical research. On the other hand, the field of

modern medicine could affect the development of modern Buddhism as

traditional practices and beliefs are incorporated into the clinical setting.

Understanding how these two entities interact with one another to provide care

for the modern Taiwanese patient will reveal compelling information on how

modern liberal-minded social health programs interact with the thriving

religious beliefs associated with Taiwanese Buddhism.

Starting from around the 1960s prominent new Buddhist denominations

flourished in Taiwan, becoming highly influential in Taiwanese society. The

success of these movements, such as Fo Guang Shan 佛光山, Tzu Chi 慈濟 and

Dharma Drum Mountain 法鼓山, can be largely attributed to their active efforts


3

to provide for the needs of the modern individual through social activism and

encouragement to participate in volunteer Buddhist outreach programs. This

Buddhist motivated social activism, or “humanistic Buddhism” aims to provide

services that help the modern individual through educational endeavors, health

services, relief work and widespread community involvement.1 The leaders of

these organizations claim that the driving force behind their outreach services is

their devotion to Mahāyāna Buddhist values and that their mission in today’s

society is based on Buddhist notions of compassion through alleviating the

suffering of others. Although such large-scale involvement in public activism is

not commonly associated with the behaviors of traditional Buddhist groups, the

leaders of these organizations find inspiration for their social outreach pursuits

from Buddhist textual sources.

Among the many outreach programs offered from these organizations,

particular attention is given to providing care for the sick, the elderly and

individuals as they approach their death. Caring for the sick and dying is

strongly rooted in Buddhist doctrine and throughout Buddhist texts there are

numerous examples of the Buddha speaking to the importance of alleviating the

suffering of individuals who are sick and as they approach their death.2 Of

1 Hung-Yok Ip, “Buddhist Activism and Chinese Modernity”, pp. 145-192. 2 Notably, in the Chinese Vinaya authority Daoxuan 道宣 (696-667) in his work, the Abridged and

Explanatory Commentary on the Four Part Vinaya 四分律刪繁補闕行事鈔 (Sifen lü shanfan buque


4

particular importance in Mahāyāna scripture is the significance of the final

thoughts of the dying.3 Additionally, there is a long textual history in Chinese

Buddhism outlining the importance of one’s end-of-life experience, and the

experience of family members, as contributing to a positive afterlife experience

and many specific Buddhist practices are deemed as essential for fulfilling the

requirements of this time of transition.4

However, since the time that these texts were written, modern

developments in biomedicine, medical technology and the invention of large-

scale medical facilities have completely revolutionalized the experience of aging,

sickness and death. Throughout the modern world, death has evolved into a

highly “medicalized process”5 in that increasingly individuals are spending their

final days within hospitals, defining their experiences using distinctly medical

concepts. Experiencing death biomedically involves understanding the dying

process explicitly as a breakdown of biological bodily functions. As such,

medical end-of-life care strives to provide highly advanced methods for

xingshi chao), he emphasizes the importance of this time in the life of a Buddhist and lists specific

recommendations for deathbed practices that were highly influential throughout East Asian

Buddhism and particularly, Pure Land groups. See Koicki Shinohara, “The Moment of Death in

Daoxuan’s Vinaya Commentary”, pp. 105-132. 3 Many Buddhist deathbed practices from various schools emphasize the importance of the last

thoughts in this life. In his Vinaya commentary, Daoxuan address this importance, among other

places, in a chapter entitled, “Attending the Sick” 瞻病送終 (Zhanbing songzhong)(ibid).

4 For today’s Taiwanese Buddhists, two of the most common of these texts are the Sūtra of the Past

Vows of Earth Store (Ksitigarbha) Bodhisattva 地藏菩薩本願經 and the Āmitāba Sūtra (Shorter

Sukhāvatīvyūha Sūtra) 阿彌陀經.

5 Michel Foucault, The Birth of the Clinic, pp. 67-77; Ivan Illich, Medical Nemesis, pp. 1-15.

http://www.woodenfish.org/images/ksitigarbha%20sutra.pdf

http://www.woodenfish.org/images/amitabha%20sutra.pdf


5

diagnosing illnesses, providing therapeutic interventions and developing

pharmaceutical drugs for pain relief.

These modern advances in biomedicine that have lead to a revolution in

the experience of sickness and death are part of a larger scientific worldview that

is not typically considered compatible with religious, non-scientific ways of

understanding and experiencing this time. Such inconsistencies between medical

and religious ways of conceiving of the end-of-life experience have lead to

questions of whether or not religious belief and practices are relevant modern

medical care. Despite the seeming incompatibility of religious beliefs and

biomedical perspectives of death, Taiwanese socially engaged Buddhist

organizations have not shied away from developments in medical technology

and have instead embraced revolutionary ways of alleviating suffering. As such,

large-scale social programs have been developed to provide Buddhist religious

support for individuals to complement modern medical end-of-life care.

The central focus of this paper is to develop an understanding of the

incorporation of traditional Buddhist doctrine and practice into modern

Taiwanese end-of-life care facilities. Specific attention is paid to analyzing

modern interpretations of Buddhist doctrine to address developments in clinical

care in Taiwan and examining which Buddhist beliefs and practices are

incorporated into the clinical setting.


6

Methodology

As the topic of this research study investigates a fairly recent phenomena

and it bridges two fields of inquiry, there is no literature directly addressing the

topic and there are no predecessors in the field in which to follow. As a result,

this study is predominantly a literature review examining various aspects of the

topic separately and combining them together for analysis.

To contextualize this study, sources include historical Chinese belief and

practices, Chinese political history and research on the behavior of Chinese and

Taiwanese Buddhist reformists. Historical research is offset with a review of

contemporary Taiwanese Buddhist outreach services, mostly obtained from the

websites of the Buddhist reformist groups. This study also includes an in-depth

review of the development of Taiwanese social health policy and recent

bioemedical research on spirituality in end-of-life care in modern clinical

settings. Additionally, throughout the time spent in Taiwan pursuing this

project, hospice care facilities were visited throughout the country including, a

Fo Guang Shan senior’s home in Yilan, the palliative care ward at National

Taiwan University and the hospice ward in a Tzu Chi Hospital. Lastly, on April

13, 2012 Dr. Rong-Chi Chen from the Lotus Foundation was met with to discuss

the development of the Taiwanese Buddhist hospice movement. As the meeting


7

was not a formal interview I have not included my questions within the thesis,

but I do reference some information shared within the time of our meeting.

The first chapter of this research paper establishes the foundation of

modern Taiwanese conceptions of death by providing a brief explanation of the

multi-faceted concept of the “spirit” in Chinese thought along with an outline of

various Chinese beliefs and practices surrounding death throughout Chinese

history. The second chapter introduces some of the main reformist Chinese

thinkers, whose visions for the future of Chinese Buddhism have greatly

influenced the development of Taiwanese Buddhist thought and proceeds to

explore the development of three major reformist Taiwanese Buddhist groups.

Specific attention is paid to social outreach programs that pertain to modern

clinical outreach and end-of-life care provided to the Taiwanese public. In

chapter three, the efforts of these health related Buddhist outreach programs are

contextualized through presenting some of the major political, economic and

social changes that have taken place in modern Taiwanese history. Chapter four

explores the development of the country’s newly reformed healthcare policy

relating to palliative and hospice care, discussing factors in this reformed policy

that gave rise to modern Buddhist clinical outreach programs and how these

programs are meeting the need of the modern Taiwanese patient. In modern

Taiwan the medical community works collaboratively with Buddhist


8

organizations to support one another in providing care, so this research paper

looks at recent Taiwanese biomedical studies surveying terminally ill patient

opinion on what aspects of care are deemed important at end-of-life. The

opinions revealed in these studies are then discussed in reference to the

traditional Chinese notions of death outlined in chapter two. As a follow-up to

these studies, this paper surveys modern Taiwanese Buddhist outreach

programs that work within the medical arena, comparing the objectives of these

programs with the needs specified by Taiwanese end-of-life patients. Lastly,

chapter five investigates the development of the role of the Taiwanese clinical

Buddhist chaplain by examining a number of recent articles written on the

subject, outlining specific practices and doctrines that are regarded as applicable

to the modern Taiwanese terminally ill patient. Throughout the entire paper,

discussion centers on the development of Taiwanese Buddhist outreach services

that attempt to meet the needs of modern society as they face complicated issues

related to biomedicine, bioethics and religious ideas of what it means to “die

well”.


9

Chapter 1:

Spirituality and Death Culture Throughout Chinese History

Section 1: Defining Spirituality

Given that this essay is an exploration of modern Taiwanese

incorporation of a type of Buddhist spirituality into modern end-of-life care, it

seems appropriate to begin with a general discussion of the concept of

spirituality, as it applies to Chinese beliefs around end-of-life. According to the

Oxford Online Dictionary, the term “spirit” comes from the Latin word spirare

“breathe” and means, “the non-physical part of a person which is the seat of

emotions and character; the soul.”1 As such, there is no equivalent Chinese

character that carries the same connotations, making the use of the term

problematic in describing both traditional and modern Chinese thinking.

Modern research investigating the spiritual beliefs in terminally ill Chinese

patients indicated that participants expressed difficulty in understanding and

expressing the definition. Chinese patients viewed spirituality as an integration

of mind and spirit, which is very different from Western perspectives that

differentiate between the body and the soul.2 Patients saw the spirit as

1 “Spiritual”, accessed April 24, 2012, http://oxforddictionaries.com/definition/spiritual. 2 Esther Mok, Frances Wong and David Wong, “The meaning of spirituality and spiritual care

among the Hong Kong Chinese terminally ill,” pp. 360-370.


10

integrating xin 心 (heart/mind) and ling 靈 (spirit) together and saw the practice

of spirituality as multi-dimensional. The human spirit was described as an aspect

of the person, but as an integrative force, rather than something separate from

the body. It is the spirit that was described as enabling and motivating a patient’s

search for meaning and purpose in life and a connection with the spirit enabled

them to accept the dying process.3

Research on conceptions of the spirit in Chinese ritual practices

surrounding death reveals that the concept of the “spirit” has been multi-

dimensional throughout Chinese history. Scholars of Chinese history explain that

numerous terms are used to describe the non-physical aspect of the individual

that could be described as the “spirit” in English terms. Historian Susan Naquin

writes that in late Imperial China the notion of the soul, or spirit was composed

of several parts4. She writes that when a Chinese person died, it was believed

that his hun 魂 (cloud soul) left the body and descended to the underworld to be

judged then was either released to be reborn or, depending on his merits, to

ascend to paradise. Naquin notes that there were connections between the hun

and the next rebirth, but they were extremely subtle. Other aspects of the

deceased survived the death such as the po 魄 (white soul) with components of

3 Esther Mok, Frances Wong and David Wong, “The meaning of spirituality and spiritual care

among the Hong Kong Chinese terminally ill,” pp. 360-370. 4 Susan Naquin, “Funerals in North China: Uniformity and Variation,” pp. 37-70.


11

the ling. Unlike the more passive hun, which leaves the body quickly, the po

actively remains with the body and stays in the family home, needing continuous

attention from the family or it may become wrathful and cause harm. Other

accounts of traditional Chinese notions of the soul indicate that the hun and the

po are made up of numerous parts and that Chinese terminology for these

concepts is not consistent.5 For instance, Anthropologist from Columbia

University Myron L Cohen writes that although it is commonly reported in

historical Chinese texts that there are three hun and seven po that still many other

texts have varying numbers and associations for these terms. Also, terms like gui

鬼 (ghost) and shen 神 (spirit/god) are sometimes used together with hun and po

to convey slightly different meanings, or they are often used to replace them

altogether.

Section 2: Death and Funeral Culture Throughout Chinese History

Just as it is essential to understand the multi-dimensional concept of the

“spirit” in Chinese culture, it is also important to discuss the extraordinary

culture surrounding death throughout Chinese history. Chinese traditional

beliefs and social practices surrounding death have been explained by scholars

5 Myron L. Cohen, “Souls and Salvation: Conflicting Themes in Chinese Popular Religion,” p.

182.


12

primarily through a combination of the teachings of Confucius, Daoist beliefs

and Buddhist doctrine and practices. Understanding the history of Chinese

culture surrounding death can help generate a better understanding of the beliefs

and practices that may still have an affect on modern Taiwanese terminal

patients.

In Chinese culture there is a widespread taboo of speaking of death and

still today, many Chinese families will not discuss issues of death and dying for

fear of invoking bad luck. Historically, the cultural taboo is believed to be a result

of Confucian reluctance to speak about death, as one scholar says:

台灣社會對於生死的禁忌是傳承自孔子有關生死的看法

The Taiwanese society's taboo toward life and death is

inherited from Confucius' views concerning life and death.6

Regardless of whether or not the origins of this superstition are accurate,

the taboo is deeply embedded into Chinese culture. The fear of speaking about

death is so ingrained into the culture that the superstition extends to include the

number four 四 (si) which sounds like death 死 (si). An example of this is that it

is common for buildings in Taiwan not to have a floor numbered four. In

hospitals, a four bedded room will not have a bed number four as nobody wants

6林慧婉, ”孔子的生死," p. 195.


13

to be assigned into the “death bed”, instead the bed numbers will skip from three

to five.7

Confucian beliefs can easily be identified as affecting Chinese death

culture in its emphasis on customary social relationships and filial piety. The

teachings of Confucius are primarily interested in improving human

relationships and promoting peace and harmony in society through clearly

defined, agreed upon social customs and ritual for relating to one another. The

Neo-Confucian teacher Zhang Zai 張載 (1020–1077) explains that proper

relationships are carried on to the afterlife as a continued exchange of love and

respect for the deceased family member.8 For the surviving family, customary

rituals performed for the dead provided a socially acceptable and dignified form

of grieving, a means to affectionately remember their deceased loved ones and a

method for keeping a positive relationship with them after they die. To “live

well” within the Confucian society is to contribute positively to family and

society. So notions about “dying well” include a feeling that one has made a

positive contribution to the world, will be remembered fondly and maintain a

reciprocal connection with living relatives.9

7 This information was obtained from a meeting with Dr. Chen, Rong-Chi at the Buddhist Lotus

Hospice Care Foundation Taiwan, 10:30-12:00 April 13, 2012. 8 Paul E. Irion and Dennis Ryan, “Death: Eastern Perspectives,” pp. 75-112. 9 Ibid.


14

Traditional practices surrounding ancestor worship foster a continuing

bond with the deceased after death, which is believed to be beneficial to both the

dead and the surviving family. Following these traditions, for Chinese dying

patients and their families, dying at home makes it easier for the deceased to

maintain a close relationship with the family leading to a distinct preference for

elderly Chinese to die within the home.10 This particular factor has been essential

in Chinese culture around death and still holds a distinct importance for today’s

Chinese patients.11

Unlike the Confucian interest in creating optimum human relationships,

Daoism focuses on non-obstruction of the natural harmonious flow of nature.

The greatest obstruction to the natural way of nature, according to the great

Daoist writer Zhuangzi 莊子, who lived around the fourth century BCE, is not to

take conventions and the traps of societal values too seriously.12 Death is part of

this natural way of nature and is inevitable for all living things. It is believed that

since this continual change is natural it is illogical to be anxious about our own

death.

10 Alice G. Yick and Rashimi Gupta, “Chinese cultural dimensions of death, dying, and

bereavement: focus group findings,” pp. 1-11. 11 Paul E. Irion and Dennis Ryan “Death: Eastern Perspectives,” pp. 75-112. 12 Ibid.


15

Although Daoists regards death as a natural part of life, the Daoist Dao

De Ching 道德經 (attributed to Lao-Tzi 老子, from the 6th century BCE) creates a

very different picture in that it portrays death as an inauspicious event that

should be avoided. And so, in an attempt to avoid prolong life, throughout

history Daoist self-cultivation techniques enjoyed widespread popularity

amongst Chinese laypeople and royalty alike.13 Lao-Tzi’s viewpoint regarding

death and dying have not only contributed to a culture of life-prolonging self-

cultivation techniques, but such ideas have influenced the Chinese taboo against

speaking about death. Such negative associations with death are still apparent in

modern Chinese culture and affect the interaction between dying patients and

their caretakers. Modern representations of Chinese death culture will be

elaborated upon further in chapter six through a survey of the various needs of

modern Taiwanese terminally ill patients.

Chinese Buddhist conceptions of death have played an important role in

belief surrounding death and the afterlife throughout history, greatly influencing

various ritual practices for the deceased. Similar to the Daoist belief that death is

a natural part of life, Buddhist doctrine surrounding death asserts that death is

inherent in the nature of every living thing. An individual life can be seen as

13Chiung-Yin Hsu, Margaret O’Connor and Susan Lee, “Understandings of Death and Dying for

People of Chinese Origin,” pp. 153-174.


16

simply a compounded being and death is the dissociation of the constituent

elements of that being.14 These elements that come together in life and dissipate

in death, are known as the five skandhas or aggregates, which are form,

sensation, perception, mental formations and consciousness. Buddhist belief

associated with death instructs that the last thoughts in life are essential in that

they have a direct influence on what is experienced in the afterlife, and the

situation of rebirth in the next life.15 Since the process of dying can be frightening

and is often associated with pain, which can lead to negativity at death,

Buddhists have traditionally offered assistance with this time through collective

chanting and other ritual ceremony preparations. Another popular Buddhist

belief relating to the time of death has to do with the last thoughts being tied to

an aspiration of rebirth in the Pure Land.16 Pure Land practices at death center

on continuous chanting of the name of Amitābha Buddha, which helps the dying

experience a more peaceful death and a good rebirth in the Pure Land.17 Not only

is the time of death important, but ritual assistance in the forty-nine days that

follow death are also essential for helping facilitate a good rebirth for the dead,

14 Ling, “Seeker’s Glossary of Buddhism,” p. 132. 15 Ibid. 16 Donald Lopez, “Seeker’s Glossary of Buddhism,” p. 133. 17 Pure Land Buddhism signifies a wide array of practices and traditions within Mahāyāna

Buddhism directed to the Buddha Amitābha and his realm, Sukhāvati (Land of Bliss), which

came to be referred to in Chinese as the Pure Land. See Daniel A. Getz, “Pure Land Buddhism,”

p. 701.


17

as the dead navigate their way through afterlife scenarios.18 An important

practice to assist the dying individual, also benefiting the dead during the period

afterward, is the transference of merits to the deceased. The Sūtra of The Great

Vows of Kṣitigarbha Bodhisattva is a popular Chinese Buddhist text that highlights

the importance of transferring merit to the deceased to assist them in their

afterlife experience as a form of filial piety.19 Transferring merit involves the

single-minded concentration and sincerity of the individual to recite sūtras to

alleviate the repercussions of the deceased’s negative karma. The importance of

filial piety within the Kṣitigarbha Sūtra indicates that this concept is not unique to

Confucian thought and was also a prominent Buddhist idea, reinforcing the

importance of maintaining close bonds with family members and assisting them

even after they have died. Another important point to note from the influential

Kṣitigarbha Sūtra that will be discussed in more detail later in this paper in

reference to modern Taiwanese Buddhist groups, is that it emphasizes the great

concentration and effort to transfer merits to deceased relatives. The sūtra

suggests instead of waiting until after someone dies, that it is much more

effective for the individual to cultivate their own merit while they are still alive.20

18 Okaz, “Seeker’s Glossary of Buddhism,” p. 135. 19 Wendi L. Adamek, "The Impossibility of the Given: Representations of Merit and Emptiness in

Early Chinese Buddhism," pp. 135-180. 20 Venerable Yifa and P.M. Romaskiewicz, (trans) Sutra on the Past Vows of Ksitigarbha.

http://en.wikipedia.org/wiki/Ksitigarbha




18

Throughout history, the ritual ceremonies performed at death have been

central to definitions to Chinese cultural identity. Preoccupation with rituals

around death, such as funeral ceremonies, affected Chinese individuals in every

social group, regardless of wealth or political standing.21 Practices and beliefs

around death were of particular cultural importance for Chinese in asserting the

importance of filial piety. Not just individuals, but also by government officials,

valued filial piety as the concept also effectively promoted the legitimacy of

government agencies, and specifically, the emperor.22 This is especially evident in

the Chinese state during the Ming and Qing periods, as Chinese funeral culture

was extremely popular in China.

From his study on late imperial Chinese death culture throughout the

country, Professor of Chinese Society and Anthropology from Harvard

University, James L. Watson notes that there was a remarkable uniformity in

beliefs, attitudes and conceptions regarding the dead, geographically and

throughout various social classes.23 In addition, it is noted that the performance

of death rituals took precedence over specific beliefs associated with such rituals,

in that variations in beliefs were more apparent than variations in specific

practices, and people went to great lengths to assure that rites were carried out

21 James L. Watson and Evelyn S. Rawski, “Preface,” p. ix. 22 Evelyn S. Rawski, “A Historian’s Approach to Chinese Death Ritual,” p. 26. 23 James L. Watson, “The Structure of Chinese Funerary Rites: Elementary Forms, Ritual

Sequence, and the Primary of Performance,” p. 11.


19

properly.24 Cohen’s essay on death culture in late imperial China, notes that ideas

of salvation after death was not a major ideological force in Chinese popular

religion, at least in comparison with what is found in the religions of other

cultures. It is suggested that the reason for this comes from the fact that the

notion of salvation contradicts fundamental tenants, such as ancestral worship,

belief in reincarnation, and the close interaction between the living and the

dead.25 Cohen notes that throughout history Chinese popular religion has

embraced a number of varying beliefs regarding the afterlife and so

contradictions in specific beliefs was not difficult to overcome. So, for the

majority of the population, afterlife beliefs concerning salvation were part of

rituals surrounding death, but were not central to beliefs surrounding this time.26

Specific customs that were found throughout China included; family

members wailing aloud, washing and dressing the dead in clothing suitable for

the afterlife journey, collecting items to transfer to the dead to assist them in the

afterlife, and the employment of professionals specializing in the performance of

ritual acts for the dead, i.e. Buddhist or Daoist monastics, or other spiritual

guides.27

24 Evelyn S. Rawski, “A Historian’s Approach to Chinese Death Ritual,” p. 22. 25 James L. Watson and Evelyn S. Rawski, “Preface,” p. xiii. 26 Myron L. Cohen, “Souls and Salvation: Conflicting Themes in Chinese Popular Religion,” p.

181. 27 Evelyn S. Rawski, “A Historian’s Approach to Chinese Death Ritual,” p. 22.


20

Thomas Laquer points out that there is no radical dualism in Chinese

thought regarding the soul separating from the body as in the moment of death,

as compared with European ideas of the transition between life and death. He

notes that one of the primary goals of Chinese funeral rites was actually to keep

the corpse and spirit together long enough for community ceremonies, as such

rituals were essential for both the dead and their continued relationship with the

living.28

Research indicates that in time of government reform, such as in the

Republican Revolution in 1922, there were attempts by government officials to

simplify funerary practices. But it wasn’t until the rise of the Communist regime,

particularly after The Great Leap Forward 大躍進 (1958 to 1961) that Chinese

culture and rituals surrounding death changed dramatically. Starting from

around the mid-1940s, the Chinese Communist Party sought to reform the

funeral culture in China, and systematically change the way that Chinese people

understand death.29 Communists deemed the idea of an afterlife, or ancestors

worship as suspicious and harmful. Additionally, money and time spent on

elaborate rituals, and land used for burial was thought to be wasteful. Instead,

funerals should be done away with. The Great Leap Forward brought the first

28 James L. Watson, “The Structure of Chinese Funerary Rites: Elementary Forms, Ritual

Sequence, and the Primary of Performance,” p. 8. 29 Martin K. Whyte, “Death in the People’s Republic of China,” p. 289.


21

concerted effort to change popular views on death. First of all, in the city greater

numbers of hospitals were being opened, where more people were dying instead

of in the home. Hospital personnel were encouraged to send bodies to crematoria,

instead of allowing bodies to be taken for burial. Next, those who wanted to bury

their relatives were met with obstructions, many urban cemeteries were

condemned and land was redistributed for construction.

The Cultural Revolution 文化大革命, from 1966 to the death of Mao in

1976, brought the greatest hostility to Chinese funeral and death culture.30 Coffin

shops, funeral specialists, incense makers, etc. were all tabooed throughout the

cities and in the rural areas of China. The Chinese Red Guard were also known

for breaking into houses and confiscating any traditional items relating to the

dead, including ancestral tablets and images of deities. During this time many

temples and shrines in China were destroyed and monastics were forced to

return to lay life.

Since the death of Mao, tolerance for traditional customs and religious

specialists in funeral culture has increased in China. Cremation instead of burial

is still heavily encouraged, especially in cities. However, even though this

practice has been promoted for a number of years now, many elderly Chinese

still do not accept cremation. Since urban hospitals predominantly send their

30 Ibid, p. 300.


22

dead to be cremated, many rural elderly Chinese are reluctant to accept referrals

to urban hospitals for fear that they will die without the option of burial. So,

although Chinese cultural practices around death have changed over time, there

is still evidence that some core beliefs still resonate within the Chinese people.

Exactly which beliefs and practices are still important in the modern world, and

how they play out in modern end-of-life scenarios will be elaborated on in the

following chapters.


23

Chapter 2:

Taiwanese Reformist Buddhist Movement

Section 1: Chinese History of Taiwanese Buddhist Reform

To understand the dynamic between Taiwanese social outreach programs

and government funded medical end-of-life facilities it is necessary to first

discuss the development of modern Taiwanese Buddhism as influenced by

revolutionary Chinese Buddhist movements. Within the scope of this research

paper the history of Taiwanese Buddhist thought will be drawn back to the late

nineteenth and twentieth century and the religious movements that came about

as China underwent numerous political and social crises and revolutions.

Taiwan’s unique practice of humanistic, or socially engaged Buddhism is for the

most part attributed to the teachings of an influential reformist monastic,

Venerable Master Taixu 太虛 (1889-1947), from Zhejiang Province, China, and

was made popular in Taiwan by his student, Venerable Master Yinshun 印順

(1906-2005). These two masters advocated for the reform of the Chinese Buddhist

institution through active social engagement to benefit the needs of modern

society. Most significantly for our purposes, and what will be elaborated on

throughout this paper, is that both Taixu and Yinshun strongly believed that the

modern Buddhist Sangha should work alongside Buddhist laity to create social


24

welfare projects that alleviate the suffering of individuals in this world, as

opposed to a predominant focus on practices aimed at otherworldly attainments.

Their focus on social activism to benefit individuals in this world led to

the establishment of numerous programs to benefit and provide care for

Taiwanese dying patients in clinical settings. Specifically, reforms that have

influenced today’s Buddhist involvement in death stem from notions advocated

by Taixu and Yinshun that took emphasis away from the Buddhist association

with funeral practices and monastic guidance through the afterlife experience.

Behind these notions is the idea that in order to engage Buddhism more securely

in this world, and help individuals here and now, Chinese Buddhism must

demonstrate the relevance of compassion within modern society. As a result,

within these programs, focus on providing care for this world altered and

expanded the role of the Buddhist practitioner in their role delivering the dead to

the afterlife. The following chapter elaborates on these ideas through outlining

the development of the history of Taiwanese Buddhist reformist movements.

What will be extrapolated for later discussion is a consideration of which

reformist ideas are most influential in Taiwanese modern Buddhist movements

and how these ideas are interpreted to apply in caring for today’s Taiwanese

Buddhists.


25

In the era before Taixu, late Imperialist China, doctrines and rituals

related to death, otherworldly attainments and the afterlife from Chinese

Buddhist texts had come to play a significant role in shaping popular beliefs and

practices surrounding death. At this time the connection between Buddhist

funerary and afterlife practices were so intertwined with death in popular

culture that a common euphemism for funeral services was foshi 佛事 or

Buddhist ceremony.1 By the end of the Ming dynasty, Chinese Buddhism became

besotted with rituals and funerals. By the Qing, such practices essentially defined

Buddhism, and therefore became the cause for its ideological attacks from

incoming Western scientific development and technological progress.

In around 1919, immediately after the success of the Republican

revolution, a movement popularly called “The New Culture Movement” 新文化

運動 (Xin Wenhua Yundong) greatly influenced Chinese intellectual thought. This

period was a time when concepts of evolution and progress coming from the

West spurred Chinese intellectuals, such as Yan Fu 嚴復 (1853-1921) and Chen

Duxiu 陳獨秀 (1879 –1942) to stress the necessity of modernization of Chinese

1 Donald Sutton, “Death Rites and Chinese Culture: Standardization and Variation in Ming and

Qing Times,” p. 135.


26

traditions and engagement in public iconoclastic rhetoric.2 At this time, various

political factions and public pressure called for social reform to build a strong

and prosperous China. The drive for reform took hold in the late Qing and

Republican periods.3 Modernist ideas from Chinese intellectuals, coupled with

incoming intellectual and cultural influences from the West, put Chinese cultural

traditions, including Buddhist beliefs and practices, under scrutiny.

Buddhist institutions were already under threat during the end of the

previous Qing dynasty as intellectuals who were weary of the role of Buddhist

monastics in China accused them of having little value to the modern world

because of lack of education and moral virtue.4 Buddhist practitioners were

consequently accused of draining resources from society and not contributing to

China’s social or economic progress. Additionally, those who accepted new

rationales coming from the West criticized religious rituals and worship as

“superstition”.5 The influence of these ideas and the dramatic changes that

occurred in Chinese society lead to a rise of a Republican Nationalist

Government 國民黨 (Guomin Dang), then after a war with the Japanese, the

Communist party reigned 共產黨 (Gongchan Dang), followed by a great

2 Donald A. Pittman, Toward a Modern Chinese Buddhism Taixu’s Reforms, p. 22. 3 Raoul Birnbaum, “Buddhist China at the Century’s Turn” p. 431. 4 Donald A. Pittman, Toward a Modern Chinese Buddhism Taixu’s Reforms pp. 28-33. 5 Kenneth, Chen, Buddhism in China, A Historical Survey, pp. 389-408.


27

persecution of Chinese Buddhist institutions and a significant reduction of the

influence of Buddhism in China. During this time of Buddhist persecution the

government intervened, deciding that property belonging to religious

institutions should be redistributed to better serve the public. Orders were thus

issued to confiscate any Buddhist property, to be used for government owned

schools.

Facing persecutions aimed at eliminating Buddhist institutions, a number of

revolutionary Buddhist thinkers came to the fore with ideas of how Buddhism

should face these challenges. The revolutionary Chinese Buddhist master Taixu

became publically known for his ideas to remodel the role of Chinese Buddhists

into more active participants in society, in turn becoming the forefather of

reformist monks inspiring Buddhist activism in Taiwan. Alternatively, other

influential reformist movements at the time took a more conservative approach

than Taixu, for instance, Venerable Hongyi 弘一 (1880- 1942) emphasized

personal cultivation, textual study, and retreat from the world.

Like Taixu, Hongyi was also known as a Chinese reformist monk, yet his

ideas for the reformed direction of Chinese Buddhism were centered on a return

to early, conservative Chinese monastic ways of life. Born in the late Qing

dynasty, Hongyi was a well-known actor, musician, writer and “modern man”

who famously walked away from his career to renounce as a monastic. Also


28

heralded as a Chinese Buddhist reformer, Hongyi became best known for his

scholarship on the Chinese Vinaya and for his dedication to conservative

religious practice. Seeing the world around him as severely troubled, his

reformer beliefs led him to be unswayed by worldly conditions and let go of

interest in worldly achievements. Interestingly, although Hongyi’s perspective

on how Chinese Buddhism should reform itself in the modern world varied

quite dramatically from that of other reformists, he shared in Taixu’s view that

elaborate ceremony and ritual at death were unnecessary as they were often

performed merely for economic gain. Hongyi concluded that much simpler and

meaningful practices at death were much more beneficial for the dying person.6

Taixu was also dissatisfied with what he saw as the failings of Chinese

Buddhism in the final days of the Qing dynasty, but unlike Hongyi, Taixu

recognized this time as an opportunity for Chinese Buddhism to grow and to

play an active role in a reformed China. Taixu believed that it was the

responsibility of Chinese Buddhists to adapt themselves and their practices to the

changing era, thereby making more of a positive contribution to the greater

society.7 He observed that the threat to Buddhism came from a number of forces

acting simultaneously; arguing that the cause of Buddhism’s poor public image

6 Raoul Birnbaum, “The Deathbed Image of Master Hongyi,” p. 187. 7 Darui Long, “Buddhist Initiatives for Social Well-Being in Chinese History, With Special

Reference to Modern Exponents of Humanistic Buddhism,” pp. 204-227.


29

did not solely come from outside persecution and instead, their poor reputation

could be attributed to the behavior of the Chinese Buddhists themselves. Public

scrutiny and the charges brought to the integrity of the institution were formed

to a great degree by mainstream Buddhist practices, predominantly the practice

of offering funeral services and expertise in otherworldly activities in exchange

for monetary gain.8 His advocacy for creating ”Buddhism for human life” 人生佛

教 (rensheng fojiao) was an attempt to make a distinct change from the public

association of Buddhism with Chinese death culture.9 Acting on his

dissatisfaction with Chinese Buddhist institutions and persecution from the

Nationalist Government, Taixu advocated for a complete “Buddhist revolution”

佛教革命 (fojiao geming) and revival of what he saw as the more important task of

Buddhists, the concentration on accumulating merit while still alive instead of

waiting for the afterlife.10

Known for his political activism, Taixu urged that all of his monastic and

lay followers be adept in political culture and active in addressing social

problems. Taixu believed that his goals for Buddhist reform could only be

reached if religious communities engaged with socio-political change.11 He

8 Mark L. Blum, “Death,” p. 206. 9 Donald A. Pittman, Toward a Modern Chinese Buddhism Taixu’s Reforms, p. 283. 10 David C. Schak, “Community and the New Buddhism in Taiwan, ” pp. 161-192. 11 Donald A. Pittman, Toward a Modern Chinese Buddhism Taixu’s Reforms, p. 60.


30

expressed that China would best make progress toward change through

adopting a “democratic socialist” government because socialism and democracy,

although flawed in practice, were similar to Buddhism in advocating for human

equality and social welfare.12

Taixu was a strong advocate for education and intellectual exchange,

believing that the philosophy and worldviews held within Buddhist doctrine

were compatible with modern scientific discoveries and rationalistic worldviews

coming from the West. “Buddhism for human life” involved a reorganization of

the Chinese Buddhist institution, particularly reducing the size of the Sangha,

instilling modern education, establishing compassionate social action and

cooperation with international religious thinkers. He felt the only way to achieve

his desired reforms and increase public involvement was to integrate lay

Buddhist practitioners with the monastic community in the pursuit of the

bodhisattva path through philanthropic activities.13 His intention was to

facilitate a transition toward a modern Chinese Buddhist institution that was

intellectually on par with the international community and actively attended to

the social problems of the Chinese community. In effect, this revolution would

keep Buddhism relevant to Chinese modern rationalist thinking and social

progress, with which he believed Buddhism was inherently compatible.

12 Donald A. Pittman, Toward a Modern Chinese Buddhism Taixu’s Reforms, p.182. 13 David C. Schak, “Community and the New Buddhism in Taiwan, ” pp. 161-192.


31

Taixu’s social engagement projects manifested in numerous ways,

including spearheading numerous religious societies that engaged in free

education, medical care, food distribution and disaster relief among other social

services.14 Taixu also had a strong belief that modern Chinese Buddhist groups

should engage in international exchange with other religious groups as well as

groups from the fields of science and philosophy. He involved himself in

numerous international conferences and traveled all over the world to interact

and exchange knowledge with the thinkers of his age.

Taixu did not characterize his revisions as deviating from traditional

Buddhism; instead, he insisted that a return to Mahāyāna scripture was the

inspiration for his ideas to reinvigorate the Buddhist community and relate the

Dharma to the needs of the modern world.15 While he was concerned with

explicating the Buddhist vision, and devoting considerable attention to reviving

interest in the idealistic philosophy offered by the Consciousness-Only School 唯

識宗 (weishi zong) he insisted that religious actions within the public sphere were

central to Mahāyāna spiritual life. Taixu emphasized that wisdom could not be

attained apart from compassionate action in this world, particularly within the

14 Donald A. Pittman, Toward a Modern Chinese Buddhism Taixu’s Reforms, p. 102 15 Ibid, p. 3-8


32

socio-political sphere, by placing great emphasis on the ethical norms of

Buddhist heritage related to social responsibility and human morality.

To achieve this objective, he called for a redirection of the Chinese

Buddhist religion away from the performance of funeral rituals focusing on other

worldly achievements, such as ascending to an otherworldly Pure Land.16 He

went so far as to claim that “Buddhism for human life” required that all religious

practice having to do with gods, ghosts and Pure Land devotionalism were

counterproductive and should be immediately discontinued. He argued that

Buddhist preoccupations with death and assistance with travels to the afterlife

were ultimately misguided. Directly combating the association between

Buddhism and otherworldly attainment, Taixu argued that Buddhists should

focus their efforts on making a favorable contribution to this world whereby

making a “pure land in this world” 人間淨土 (renjian jingtu). Regarding his

views on Buddhist practices focusing on death and the afterlife he is quoted in

the work, “An Introduction to a Buddhism for Human Life”人生佛教開題

(Rensheng fojiao kaiti) as stating; “So-called death is actually a part of life. Only

when we are able to understand life will we be able to understand death. On the

16 Pure Land Buddhism signifies a wide array of practices and traditions within Mahāyāna

Buddhism directed to the Buddha Amitābha and his realm, Sukhāvati (Land of Bliss), which

came to be referred to in Chinese as the Pure Land. See Daniel A. Getz, “Pure Land Buddhism,”

p. 701.

https://www.google.com/search?hl=en&client=firefox-a&hs=6h0&rls=org.mozilla:en-US:official&sa=X&ei=tSCOT66zGOGMmQWPks2ADA&ved=0CCMQvwUoAQ&q=%E4%BA%BA%E9%97%B4%E5%87%80%E5%9C%9F&spell=1


33

contrary, if we only understand death, not only will we not understand life, we

will not really understand death”17.

Here, it is important to note that although Taixu’s vision for the future of

Chinese Buddhism is evident in today’s Taiwanese Buddhist movements, during

his lifetime there were many who disagreed with his perspectives; for instance,

the writings of the previously mentioned conservative monastic Hongyi were

highly influential. Also, many of the organizations established by Taixu

eventually failed and at the end of his life, even he himself considered his reform

movement to be a failure.

Taixu’s student and biographer, Yinshun 印順, effectively brought the

reformist movement to Taiwan when he came on the advice of Taixu in 1952. In

Taiwan he became the editor of an influential Buddhist journal, mentored many

monastics and was a respected scholar monk. Buddhologist Marcus

Bingenheimer explains that Yinshun was initially under the influence of Taixu’s

activist reform movement but his real contribution to modern Buddhism was far

more scholastic than activist, through his reevaluation of historical Buddhist

texts and applying them to the modern world.18 Bingenheimer describes that

Yinshun modernized the practice of historical Buddhist studies for scholars and

17 Donald A. Pittman, Toward a Modern Chinese Buddhism Taixu’s Reforms, pp. 175-176. 18 Marcus Bingenheimer, “Writing History of Buddhist Thought in the Twentieth Century:

Yinshun (1906–2005) in the context of Chinese Buddhist historiography," pp. 255-290.


34

used influential Indian Mahāyāna scholarship, allowing others to look into the

roots of Buddhism to support social engagement or “Humanistic Buddhism” 人

間佛教 (Renjian Fojiao).

In Bingenheimer's analysis, some of Yinshun's hermeneutic devices were

well established in the tradition of Chinese Buddhist historical writing. However,

it is also noted that Yinshun used selective Buddhist historical perspectives that

were more conducive to Buddhist activism in this world. For instance, Yinshun

did not emphasize the teaching of the three ages involving the concept of mofa 末

法, "the final days of the Dharma."19 The idea that we are now living in the final

days of truth’s decline is at odds with the optimism and reformism of Buddhist

modernism, which is based on the possibility of social change for the better. So

although mofa was widely emphasized by the Pure Land movements in Japan, it

19 The notion of the “final days of the Dharma” comes from the idea that while the truth about the

nature of reality (dharma) propounded by Sakyamuni and other Buddhas before him is

considered to be unchanging, human expressions of that truth and their communities are

viewed as conditioned, thus impermanent phenomena. According to this understanding, each

Buddha discovers the same truth about reality as that realized by his predecessors, and then he

teaches it to a community of followers. After a certain period of time, however (commonly

ranging from five hundred to five thousand years), this truth will be forgotten, thus

necessitating its rediscovery by another Buddha in the future. See Jan Nattier, “Decline of the

Dharma,” pp. 210-213.


35

did not go well with his vision of renjian fojiao, aimed at the betterment of the

world20.

His notions of the role of Buddhism in society are argued as even more

centered on improving society than Taixu's, partially because Yinshun was much

less politically minded than his teacher and focused instead on local participation

and reform through education.21 However, despite being less of a political

activist than Taixu, Yinshun did not waiver on certain controversial issues taken

up by Taixu, particularly his disdain for Buddhist monastic involvement in

funeral and afterlife rituals. In fact, upon first arriving in Taiwan, Yinshun was

met with public outcry over criticisms he made regarding Pure Land piety.22

As the government was systematically eliminating Buddhism in China,

the impact of the vision of these reformist monks became most evident in

Taiwanese Buddhist social movements. In the 1960s, when Yinshun was

promoting “this world Buddhism”, Taiwan was transforming from a politically

oppressed society to an independent state that was looking for ways to support

the social needs of the people. Although Taiwan was establishing an empowered

and independent nation, there was still a cultural need to maintain a connection

20 Marcus Bingenheimer, “Writing History of Buddhist Thought in the Twentieth Century:

Yinshun (1906–2005) in the context of Chinese Buddhist historiography," pp. 255-290. 21 Philip Clart and Charles B. Jones, Religion in Modern Taiwan, p. 172. 22 Marcus Bingenheimer, “Writing History of Buddhist Thought in the Twentieth Century:

Yinshun (1906–2005) in the context of Chinese Buddhist historiography," pp. 255-290.


36

with Chinese religious roots. At this time, ideas promoted by Taixu and Yinshun

of attaining a pure land in this world and building a strong socially active

Buddhist community were particularly inspirational. Taixu’s advocacy for a

democratic socialist government and ideas for Buddhist interaction with modern

international organizations addressed the Taiwanese desire for government

reform and international connections. As Yinshun’s views began to take root in

Taiwanese society, his scholastic endeavors to educate Taiwanese Buddhists and

mentor Buddhist monastic leaders brought the ideas of humanistic Buddhism to

the Taiwanese people.


37

Section 2: Modern Taiwanese Buddhist Groups

Today Buddhist activist movements have developed deep roots in

Taiwanese society. Over the years, the founders of the highly successful

Taiwanese Buddhist organizations have led their followers to build amazingly

successful institutional and outreach programs to serve the public. Among their

many social programs and services for the public, these groups have worked to

successfully revive a strong discipline of monastic study and practice that was

temporarily lost in Mainland China, create the largest movement of fully

ordained female monastics in the Buddhist world and at the same time, develop

a highly motivated lay membership working together with Buddhist

practitioners to provide funding and volunteer services for countless social

programs across the country. This chapter will introduce three of these leaders

who have made prominent contributions to modern Taiwanese healthcare,

namely Venerable Masters Xingyun 星雲 (1927-present), Zhengyan 證嚴 (1937-

present), Shengyan 聖嚴 (1930 – 2009). Specific attention will be paid to

highlighting their visions for modern Buddhist involvement in healthcare and

how the programs initiated by these masters relate to those of their reformist

predecessors.


38

The first such leader, Venerable Master Xingyun (1927-present), is a

monastic of Chinese descent from Yangzhou near Nanjing in Jiangsu Province.

Leaving the mainland for Taiwan at age 23, immediately preceding the

Communist takeover, he became the leader of one of Taiwan’s most popular

socially engaged Buddhist groups. Based on his highly successful enterprise Fo

Guang Shan Monastery 佛光山寺 Buddhist organization founded in 1967, and

the lay organization Buddha Light International Association 國際佛光會 founded

in 1992. Due to his great accomplishments Xingyun has been called “the leader of

the most vigorous, innovative, and expansive Chinese Buddhist movement of the

post-war generation.”1 Claiming that his inspiration comes from Taixu, Xingyun

is hailed as the monk who successfully put “Buddhism for human life” into

practice, renaming it “Humanistic Buddhism” 人間佛教. He advocates for

education through building numerous universities, and social outreach

programs to benefit the general public. Committed to Taixu’s vision for the

establishment of international humanistic outreach, Xingyun has established

over two hundred Fo Guang Shan branch centers and temples internationally.

1 Donald A. Pittman, Toward a Modern Chinese Buddhism Taixu’s Reforms, p. 273.


39

Xingyun focuses on activism that attempts to make “a pure land on

earth” and states that the pure land is within the mind of the individual.2 In

discussions on exactly how Buddhists are to practice compassionate behavior

toward others, Xingyun shares views closely with Taixu, yet his stance is slightly

different on a few specific topics. Although it has caused for mixed response

from the public, Xingyun is known for his political participation and considers

such activities as part of one’s social responsibility.

Xingyun’s Fo Guang Shan Buddhist groups take responsibility to provide

social welfare for the Taiwanese public through establishing orphanages, senior’s

homes, universities such as Fo Guang University 佛光大學, Nanhua University

南華大學, museums, etc. Most notably for our purposes Fo Guang Shan’s

healthcare services focus mainly on establishing programs to provide volunteer

outreach services. For instance, the Fo Guang Shan Compassion Foundation 佛光

山慈悲社會福利基金會 (Foguangshan cibei shehui fuli jijinhui)3 organizes mobile

hospital vans to visit remote areas of the country and provide at home medical

care for people who find it difficult to access care. Fo Guang Shan has also

established a Buddhist run senior’s home, Lanyan Foundation of Seniors

2 Ibid, p. 274. 3 “Fo Guang Shan Compassion Foundation,” Accessed April 24, 2012,

http://www.compassion.org.tw/index/index.tpl.htm.


40

Citizen’s Home in Yilan County 財團法人宜蘭私立蘭陽仁愛之家 (Caituanfaren

yilan sili lanyang renai zhijia)4 where monastics, nurses and volunteers work

together to care for seniors in a Buddhist temple environment. Additionally,

monastics within Fo Guang Shan have acted as leaders in educating the public

on life and death and have worked to incorporate the study of life and death into

public dialogue and mainstream university curriculums. For instance, Xingyun’s

disciple Venerable Huei Kai 慧開 lectures to physicians, nurses and to the

general public on life and death, encouraging open discussion on the topic to

help individuals come to terms with death and as a result, have a more fulfilling

life. To date, Huei Kai he has released two DVDs exploring Buddhist ideas of life

and death in the modern world, as well as presented Buddhist views on this

topic at numerous international religious and inter-faith conferences. More

substantially, Huei Kai has successfully established a Life and Death department

at Nanhua University 南華大學 in central Taiwan, securing the once taboo topic

into the realm of scholastic study. These substantial contributions reflect a

significant change in the role of the Buddhist monk in preparing the public to

face death. The work of monks like Huikai has reaffirmed the association of the

4 “Lanyang Foundation of Senior Citizen's Home Ilan R.O.C.,” Accessed April 24, 2102,

http://dharma.fgs.org.tw/shrine/fgsastw8y/01/index.htm.


41

Buddhism with death, but in a modern, intellectual and ultimately beneficial

way for the modern world.

Although the efforts of Fo Guang Shan’s Buddhist monastics center on

activism in this world, it is still very common for the Taiwanese public to request

conventional or otherworldly Buddhist practices to help them as they approach

death. As such, Fo Guang Shan monastics will regularly participate in traditional

funeral ceremonies, or ritual chanting on behalf of the deceased as needed by the

public. Fo Guang Shan temples also hold Pure Land chanting retreats aimed at

reinforcing belief in the aspiration for rebirth in an otherworldly Pure Land.5

Our second modern Taiwanese Buddhist leader, Venerable Master

Zhengyan, founded the renowned Tzu Chi Foundation 慈濟功德會 (Ciji gongde

hui) in 1966. Zhengyan shares her vision and life’s mission with that of her

tonsured master Yinshun. Like her predecessors, Zhengyan advocates that

Buddhism and modern science share compatible worldviews as they are both

based on rational thought. Tzu Chi’s monastic and lay following are known for

their active role in developing compassionate service for society, rather than

focusing on religious worship or studying Buddhist doctrine. Zhengyan insists

that Buddhism’s role in humanity is not passive, and that followers of the

Buddha should actively bring positivity to the world around them through good

5 Philip Clart and Charles B. Jones, Religion in Modern Taiwan, p. 172.


42

deeds and social programs to help the needy and establish a pure land in this

world.6 The extensive outreach programs of Tzu Chi work to deliver social

services not just in Taiwan, but also in many countries around the world.

Since 1986 Tzu Chi has made a very special, large-scale contribution to

the field of medicine in Taiwan. After tremendous efforts in fundraising and

financial assistance from Yinshun himself, Tzu Chi opened the first general

hospital in the remote eastern city of Hualian, where locals were suffering from

limited access to healthcare. The establishment of this first major Buddhist

hospital helped to solidify the transforming role of the Buddhist institution, from

a purely religious association concerned with otherworldly attainments to a

major authority and provider of medical care in this world. Tzu Chi Buddhist

hospitals are at the forefront of Taiwanese biomedical intervention; treatments

such as organ and marrow donation are common within these facilities.7 The

organization also founded large-scale health educational facilities such as a

college of nursing (1989) as well as a college for medicine, Tzu Chi University 慈

濟大學 (1992) and funded numerous medical research endeavors. After the

success of this first facility, five subsequent branch hospitals were established

across the island.

6 Donald A. Pittman, Toward a Modern Chinese Buddhism Taixu’s Reforms, p. 287. 7 Donald A. Pittman, Toward a Modern Chinese Buddhism Taixu’s Reforms, p. 289


43

Despite her obvious interest in the health and welfare of the Taiwanese

people, Zhengyan shares Yinshun’s distain for involvement with politics and

forbids her disciples from becoming involved in political campaigns.8 Following

lead devotees did not publically involve themselves in health policy reform and

were not part of the movement to socialize healthcare in Taiwan.9

Although the central aim of the Tzu Chi hospitals is to provide medical

care for patients, these facilities each provide space for accommodating

traditional Buddhist end-of-life ritual practices. The Tzu Chi hospitals include

hospice wards, which have special rooms set aside for religious practices at

death. There are cleansing facilities where families can wash their dying loved

ones and rooms are prepared with interchangeable religious icons for people to

chant with the dying patient for as long as they deem necessary.10 The inclusion

of such amenities within Tzu Chi hospitals indicates that the public still requires

such practices at death, and that the Buddhist communities in Taiwan provide

the means to meet these needs within modern biomedical facilities.

The third and last modern Buddhist leader who will be introduced is

Venerable Master Shengyan, whose Buddhist activism was highly influenced by

his close connection with the charitable and scholarly Venerable Dongchu 東初

8 David C. Schak, “Community and the New Buddhism in Taiwan, ” pp. 161-192. 9 Philip Clart and Charles B. Jones, Religion in Modern Taiwan, p. 176. 10 This information was obtained through person observation when visiting Tzu Chi hospitals and

speaking with Buddhist chaplains in November of 2011.


44

(1907–1977), a lesser known monastic who was also studied under Taixu. Born in

a rural area near Shanghai, Shengyan became a novice monk at the age of twelve.

By 1949, the Chinese Nationalist government was in disarray and being

overthrown by the Communist Party. Such political and social strife inspired

Shengyan to temporarily leave his monastic pursuits and enlisted in the military,

in an attempt to contribute to a positive future for China. Ultimately the

Nationalist Party was defeated and retreated to Taiwan, where Shengyan was

transferred. In Taiwan, Shengyan left the military to return to monastic pursuits

and received tonsure under Dongchu.11 In 1969 he left Taiwan to pursue a

doctoral degree in Buddhist literature in Japan, later becoming the first Chinese

Buddhist monastic to earn a doctoral degree.12 After this time he traveled to

America to educate western scholars about Buddhism and establish Zen

meditation centers. However, in 1977 Donchu passed away unexpectedly and in

his will was the request that Shengyan take over his Buddhist organizations,

prompting Shengyan to return to Taiwan.13 Throughout the rest of his life

Shengyan frequented back and forth between America and Taiwan teaching at

various universities and establishing Zen meditation centers in America. In 1989

11 Shi Shengyen, Orthodox Chinese Buddhism: A Contemporary Chan Master's Answers to Common

Questions, pp. 19-31. 12 Donald A. Pittman, Toward a Modern Chinese Buddhism Taixu’s Reforms, p. 280. 13 “About, ”Accessed April 24, 2012,

http://www.dharmadrum.org/content/about/about2.aspx?sn=50


45

Shengyan founded Dharma Drum Mountain 法鼓山 (Fa Gu Shan) in the north of

Taiwan, with the goal of “uplifting human nature and establishing a pure land

on earth.”14

In 1994 the National Taiwan University Hospital (NTUH) Department of

Family Medicine, established a clinical monastic training program under the

sponsorship of the Buddhist Lotus Hospice Care Foundation 佛教蓮花基金會

(Fojiao lianhua jijinhui) at the Palliative Ward of NTUH. In 1998 the dean of

Dharma Drum Mountain College of Buddhism, Venerable Huimin 惠敏, was

invited to join the activities of the Lotus Foundation and became a prominent

supporter and member of the board. In an attempt to offer non-sectarian training

and care to Taiwanese end-of-life patients, Huimin does not play a very public

role in the foundation and encourages monastics from various Buddhist groups

to study or lecture at the facility.

Inspired by the Christian based chaplain groups providing hospice care

in Taiwan, the mission of the foundation became to establish a clinically trained

Buddhist group of care practitioners to meet the particular spiritual end-of-life

care needs of the Taiwanese population. Hence, the first major teaching facility

was established to train Buddhist Chaplains to work alongside physicians to

14 Donald A. Pittman, Toward a Modern Chinese Buddhism Taixu’s Reforms, p. 283.


46

deliver spiritual care to compliment medical care.15 Since its inauguration, the

foundation has grown immensely popular and now provides comprehensive

training programs for chaplains to actively participate in-patient and family care,

focusing on education programs to understand the nature of death and being a

prominent member of the clinical team in end-of-life care.

What we can observe from the progress in health related outreach

activities of these three groups is quite different from the type of services that

Chinese Buddhists have historically provided at death. In Taiwan, the Buddhist’s

role at end-of-life is evolving. Buddhists are involved in meeting the ritual,

spiritual and now the clinical care needs of individuals, providing a variety of

services that benefit patients in life and in death. As advocated by their

predecessors, Taiwanese Buddhist groups are actively changing the public image

of monastics as being preoccupied solely with funeral ceremonies to having a

much more active role in the health and wellbeing of individuals while they are

still alive and as they approach death. Through involvement in such activities as

facilitating public health services, modern Buddhist groups established

themselves as care providers for the health needs of individuals in this world. Fo

Guang Shan’s outreach services effectively brought medical care to remote areas

of the country through a mobile hospital vehicle. In addition, the Buddhist

15 Chen Rong-Chi, “The Spirit of Humanism in Terminal Care: Taiwan Experience,” pp. 7-11.


47

senior’s home created a place where elderly Buddhists could spend the end of

their life in a religious setting. The efforts of Tzu Chi to create large-scale

Buddhist medical facilities and fund modern medical research projects

tremendously altered the role of the Buddhist group as the major health service

provider in the country and as actively promoting research in modern

biomedical technology. The last example provided, the creation of the clinical

Buddhist chaplain, exhibits the most significant change in the role of the

Buddhist at end-of-life in that Buddhist groups are now actively participating in

physician centered care.


48

Chapter 3:

Social Changes and Healthcare in Modern Taiwan

Section 1: Prosperity and a Changing Social Demographic

Concurrent with the modern Buddhist movement in Taiwan, over the last

few decades the country has experienced tremendous political change and

economic growth, creating vast improvements in the standard of living for the

country changing the social demographic of the nation. What is referred to as the

“Taiwan miracle”1, the rapid industrialization and economic prosperity of the

nation, has meant that Taiwan has opened its doors to foreign influence, leading

to rapid social development and modernization. In the past century the country

has gone from Japanese rule, to Chinese Republican rule, up until the late 1980’s

a system of martial law under the retreating Nationalists and in 1996 having the

first Taiwanese democratic election. In addition, the Taiwanese government

supported tremendous economic growth through a focus on exporting goods to

Western countries.2 Along with this trend of political and economic reform, a

socially funded National Health Insurance (NHI) program was implemented in

Taiwan in 1995, greatly enhancing individual financial protection against

unexpected medical expenses and free access to health services for all. Together

1 Richard Madsen, Democracy’s Dharma: Religious Renaissance and Political Development in Taiwan,

pp. 1-15. 2 Hsin-huang Michael Hsiao, “Recapturing Taiwan’s Democratization Experience,” pp. 1-12.


49

these changes have brought about major improved standard of living in Taiwan

and significantly changing the degree of overall medical care received and life

expectancy of the average Taiwanese.

Despite high satisfaction ratings, Taiwan’s reformed healthcare system

faces new challenges. As medical technology and access to innovative

procedures continue to develop in Taiwan, difficult questions begin to arise such

as how the government is to fund medical treatments for citizens who are living

longer and becoming more accustomed to healthcare intervention. In a country

with socialized healthcare, issues of funding force government policy committees

to consider what types of treatments are required to help facilitate good care for

patients at end-of-life and to what extent curative treatments are appropriate for

the terminally ill.3

Adding to this pressure is the necessity to recognize and prepare for

Taiwan’s growing aging population. Statistically, the demographic transition of

birth and death rates in Taiwan from 1960 to the 21st century has brought about

dramatic shifts in the age structure of the country.4 In Taiwan, the rate of

population aging has increased by an estimated 0.6% every year since 2006 and

the growth rate of the elderly segment of the population is among the highest

3 Jui-Fen Rachel Liu and Tung-Liang Chiang, “Evolution of Taiwan’s Healthcare System,” pp. 85-

107. 4 Lin Ming-Hsien, et al., "Population aging and its impacts: Strategies of the health-care system in

Taipei," pp. S23-S27.


50

globally.5 The rate of population aging in Taiwan is reported to be so high that

by 2050 the elderly population is estimated to exceed 30% of the country’s

population, surpassing the United States.6

Taiwan is not alone in this situation as studies are showing that across

Asia, and the rest of the world societies are rapidly aging, this change in

demographic is attributed to such factors as declining fertility combined with an

increased life expectancy. What makes these issues unique in Taiwan is that

healthcare providers have strong social and economic support from well-

developed, highly active humanitarian Buddhist groups. Through programs

such as those outlined in the previous chapter, Buddhist groups provide strong

complimentary health support to government funded healthcare programs.

While the assistance provided through these outreach programs provides much

needed service to the Taiwanese, it is interesting to consider how the views and

ideals of these Buddhist groups influence the types of care that are provided for

dying patients, and alternatively, how biomedicine and the clinical setting has

influenced the practices of modern Buddhist end-of-life caretakers. For instance,

the outreach programs of some of these Buddhist organizations in Taiwan

appear to meet modern bioethical issues head on by embracing modern

5 Lin Ming-Hsien, et al., "Population aging and its impacts: Strategies of the health-care system in

Taipei," pp. S23-S27. 6 Ibid.


51

biomedical technologies and providing services in some of the most advanced

procedures at end-of-life. For example, the modern procedure of post-mortem

organ donation is a highly contentious for some religious groups, and even

conflicts with the beliefs of some Buddhist groups, but this treatment is provided

through Taiwanese Buddhist healthcare facilities and is considered an

appropriate practice for the modern Buddhist individual.7

Although modern biomedical research and procedures are popular in

Taiwan, it is important to note that a number of recent biomedical research

studies reveal that many terminally ill Taiwanese patients struggle with their

religious or culturally based needs being adequately met in modern medical

facilities. These studies, that will be discussed in chapter six, indicate the

possibility that modern medical and religious reform may be moving more

quickly than is appropriate for some Taiwanese individuals when it comes to

beliefs and practices that are important at end-of-life.

7 In Japan, for instance, organ donation has not been accepted within the culture. See

Margaret M. Lock, Twice Dead: Organ Transplants and the Reinvention of Death, pp. 1-14.


52

Section 2: Taiwan Healthcare Reform For The Aging

The massive healthcare reforms that have taken place in 20th century in

Taiwan, establishing it as an international competitor as far as public access to

medical care, marks the first time the country’s government has played a

significant role in health care delivery and financing.1 Western medicine first

started to be practiced in Taiwan by missionaries coming from the UK in the late

1860s. Before this time Chinese doctors dominated mainstream health care

delivery but there was no formal system of licensing in the country. The

prominence of Chinese medicine began to diminish soon after Japan took over

Taiwan and the colonial government increased the supply of Western-style

providers by establishing the first school of Western medicine and constructing a

number of public hospitals staffed by licensed doctors trained in Western

medicine. After World War II, as the government changed hands back from

Japanese back to Chinese rule, Western medicine continued to flourish and

dominate Taiwanese healthcare, while at the same time there was also strong

public demand for Chinese medicine.2

With the establishment of the Department of Health (DOH) under the

national cabinet in 1971, Taiwan’s healthcare system moved into a new era


107. 2 Ibid.


53

characterized by the government’s active involvement in health care reform.

Since then, Taiwan’s healthcare system has undergone two important periods of

development: first the pursuit of health care for all, from 1971–1995 and second,

the moving toward a high performing health system from 1995 to the present.

After much planning and consideration beginning in the early 70’s, Premier Yu

Kuo-hwa made a policy announcement calling for “health insurance for all by

2000”, thereby making healthcare reform recommendations a chapter of the

“Long-term Economic Perspectives in Taiwan, 1986–2000”, which eventually

formed Executive Yuan’s policy guidelines for Taiwan’s economic development.3

At the same time, as was mentioned earlier, Taiwan’s political

environment and climate was undergoing major transitional changes. In the

process of democratization, Taiwan’s first opposition party, the Democratic

Progressive Party was officially formed on 28 September 1986, and in 1987 the

government lifted the Emergency Decree Law (martial law).

On 28 February 1989, Premier Yu announced the plan to advance the new

target year for implementing the NHI program to 1995.4 The accelerated

implementation timeline of NHI, five years ahead of its original schedule, was

largely a product of increasing public demand for universal health coverage. The


107. 4 Ibid.


54

current NHI program was also updated to include providing a comprehensive

benefits package covering preventive and medical services, prescription drugs,

dental services, Chinese medicine and home nurse visits.

Section 3: Biomedical Research On End-Of-Life Needs Of Taiwanese Patients

In this next section, a number recent biomedical studies will be

introduced that address various challenges faced by Taiwanese end-of-life

patients within the reformed system of care. In order to highlight the specific

care needs that would involve Buddhist caretakers, the information presented

from the studies will be limited to non-physical needs, ones that were

categorized as religious, spiritual or cultural. The intention is to highlight

Taiwanese end-of-life needs as identified within the new structure of socialized

health care in order to later compare these needs with programs that are

provided by Buddhist chaplains and Buddhist end-of-life care programs.

The accelerated implementation of socialized healthcare and the

introduction of specialized policy for terminally ill patients has brought

Taiwanese health policy rapidly into the modern age of biomedicine. However,

recent Taiwan based biomedical studies that will be examined within this

chapter show that many patients indicate fear of not having their religious or

cultural end-of-life needs met in medical facilities. It is possible that even though


55

reformed government health policy has dramatically improved Taiwan’s

standards in providing access to medical care, this transition has perhaps

overlooked the needs of many Taiwanese end-of-life patients. These studies

suggest that modern ways of caring for terminally ill patients that do not

accommodate for patient’s beliefs in reincarnation and the afterlife experience

will not adequately meet their needs as they approach death. So, while modern

Buddhist end-of-life caretakers may focus on helping the individual in this

world, a number of Taiwanese patients still require religious guidance and

assistance with their otherworldly beliefs. These studies indicate that cultural

and religious beliefs of individuals are not necessarily always compatible with

modern medical practices, suggesting that there is room for improvement in

accommodation of the otherworldly needs of Taiwanese terminally ill patients.

A 1997 study from Wang et al. on medical care for AIDS patients in

Taiwan showed that while physical discomfort was being treated, patients

indicated that end-of-life care was not adequately addressing the psychological

needs of its patients.5 The study found that a number of the psychological issues

were unique to Taiwan’s specific religious and cultural beliefs. For instance,

patients expressed a desire to return to their home to die, as expressed as a belief

that if one does not die at home, the spirit would become a restless ghost and

5 Shirley S.L. Wang et al., "The Health Care Needs of Hospitalized Patients with AIDS in Taiwan,"

pp. 179-188.


56

harm members of the remaining family. Additionally, a number of patients

communicated a desire to be cleaned and dressed in appropriate attire before

they die, as they believed that a person who dies in non-formal clothing would

be a beggar in their next life. A third issue was that patients found it undesirable

and even against their cultural values to speak about death, either with their

doctors or with family members. Patients claimed that to speak about death

directly was a social taboo in traditional Chinese culture, instead preferring to

use the phrase "go home" as opposed to “death”.

A 2006 study of Taiwanese terminal cancer patients from Shih and her

research team indicated similar evidence to Wang’s study. In this study 86% of

the participants expressed a wish to die at home, believing that without this the

soul of the dead cannot be reunited with his or her family and become lost in the

underworld. Results from this later study also revealed that patients regarded

discussion around death and dying to be culturally taboo and were

uncomfortable discussing such issues with family members and physicians.

What was interesting about this study was that although talking about illness,

death and dying were considered cultural taboos and bad luck to the patients,

many older patients who were participating in the research study admitted that


57

they appreciated the opportunity to discuss their health status and their

preparations for a peaceful death.6

A later study from Shih and her team published in 2009 aimed to identify

the spiritual needs of Taiwanese end-of-life patients and evaluate the various

measures of care provided to meet these needs in a healthcare environment7. This

study noted tremendous difficulties in even determining a common definition of

spirituality or religion that suited all of the patient participants. Despite these

difficulties, the study revealed the common theme that fulfillment of patient

needs during the final phase of life involved a process that involved pursuing an

afterlife as a transcendental spiritual being. Similar to the two previous studies

discussed, many of the participants were concerned with their bodily appearance

at death and expressed a desire to take their last breath at home, as these factors

had relevance to their beliefs and preconceptions about afterlife experience and

rebirth. This study also noted that although patients generally feared their own

death and were not generally comfortable discussing it, they found it helpful and

important to open up to discussions on life and death.

A fourth study from Chao et al. looked at a cross section of Taiwanese

terminally ill patients from various age groups to see if end-of-life needs were

6 Shih Fu-Jin et al., “Death and Help Expected from Nurses when Dying,” pp. 360-375. 7 Shih Fu-Jin et al., “Spiritual Needs of Taiwan’s Older Patients With Terminal Cancer,” pp. 31-38.


58

common to specific age brackets.8 The study found that across all age groups fear

of death was a common characteristic among palliative care patients, and this

fear increased as the patient approached their last days of life. Based on these

findings the research team concluded that comprehensive care in the palliative

care unit should include a focus on the relief of the death fear in cancer patients,

consequently revealing a need for psychological and spiritual care in care

facilities for the terminally ill.

The findings of these studies reveal an interesting pattern consisting of

distinct themes in end-of-life desires of Taiwanese patients: wanting to die in the

home to assist their spirit in reconnecting with the family, a desire to be properly

washed and dressed upon death as it affected the afterlife experience, and a

general fear of death combined with a cultural taboo of speaking about it

whatsoever. Based on how these specific end-of-life needs were described by the

patients, it is clear that beliefs from traditional Chinese death culture, as

described in chapter one, are still prevalent in modern Taiwan.

Nevertheless, the findings from these studies suggest that terminally ill

patients in Taiwan generally fear death and would benefit from more open

discussion regarding life and death. Also, terminally ill patients indicate having

8 Tsai Jaw-Shiun et al., “Fear of Death and Good Death Among the Young and Elderly with

Terminal Cancers in Taiwan,” pp. 343-351.


59

specific hopes for end-of-life scenarios that include assistance in preparing for an

otherworldly afterlife experience. The findings of these studies suggest that the

terminally ill population in Taiwan would benefit from the care of a religious

chaplain to instigate open discussions on death to help alleviate fear surrounding

the experience. Additionally, patients appear to require assistance in preparation

for otherworldly activities, which was a large part of Buddhist end-of-life care in

the past and is still part of care services today. Post-mortem rituals including

chanting with a body for a number of hours after death is still practiced, and

facilities are provided to accommodate such practices in Tzu Chi hospitals,

National Taiwan University Hospital and many hospice units, but such ideas are

generally not compatible with the clinical understanding of what happens after

death.

In Taiwanese hospitals, hospices that care for the needs of dying patients

are modeled after the Christian hospices; however, these Buddhist facilities have

altered their services to meet the specific end-of-life needs of the Taiwanese

population. To gain a better understanding of how traditional Buddhist care for

the dying is incorporated into the clinical setting to provide spiritual care to suit

the specific needs of the Taiwanese population, the following two chapters will

provide information on the hospice movement in Taiwan and investigate the role

of the Buddhist chaplain.


60

Chapter 4:

The Hospice Movement In Taiwan And Buddhist Chaplaincy

Section 1: Hospice and Palliative Care in Taiwan

Presently, Buddhist chaplains and lay Buddhists belonging to the modern

socially engaged Buddhist denominations outlined earlier provide clinical

spiritual care in Taiwan. However, as was also outlined earlier, in the clinical

setting these groups focus centrally on caring for the needs of this world and do

not focus on otherworldly attainments. Considering the findings of studies on

Taiwanese terminally ill patients, it would appear that not all Taiwanese adhere

to the reformed Buddhist teachings regarding the rejection of otherworldly

attainments. In fact, it seems as though otherworldly attainments and afterlife

experiences are very important to Taiwanese individuals, especially as they

approach death. Such findings evoke questions as to the type of care that is

provided by modern Buddhist groups and how these groups care for individuals

who do not adhere to modern religious beliefs. Additionally, policy that looks to

provide appropriate care for Taiwanese end-of-life patients needs to be evaluated

to analyze whether or not the types of treatments that are provided can

accommodate what the public deems as necessary for a “good death” physically

and spiritually.


61

This chapter will explore more closely end-of-life care as it is provided by

government funded healthcare and religious organizations in an attempt to

better understand exactly what measures are provided for individuals as they

approach death. Central to this discussion will be an analysis of the evolvement

of publically funded hospice and palliative care in Taiwan, followed by an in-

depth exploration of the types of services provided by caregivers at these

facilities. Spiritual care is highlighted as one of the central care services provided

within these facilities. Although Taiwanese hospice services and spiritual care

are inspired by Christian based hospices, today Buddhist chaplains provide the

majority of hospice care in Taiwan and so for the purposes of this study special

attention will be paid to outlining Buddhist involvement in these services.

The hospice movement in Taiwan began as part of a larger Asia Pacific

hospice movement that spread very rapidly in the 1990’s. The Asia Pacific

Hospice Network was founded in 1995 and by 1998 it had delegates from 13

countries.1 Taiwan's first hospice ward was established in 1990 as a religiously

Christian based facility as part of the Mackay Memorial Hospital in Taipei

County. The Taiwan Department of Health established a Task Force for Hospice

Care in 1995 as there was public concern regarding the nature of care for

terminally ill patients. At that time a palliative ward was established at the

1 Joan C. Lo, “The impact of hospices on health care expenditures - the case of Taiwan,” pp. 981-

991.


62

National Taiwan University Hospital in Taipei City, and comprehensive home

hospice care was started to become popular in 1996. The movement in Taiwan

was spurred by concern over the growing medical cost to treat the rising

population of terminally ill cancer patients in Taiwan. Cancer has been the

leading cause of death in Taiwan since 1982 and the huge amount of money

being spent in the acute care setting for terminally ill cancer patients was not

proving to increase their wellbeing2. Home-care nursing institutes providing

home-based, long-term nursing care had become the most popular model of

long-term care services and were reimbursed by NHI. However, the home-care

model, which provided mainly nursing treatments, did not meet the many and

complex needs of those receiving care, particularly the elderly.

In 1996 NHI policy was amended to include hospice home care as part of

general comprehensive coverage and after much lobbying and public debate, in

2000 a Hospice Palliative Care Act (HPCA) was passed. It was the first time in

the world that government social policy had used the terms “Hospice Palliative

Care” in the name of a legal act, defining it as “palliative or supportive care for

decreasing or relieving pain and suffering of the terminal patients.” What is also

known as the Natural Death Act, legally enacted under the HPCA, effectively

legalized and made standard a number of modern, potentially contentious

2 Joan C. Lo, “The impact of hospices on health care expenditures - the case of Taiwan,” pp. 981-991.


63

medical practices that were not practiced previously in Taiwan, such as Do No

Resuscitate (DNR) orders, Advanced Care Directives (ACDs) and the option of

organ donation for terminally ill patients.3 The intention behind the Natural

Death Act was to provoke discussion of end-of-life healthcare wishes and to

avoid unnecessary pressure from physicians for terminally ill patients to

undergo medical treatments, instead allowing patients to focus on non-curative

treatments for physical or psychological pain. Publically funded hospice care

was an important part of healthcare for Taiwanese as it emphasized more on the

various non-physical needs of patients as opposed to purely medical care at end-

of-life. Terminally ill patients were thus considered to be a unique patient

population with unique medical and psychological care needs. Additionally,

international studies showed that overall costs of hospice care for patients in

their last months of life are far less than conventional care.4 The benefits of the

HPCA as outlined under NHI specifically for terminally ill patients include

inpatient and outpatient services, home care, home hospice care services,

preventive medicines including Chinese medicine, and pharmaceutical drugs.

The beginnings of hospice care treatment came from religious

organizations that created the foundations for promotion of this movement,

namely, the Catholic Sanipax Socio-Medical Service & Education Foundation

3 Chen Rong-Chi, “The Spirit of Humanism in Terminal Care: Taiwan Experience,” pp. 7-11. 4 Joan C. Lo, “The impact of hospices on health care expenditures - the case of Taiwan,” pp. 981-991.


64

(1983), the Christian based Taiwan Hospice Foundation (1990) and the Buddhist

Lotus Hospice Care Foundation (1994), which is backed by numerous Buddhist

groups, as noted earlier. As the hospice movement became more recognized for

providing important care measures for terminally ill patients, other health

professionals became involved. For instance, the Taiwan Hospice Organization

was founded in 1995 to unite all care providers and personnel involved and in

1999, physicians desiring formal involvement in the hospice palliative movement

established the Taiwan Academy of Hospice Palliative Medicine.5 In 2004, the

National Health Research Institute launched the first geriatrics fellowship

training program in Taiwan with assistance from Mt. Sinai Medical School of

New York. The pilot program ended in 2006 due to budget limitations. However,

in 2006 Taipei Veterans General Hospital also started its own geriatrics

fellowship training program through a collaboration with the British Geriatrics

Society.

Today, many professional home-care services targeted to serve the needs

of end-of-life patients such as, nursing services, home-based physical therapy,

occupational therapy, nutritional therapy and respiratory therapy, meal delivery

services, day services, respite care services, transportation services, and many

other social services are all reimbursed under the NHI program. To avoid over-

5 Chen Rong-Chi, et al., “The Development of Hospice Palliative Care in Taiwan,” pp. 2108-2110.


65

hospitalization of end-of-life care, a pilot program to step-up care within homes

and to provide end-of-life care in communities was launched in 2010.6

Additionally, to cope with the rapidly increasing elderly population and long-

term care needs a new National Long-Term Care Insurance, set to be launched in

2012, to provide seamless care for older people, from health-care to social

welfare. The pending National Long-Term Care Insurance program plans to

partially reimburse the institutional care of severely disabled older people.7

An in-patient Palliative Care Ward was successfully founded at the

National Taiwan University Hospital (NTUH) in 1995. During the period from

1998 to 2006, due to the growing demands for spiritual guidance for terminally ill

patients in hospice/palliative care and their families, the NTUH Palliative Ward,

along with the Buddhist Lotus Hospice Care Foundation and Yi-Ju Sanctuary

Hospice Care Association, developed a spiritual care model for terminal patients

that included clinically trained Buddhist chaplains to provide spiritual care.

Section 2: The Taiwan Association of Clinical Buddhist Studies

In 2000, the first facility for Buddhist monastics was founded to train

Buddhist chaplains to participate in medical care. The Taiwan Association of

6 Lin Ming-Hsien, "Population aging and its impacts: Strategies of the health-care system in

Taipei," pp. S23-S27. 7 Ibid.


66

Clinical Buddhist Studies (TACBS) training center was created at the Palliative

Ward of NTUH. The stated mission of the TACBS is to integrate modern

medicine with Buddhist studies, develop a spiritual care model indigenous to the

culture of Taiwan and to enhance the quality of palliative care for terminally ill

patients. These proposed ends are met through research activities, education

programs, and training courses with a focus on clinical Buddhist studies and

work for the incorporation of palliative care training and life education as

components of health promotion activities and courses.8 Today clinical Buddhist

chaplains can be seen providing spiritual care for terminal cancer patients in

nearly 30 hospitals throughout Taiwan. Chen writes that the future plans for the

foundation include promoting the incorporation of a clinical Buddhist monastic

training program within the curriculum of Buddhism colleges in Taiwan

universities.9

In the TACBS mission statement written by Chen, he addresses the need

for spiritual care in clinical facilities for the terminally ill to help relieve what he

calls “spiritual unrests” suffered by the patients. He writes, “these spiritual

unrests are caused by, as well as causing, loss of self-respect, self-abandonment,

attachment (e.g., reluctance, worries, ties and regrets), fear of death, and

8 “Taiwan Association of Clinical Buddhist Studies,” Accessed April 24, 2012,

http://www.tacbs.org/xms/. 9 Chen Rong-Chi, “The Spirit of Humanism in Terminal Care: Taiwan Experience,” pp. 7-11.


67

unfulfilled wishes.”10 TACBS aims to provide spiritual care for terminally ill

patients through the integration of core Buddhist wisdom into contemporary

medical care, helping thereby to render Buddhist spiritual care an essential

aspect in providing modern healthcare. He writes that based on their unique

religious and spiritual learning background, clinical Buddhist chaplains are able

to better interact with terminal patients and guide them on their journey to a

peaceful death.

The establishment of the TACBS is a prime example of modern Buddhist

social outreach with the aim of maintaining a lasting connection between modern

Buddhist monastics and physicians so they can work together to care for the

various needs of a dying patient. Thinking back to the studies that described

Taiwanese end-of-life needs, the TACBS mission statement directly addresses the

need to alleviate patient fear of death and to fulfill end-of-life wishes. What is

perhaps more interesting is in describing the various needs of hospice patients

Chen does not mention anything regarding funeral preparations or assistance in

the journey into the afterlife. In fact, he says quite the opposite stating that the

Buddhist chaplain is to guide terminal patients in their journey toward death. He

addresses a number of specific “spiritual unrests” experienced by patients, but is

not explicitly clear exactly what is meant by this term.

10 “Taiwan Association of Clinical Buddhist Studies,” Accessed April 4, 2012,

http://www.tacbs.org/xms/.


68

From what was discussed earlier with regards to the changing

perspectives of modern Buddhist groups regarding end-of-life, it seems possible

that Buddhist chaplains working in a clinical setting are not trained by the

TACBS to handle otherworldly matters. However, since ceremonies and rituals

involving the afterlife are commonplace in Taiwan, we know that Buddhist

monastic training already includes education on how to assist individuals with

these matters. This leaves the question, what exactly is taught in the Buddhist

chaplaincy programs offered though the TACBS? What is offered as far as

Buddhist doctrine, how does it relate to issues of afterlife attainment and how is

such training applicable to the clinical setting?

As we have seen so far in this paper, Taiwan’s recent implementation of

socialized healthcare has had great support from modern Buddhist outreach

programs that have undergone equally proportionate restructuring. Through

their extensive outreach activities, such groups have alleviated some of the

pressure on government agencies by providing programs to care for the sick and

dying. The wide range of services offered by these groups includes providing

mobile medical care to remote areas of the country, establishing modern

hospitals, providing in-hospital or outreach spiritual care for sick patients, and

centers to train spiritual chaplains to care for patients in hospitals. The success of

these services indicates that there is a thriving relationship between Taiwanese


69

modern Buddhist activities and the interests of modern medical facilities,

negating questions of the incompatibility of the two social entities. Care is

provided in the clinical setting, while Buddhist connections with supernatural or

otherworldly attainments are still recognized and accommodated in modern

Taiwan regardless of whether or not they fit within the reformed Buddhist view.

Considering what has been established thus far, what has yet been discussed is

exactly what Taiwanese clinical Buddhist end-of-life care is. Does the influence of

the clinical setting dictate the types of religious care that can be provided? How

are otherworldly practices still carried out and modified within the medical

arena? Which Buddhist tenants or doctrine is considered appropriate for modern

terminally ill patients? If Taiwanese Buddhist groups regard their beliefs as

compatible with biomedicine, how are new procedures and technologies

negotiated when they conflict with traditional practice? These questions will be

addressed in the eighth and final chapter of this research paper through an

examination of nine different articles on Buddhist chaplaincy written by

Taiwanese physicians.


70

Chapter 5:

Articles From The Taiwan Association For Buddhist Studies

In an attempt to answer some of these questions and to gain a clearer

understanding of how the care provided by Buddhist chaplains relates to both

Buddhist doctrine and modern medicine, the following chapter will review a

number of recent articles written by Taiwanese physicians directly addressing

the specific role and practices of Buddhist chaplains, as trained by the Taiwan

Association for Buddhist Studies (TACBS). Although these articles were written

and published in Chinese, their abstracts have been translated into English and

posted on the TACBS website. The website does not indicate in which scholarly

journals these articles were published in their original Chinese format, but each

of them was written by Taiwanese physicians working in NTUH. The following

sections of this final chapter will draw upon and discuss the various Buddhist

practices and beliefs outlined as beneficial to palliative patients, and how they

relate to the objectives of modern medical care. The studies also provide insight

into how modern bioethical issues regarding death and dying are contextualized

for the clinical Buddhist audience. In an attempt to organize these abstracts, they

will be grouped together and analyzed in terms of basic themes of discussion.

The first group of studies provides a basic outline of the role of Buddhist

chaplains in providing end-of-life care. The second group focuses on educational


71

role of the chaplain to teach patients and their families about the nature of life

and death and guide them to accept their inevitable fate. The third groups of

studies outlines specifically which Buddhist doctrine is recommended for caring

for terminally ill patients and their families and the last article discusses the role

of the clinical Buddhist chaplain in participating in end-of-life ceremonies.

Section 1: The Role of the Buddhist Chaplain

The first abstract from the TACBS website entitled, The Role of Clinical

Buddhist Chaplains in the Hospice/Palliative Care1, written by Tsung-Tueng

Bhikkhuni and her research team, delineates various aspects to the role of the

Buddhist chaplain in caring for the terminally ill. The first aspect is the

importance of guiding patients to accept their death as a natural course in life.

Symptom control is listed as the second priority of the chaplain including

physical discomfort, mental, social, or spiritual stress. The third is the necessity

for clear communication in an effort to acknowledge and understand specific

physical and mental needs as well as any spiritual needs of the patients. The final

aspect of the role of the chaplain is to work as part of a professional team

1 Tsung-Tueng Bhikkhuni, et al., “The Role of Clinical Buddhist Chaplains in the

Hospice/Palliative Care.”


72

consisting of doctors, nurses, psychiatrists, chaplains, social workers, volunteers,

etc. to provide patient-centered family-focus total care.

A second abstract entitled, The Spiritual Care for End-stage Cancer Patients

in Taiwan2, written by Chen, shares similar aspects to the first article in asserting

that providing care to Taiwanese palliative patients requires an understanding of

the unique needs of this population. To realize and satisfy these needs, role of the

caretakers is to work as part of the clinical team to alleviate psychological issues

associated with coming to terms with death, address physical discomfort,

accommodate the essential social relationships involved and provide appropriate

spiritual guidance.

Before unpacking the asserted role of Buddhist chaplains in providing

this care, it is important to discuss the distinct definition of “spirit” provided in

this study. As was mentioned in chapter one, chapter four and chapter six,

addressing the spiritual needs of an individual at end-of-life is not a simple task,

Taiwanese patients participating in research found it difficult to even describe

define “spirituality” as a concept. However in Dr. Chen Ching-Yu’s study, the

term is clearly defined. He writes, “for end-stage patients, the term “spirit” was

defined as the personal capability to recall, enlight (sic) and understand the

2 Ching-Yu Chen, “The Spiritual Care for End-stage Cancer Patients in Taiwan.”


73

Buddha’s teachings.”3 This is quite a distinct definition of the term with explicit

implications, if indeed this notion of spirit adequately reflects the sentiment of

Taiwanese Buddhist chaplains. Using the information again revealed in previous

research on end-of-life Taiwanese patients, needs that were identified as non-

physical or otherworldly reflected specific desires that were both Buddhist and

non-Buddhist in nature. To assume that the spiritual needs of a patient

necessarily entail understanding the Buddha’s teachings could lead to

inappropriately impose specific religious beliefs to a highly vulnerable

population who might not wholly subscribe to this set of beliefs. Patients nearing

their death could become convinced that their own beliefs are thereby incorrect,

potentially causing mental anguish and undue stress. At this time it is unclear

how this assumption, if it is indeed true, that “spirituality” is necessarily

Buddhist in nature affects Taiwanese chaplain care; however, more information

will be revealed as these studies are further examined.

Chen Ching-Yu’s study asserts that the Buddhist chaplain essentially

works to compliment or “upgrade” purely medical care as an essential aspect of

a system of complete care for mind, body, society and spirit of the patient. The

role of the Buddhist chaplain in clinical care is described as providing the four

major elements of hospice care to improve patient experience at end-of-life.

3 Ching-Yu Chen, “The Spiritual Care for End-stage Cancer Patients in Taiwan.”


74

These elements are: (1) helping the patient to accept death, (2) providing

humanistic care, (3) ensuring good communication, and (4) offering team care.

The framework of spiritual care in Taiwan is stated as consisting of informing

patients of their conditions and guiding them to accept death, helping the patient

experience and feel the existence of their spirit, and assist the patient in abiding

by and upholding the Buddhist Dharma as they approach death.

Although these two articles vary in their description of the role of the

Buddhist chaplain, they both emphasize the same basic elements in providing

complete care for dying patients and together they appear to satisfy a variety of

the needs identified by Taiwanese end-of-life patients in chapter six. The

elements as outlined in the first article unmistakably affirm the goals of modern

Taiwanese Buddhist movements and emphasize the importance of meeting the

unique needs that the terminally ill population may have; whereas the second

article draws a much clearer association with Buddhist doctrine and provides

more cause for thought. When it comes to the administration of Buddhist care

that emphasizes a focus on upholding Buddhist Dharma, it is important to

consider what aspects of Buddhist Dharma are being emphasized as appropriate

for end-of-life patients and how the Dharma is being administered to the public.

At the forefront, the role of the chaplain emphasized in these two articles

is to guide the patient to come to terms with and accept death. Not only does this


75

highlighted aspect of Buddhist chaplaincy directly address the predominant

issue of fear of death by asserting that, “Patients should be informed of their

illnesses and guided to accept death and be prepared for it”4, but it also

synchronizes the clinical objective with the role of the chaplain. The chaplain’s

responsibility toward this goal is asserted as clarifying that death is a natural

part of life, a concept that easily associated with early Buddhist and Daoist

doctrine, as was shown in chapter one.

Although outlining the role of the Buddhist chaplain as one who helps to

alleviate fear of death by promoting the acceptance and understanding, which is

a manner of thinking in keeping with Buddhist concepts, conceiving of life and

death in this way has generated interesting outcomes in the clinical setting in

Taiwan. The importance for Taiwanese Buddhist chaplains to guide terminally ill

patients to accept death has directly affected trends in Taiwanese bioethical

decisions regarding the implementation and perspectives toward such

biomedical notions as Do Not Resuscitate Orders (DNRs). A DNR is an

advanced care directive that indicates a patient’s wishes not to be resuscitated

when their heart or breathing stops and they are unable to communicate their

wishes5. Advocates from the Buddhist Lotus Hospice Care Foundation and the

TACBS were at the forefront of the promotion of legalizing the Natural Death

4 Ching-Yu Chen, “The Spiritual Care for End-stage Cancer Patients in Taiwan.” 5 Chen Rong-Chi, “The Spirit of Humanism in Terminal Care: Taiwan Experience,” pp. 7-11.


76

Act in Taiwan. In a 2009 article published by Chen Rongh-Chi, he endorses the

DNR as a means for bringing a peaceful ending for patients and giving the

patient and the family a form of gracious closure of a difficult life. He urges

medical professionals: “Do not neglect your solemn duty of helping [the] patient

[die] a good death. Please help the patient to make DNR planning in due time

and offer hospice care to the patient in need to ensure peaceful dying for each

patient.”6 Chen Rong-Chi ultimately states that maintaining a religious and

holistic spirit of removing suffering of patients and providing happiness includes

promoting patients to sign a DNR living will and training Buddhist monastics as

chaplains to serve in hospice care.

The idea that Buddhist chaplains should advocate that a DNR is

associated with a “good death” and that it is a way to show acceptance of death

clearly reinforces religious reformist ideas that Buddhist doctrine is compatible

with modern medical thinking. What is also evident from this example is that

Buddhist religious beliefs are being used to encourage public opinion on

biomedical decisions. Further, the fact that it was Buddhist groups that joined the

groups advocating for DNRs to be legalized in Taiwan shows the influence that

these groups have on public health policy.

6 Chen Rong-Chi, “The Spirit of Humanism in Terminal Care: Taiwan Experience,” pp. 7-11.


77

Proceeding from this first example comparing the articles by Tsung-

Tueng Bhikkhuni and Chen Ching-Yu, the subsequent elements outlined as

central to the role of the Buddhist chaplain can also be understood in relation to

reformed Buddhist thought. The specified aspect of Buddhists organizations

providing humanistic care to patients and their families while they are still alive,

and not simply assisting them in death, directly aligns with the Buddhist reform

movement as advocated by Taixu and Yinshun, therefore suggesting a lineage in

this matter.

The role of generating communication with patients and their families,

specified in both of the articles, simultaneously promotes social bonds and

addresses the issue of cultural taboos when discussing death. To advocate for

proper communication within the care team and with the patient and their

family directly addresses what numerous research studies have outlined as a

major bioethical issue for Asian end-of-life patients in modern medical facilities.

The issue of lack of communication between physicians, families and patients is

commonly associated with ideas of taboos around speaking of death, as

discussed in chapter one, and is currently regarded as not beneficial to patients

in terms of decision-making and overall psychological experience as they

approach death. While the topic of good communication was not specifically

associated with Buddhist ways of thinking in these articles, it is clear that the


78

Buddhist chaplain is responsible for promoting open discussion regarding the

issue.

The final aspect of care expressed in the article by Tsung-Tueng

Bhikkhuni, upholding the Buddhist Dharma as patients approach death,

identifies that chaplains should assist patients by employing a specific set of

ascribed beliefs that could prove problematic in end-of-life patients, as was

mentioned earlier. This is problematic for patients who do not subscribe to a

Buddhist worldview, and also to patients professes to subscribe to a Buddhist

worldview that does not necessarily correspond perfectly to the “spiritual” one

being advocated in this program.

It appears as though the Buddhist doctrine that is being advocated in the

training of Buddhist chaplains is greatly influenced by the teachings of the

Chinese reformer Buddhists outlined earlier. As we have already discussed, since

the beginning of the reform movement in Taiwan, guidance has come from

masters who advocate for the greater importance of assisting people in this

world and downplay Buddhist association with otherworldly beliefs. This

system of thought is clearly identified in chaplaincy training and the defined

clinical role of the Buddhist in end-of-life care in Taiwan.


79

Section 2: Buddhist Life and Death Education in the Clinical Setting

The next few articles posted by the TACBS discuss the important role of

education in the work of Taiwanese Buddhist chaplains. These articles specify

that the role of the chaplain is to integrate Buddhist teachings into education for

patients regarding the nature of life and death and to council families

emotionally through grieving the death of their loved one. What is perhaps most

interesting about these studies is that they all specify the importance of using

Buddhist doctrine to guide modern Taiwanese patients and their families, but no

explicit mention is made of the afterlife. Although reference to Buddhist doctrine,

specifically doctrine that related to death, implies an afterlife experience, these

articles outlining the role of the clinical Buddhist chaplain focus on how to use

Buddhism to help individuals in this world.

One article written by Der-Chia Bhikkhuni and her colleagues entitled,

The Application of Buddha’s Teaching in the Life and Death Education of Terminal

Cancer Patients’ Families7 provides an overview of the reasoning behind using

Buddhist doctrine to prepare and educate family members of end-of-life patients

and specifies more clearly the various actions that the chaplain role entails. Due

to the emotional anxiety felt by many family members, it is stated that one of the

7 Der-Chia Bhikkhuni, et al., “The Application of Buddha’s Teaching in the Life and Death

Education of Terminal Cancer Patients’ Families.”


80

goals of Buddhist chaplains is to provide life and death education that will

prepare families for the death of their loved one. For instance, the study

advocates the use of Buddhist teachings to guide families in understanding the

essence of impermanence and to break through the difficulties of life and death.

Also the role of the chaplain includes educating families on near death

symptoms so they can prepare for the experiences they will encounter with their

family member. Chanting Buddhist dharma at the time of death is specified as

important for many patients, as well as funeral consultation, and grief guidance.

The article emphasizes that providing these services lessens the family’s

anxiety while creating an acceptance of the illness. It is noted that if the family

can be lead to accept the death of their loved one then they can begin to consider

various consent orders, specifically DNRs, and finally help to participate in

creating a peaceful death for the patient. While this article provides a better

understanding of the activities that are associated with the work of the Buddhist

chaplain, and the practice of chanting with the dying patient is mentioned, a

more detailed account of what these activities entail and which Buddhist

teachings and practices are used in end-of-life care are discussed in the following

subsequent articles.


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Section 3: The Use of Buddhist Doctrine in End-of-Life Care

The next group of studies from the TACBS elaborates on exactly which

Buddhist doctrines and sūtras are used by chaplains and explains the particular

benefit that these teachings have for terminal patients and their families. In

particular, teachings from Bodhidharma, chanting the Buddha’s name at death,

specifically Amitabuddha or Amitabha Buddha, the Heart Sūtra, Sūtra of

Impermanence are described as specifically addressing the needs of end-of-life

patients and for their grieving families. Themes that are drawn upon from these

teachings are letting go of attachments, realizing that all things are impermanent

and more generally, using these teachings allows the Buddhist chaplain to open

up discussion on life and death.

The first of these studies, written by Hui-zhe Bhikkhuni et al., explains

that Buddhist chaplains are trained to guide patients through what is called

“clinical dharma talks”8. Clinical dharma talks are described as involving a

therapeutic review of one’s life with the guidance of the clinical Buddhist

chaplain. Reviewing one’s life entails affirming the meaning and value of life,

attaining end-of-life aspirations and moving towards spiritual growth. The use of

Buddhist dharma is stated as necessary for the patient as the means for the

patient to obtain liberation from suffering associated with death. The Buddhist

8 Hui-zhe Bhikkhuni, et al. “Clinical Dharma Talks During Life Review.”


82

dharma specifically mentioned as useful for the clinical dharma talk is a teaching

from the recently rediscovered text from Dun Huang 燉煌, which the study calls

the “Bodhidharma four-line concept” 達摩四行觀, (Damo sixing guan).9 What this

study is referring to is a teaching ascribed to the Indian sage Bodhidharma, who

is credited for bringing Chan to China. An English translation of this teaching

delineates how to follow the Buddhist path of practice, which is coupled with the

path of reason. The path of practice has four aspects, suffering injustice, adapting

to conditions, seeking nothing and practicing the dharma.10 The four aspects

outlined in Bodhidharma’s teaching are seen as important and appropriate

concepts to discuss with terminally ill patients, as such they can lead to

discussions on what it means to suffer, coming to terms with one’s current

condition and ultimately letting go of this life.

The second article from this group, written by Tsung-Tueng Bhikkhuni

and her colleagues, examines the practice of reciting the Buddha’s name at and

before death as a way to assist end-of-life patients in letting go and to assist to

comfort the family.11 In Chinese Buddhism, the practice of chanting the Buddha’s

9 Hui-zhe Bhikkhuni, et al. “Clinical Dharma Talks During Life Review.” 10 Red Pine, The Zen Teaching of Bodhidharma, pp. 3-8. 11 Tsung-Tueng Bhikkhuni, et al., “The Clinical Application of End-of-life Dharma Speech and

reciting Buddha’s name to Dying Patients.”


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name at the end of life is a popular Pure Land practice called nianfo 念佛12. Most

commonly throughout Chinese Buddhist death practices, the practice of chanting

the Buddha’s name has the particular purpose of assisting a dying person to be

reborn in the blissful Pure Land of Amitābha Buddha. However, in the study

from the TACBS the practice is only references as a method for alleviating

suffering in this world and there is no mention of attaining otherworldly rebirths

whatsoever. The practice of chanting the Buddha’s name is described as a way

for the clinical Buddhist chaplain to teach the patient to let go of their fear of

death, which was earlier outlined as a central cause for suffering in terminally ill

patients. Also, the chaplain is encouraged to invite patients' family members to

recite Buddha’s name for the deceased as a means of comfort them through the

process of grieving. This new way of conceiving of the practice is certainly a shift

in meaning from popular Pure Land practices that are focused around obtaining

an afterlife in Amitābha’s Pure Land. What is perhaps most interesting about the

use of this practice in clinical settings is that the purpose and meaning of the

popular practice of chanting the Buddha’s name at death would be very clearly

associated with otherworldly attainments by both the Buddhist chaplain and

those participating in the ritual chanting. It is probable that when writing this

12 Charles B. Jones, “Foundations of Ethics and Practice in Chinese Pure Land Buddhism,” pp. 2-

20.


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study those who are training chaplains highlight the worldly benefits of the

practice as a means to open the practice to a wider audience who do not

necessarily believe in an otherworldly Pure Land. It could also be argued that the

practice is being described in this manner to make it appear more compatible

with the clinical setting, where rebirth and Pure Lands are not recognized.

Tsung-Tueng Bhikkhuni and her colleagues authored the third study in

this group, which promotes the practice of applying the major principles of the

Buddhist Heart Sūtra as the simplest and most practical doctrine by which to

guide terminal cancer patients.13 The four major principles of the sūtra as

outlined by this study are dependent arising, suffering and the cessation of

suffering, contemplations on phenomena, and emptiness of all phenomena.

Based on the psychological needs of the patient, these four principles are

highlighted as particularly practical for helping people to accept their condition

and let go of this life.

The final article in this group by Tien-Lin Bhikkhuni et al. promotes the

Sūtra of Impermanence as beneficial in caring for terminally ill patients.14 In the

study it is emphasized that the teachings from this text help to transform fears of

death due to fear of loss, separation and hopelessness; indicating that patients

13 Tsung-Tueng Bhikkhuni, et al., “Implementation of Heart Sūtra in Spiritual Care of Terminal

Cancer Patients.” 14 Tien-Lin Bhikkhuni et al. “Clinical Application of the Sūtra of Impermanence in Life and Death

Education.”


85

who hold onto this life tend to suffer more emotional pain. The chaplain is

encouraged to use doctrine such as what is found in the Sūtra of Impermanence to

help patients let go and accept death as a natural as aspect of the life course,

thereby giving the patient more psychological strength and understanding to

break away from emotional pain.15

These four articles introduce some concepts from Buddhist teachings

deemed suitable for addressing the specific needs of today’s terminally ill clinical

patients. On a deeper level, an in-depth look at any of the suggested teachings

and practices might reveal notions of otherworldly attainments or notions of past

lives and reincarnation. However, the way that these Buddhist concepts were

described in these articles de-emphasizes specific concepts and instead stresses

their ability to timelessly correspond to anxiety about death in general. The next

study from the TACBS website that will be introduced presents a very different

approach to interpreting Buddhist text to assist today’s dying patients. Similar to

the previously discussed scenario where the Buddhist idea of letting go of this

life was used to promote DNRs in the clinical setting, this next study employs the

15 The Sūtra of Impermanence is actually the text recommended by Daoxuan in his commentary to

the Chinese Vinaya for assisting the final thoughts of the dying. Additionally, it is lectured on in

the Buddhist Colleague, which was established by Yinshun and was the principle text chanted

at his funeral. See Koichi Shinohara, “The Moment of Death in Daoxuan’s Vinaya

Commentary,” p. 126.


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Buddhist doctrine of the Lotus Sūtra to promote another socially and politically

contentious medical procedure, organ transplantation.

Included on the TACBS website is a study by Heng-Chu Bhikkhuni et al.

that supports clinical Buddhist chaplains to use the Universal Gate Chapter of the

Lotus Sūtra as a way to help patients overcome their fear of death.16 This study

relays that the importance of giving is emphasized in the Universal Gate Chapter

of the Lotus Sūtra and the Six Perfections is that they emphasize, “giving

fearlessness” 施無畏 (Shi wuwei ) which teaches individuals not to fear death. The

article proceeds to explicitly designate organ donation as a highly noble type of

“giving fearlessly” at death, tying the concept of overcoming fear of death with

specific notions of the very modern medical procedure of donating one’s organs

at death to someone else in need.

In the Universal Gate Chapter of the Lotus Sūtra the bodhisattva Guanyin is

described as the one who gives courage and “bestows fearlessness in times of

fearful calamity. For this reason everybody in this sahā world calls him

Abhayaṃdada (Giver of Fearlessness)”17. The sūtra states that with true faith in

the bodhisattva, all pain and suffering in death will dispel, “The pure seer

16 Heng-Chu Bhikkhuni et al., “The Clinical Application of the Universal Door Chapter in Lotus

Sūtra to Overcome Fear of Death in Terminal cancer Patients.” 17 Tsugunari Kubo and Akira Yuyama, “https://www.bdkamerica.org/default.aspx?MPID=81,” p.

298.


87

Avalokiteśvara will be a refuge when suffering distress or the misery of death”18.

However, within the chapter there is no mention of personal giving, or even a

broader teaching on giving up one’s body to serve another. On the contrary, the

text is focused on calling upon the power of the Bodhisattva Avalokiteśvara in

times of need.

The second doctrinal selection suggested in this study for promoting organ

transplantation, the Six Perfections, seems much more applicable. The Six

Perfections, “giving in charity, keeping the precepts, tolerating insults, diligence,

meditation, and wisdom, and ultimately gain the wisdom that transcends

death”19 emphasize the individual’s role in alleviating suffering. More

specifically, the first perfection of “giving in charity” or “the perfection of

giving” dāna-pāramitā is described as being of significant benefit to both oneself

and to others.20 This first perfection can be directly related to the notion of organ

donation, as the giving of one’s organs could potentially save the life of another.

In fact, the act of giving one’s body to benefit another is a fairly common theme

in Buddhist literature throughout its history. Within Indian Buddhist literature

18 Ibid. 19 Heng-Chu Bhikkhuni et al., “The Clinical Application of the Universal Door Chapter in Lotus

Sūtra to Overcome Fear of Death in Terminal cancer Patients.” 20 For an elaboration on the extensive benefits of the six perfections to oneself and to others see

Shi Xingyun, Of Benefit To Oneself And Others: A Critique Of The Six Perfections, pp. 7-21.


88

and tales of the Buddha’s previous lives, there are numerous examples of the

Buddha as a human being or an animal selflessly giving his eyes, flesh, blood or

entire body on behalf of someone in need.21 These stories are exemplary of the

Buddha’s utmost compassion for others and complete detachment from the

physical self.

In the modern world, the practice of organ donation is a complicated

bioethical concept in terms of Buddhist belief and still no consensus has been

reached as to how a Buddhist should understand such a situation. Buddhist

bioethics scholar Damien Keown addresses this very issue in depth in his 2010

paper, “Buddhism, Brain Death and Organ Transplantation”22. He notes that

organ donation can be considered a valuable opportunity on several levels, as a

way to sever attachment to one’s own body, to place another person’s welfare

above one’s own, etc. However, he states his serious reservations concerning the

current medical practice for Buddhists, writing, “This is not because Buddhism is

opposed to organ donation per se, but because it rejects the concept of “brain

death,” which is typically used to determine death prior to the harvesting of

organs”23. What Keown is referring to is the fact that the issue of organ donation

sits between two sets of prominent Buddhist based beliefs. On one hand there is

21 Reiko Ohnuma, Head, Eyes, Flesh, And Blood: Giving Away the Body in Indian Buddhist Literature,

pp. 199-241. 22 Damien Keown, “Buddhism, Brain Death and Organ Transplantation,” pp. 1-36. 23 Ibid.


89

the aspiration to become detached from the physical body as one approaches

death, coupled with a desire to compassionately help others in need. On the

other hand Buddhist practices surrounding death, which are both traditional and

advocated in modern days24, are not compatible with organ donation because of

requirements that the physical body not being touched for a set period of time,

usually for eight hours. Not touching the physical body is born the notion that

death is a transitional process rather than occurring in a singular moment and so

the individual needs time to allow the dying process to occur. Keown cites early

Buddhist sources emphasizing the “subtle body” made up of elements within the

body that take various amounts of time to dissipate. However, the biomedical

standard for determining the death of a person is based on the internationally

recognized neurological death that is determined as a single point in time.25

Organ transplantation is very time sensitive and in some cases, as in the heart

transplant, the organ needs to be fully functioning as it is taken from the body.

The standardized neurological death defines the moment of death to be based

solely on the functionality of the brain, allowing for other organs to be removed

from the patient while they are still functioning.26 Consequently, if the patient

does not subscribe to the notion of the neurological death, he is inclined to

24 Raoul Birnbaum, “The Deathbed Image of Master Honyi,” pp. 175-207. 25 Martin Smith, “Brain death: time for an international consensus,” pp. 6-9. 26 Martin Smith, “Brain death: time for an international consensus,” pp. 6-9.


90

believe that an individual is not yet dead when organs are being removed, which

would cause great pain and suffering. Keown argues that cutting up the body

while the subtle elements of the body are still present is equivalent to cutting up

a living person.

The perspectives of Buddhist groups in Taiwan vary regarding this issue,

in that some groups advocate that the compassion involved in organ donation

supersedes any negativity that might be involved, and there are others that

adhere to practices from traditional doctrine. The highly regarded Chinese monk

Hongyi, whose conservative ideas for Buddhist reform were introduced in

chapter two, gave a highly influential public lecture in 1933 on how to create a

positive end-of-life scenario.27 Hongyi’s public discourse on death was so widely

revered that it was quickly published and disseminated widely, the instruction of

which still resonates with Buddhists today. Hongyi stresses that the body should

not be handled under any circumstance for at least eight hours after the person

has died as the dying process lasts for numerous hours after the last breath has

been taken and intense pain is felt if the physical body is touched which will

distract the dying person as they transcend into another existence. Contrary to

this view, the Taiwanese Tzu Chi Buddhist group promotes organ donation as

27 Raoul Birnbaum, “The Deathbed Image of Master Honyi,” pp. 175-207.


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“one of the greatest gifts of life one can give”28, and Venerable Zhengyan has

spoken out publically in support of the procedure.

The article referencing the Lotus Sūtra interprets a Buddhist text to meet a

potentially contentious modern biomedical situation, even though conceiving of

the text in this way is contrary to traditional ritual behavior surrounding death.

This tactic appears to reflect the reformist spirit of Taixu who promoted that

Buddhism’s main concern is caring for people in this life. He believed that there

was a deep connection between Buddhist thinking and rationalistic science and

so promoted re-visiting Mahāyāna scripture and conceptualizing it in a way to

meet the needs of the modern world. Thus, taking the stance that it is more

important to donate organs in order to save someone in this world than to

adhere to traditional timelines for post-mortem practices also reflects the values

of a reformist Buddhist view.

However, the promotion of organ donation in modern Taiwan does not

mean that all dying patients adhere to modern interpretations of end-of-life, nor

does it indicate that Tzu Chi hospitals or Buddhist chaplains do not facilitate

traditional Buddhist practices of leaving a body untouched at death. Post-

mortem rituals including chanting with a body for a number of hours after death

28http://www.tw.tzuchi.org/en/index.php?option=com_content&view=

article&id=387%3Apass-on-the-love-organ-donation

http://www.tw.tzuchi.org/en/index.php?option=com_content&view=article&id=387%3Apass-on-the-love-organ-donation

http://www.tw.tzuchi.org/en/index.php?option=com_content&view=article&id=387%3Apass-on-the-love-organ-donation


92

is still practiced, and facilities are provided to accommodate such practices in

Tzu Chi hospitals and many other hospice settings.

Section 4: The Role of the Chaplain in Rituals at Death

The final article that will be examined from the TACBS website deals

specifically with the Buddhist chaplain’s role in the dying process. As far as the

discussion and questions that have been raised so far in this paper, regarding

modern Buddhist beliefs and practices at end-of-life, this last article will

ultimately shine some light on the role of the Buddhist chaplain at death.

Specifically, what is most important for this study is that it presents exactly how

the work of the chaplain differentiates from other monastics who may be

administering more traditional ritual care to the patient at this time.

This last article outlines the Buddhist chaplain’s role in delivering the

dead through Buddhist ceremonies and how to assist the family members of the

deceased.29 The study first indicates that there are two purposes of holding

Buddhist services to deliver the dead. The first one is to deliver the deceased to

the otherworldly Pure Land and the second one is to comfort the families of the

29 Man-Shyang Bhikkhuni et al., “Delivering the Dead with Buddhist Ceremonies and Guiding

the Family Members of the Dead.”


93

dead with Buddhist teachings. It is stated that the role of the clinical Buddhist

chaplain at the time of death is to alleviate the grief of the family using Buddhist

teachings, rather than to perform Buddhist service for the deceased.

The study states that if it is necessary, Buddhist chaplains trained by the

TACBS do in fact administer services to assist family members to spiritually

connect with the deceased within 49 days after their loved ones passed away, but

this is regarded as more of a service for the living as opposed to a service for the

dead. In accordance with the desire of the family members of the deceased, the

clinical Buddhist chaplains are taught to use various Buddhist doctrines to guide

the family members suffering from various issues. For example, for those who

feel worried or even sorry because they did not provide enough care for the

dead, the Repentance Liturgy of Emperor Liang or Water Repentance Liturgy are

recommended. For those who have a closer relationship with the deceased and

therefore have difficulties letting go, the Diamond Sūtra and the Heart Sūtra are

explained to be better choices. For those who believe in the Pure Land or those

who accept death and hope for a better future for the deceased, Amitābha Sūtra

and the Discourse on Samantabhadra Bodhisattva’s Beneficence Aspiration are said to

be usually selected. For the dead who had been sick for a long time or died an

untimely death, Amitābha Sūtra and the Medicine Buddha Sūtra and the Medicine

Buddha Repentance are often chanted.


94

A “proper Buddhist ceremony” for the deceased is considered beneficial

for the dead, but more importantly for the role of the chaplain, such ceremonies

are deemed as helping the surviving family members cope with their grief. In

Buddhist deliverance ceremonies, the most important role of the Buddhist

chaplain is not in performing the rite itself, but in guidance for the living. From

the clinical care perspective, Buddhist deliverance ceremonies extend the

patient’s spiritual growth before dying, promote the proper frame of mind

during death, and provide guidance for the surviving family members. This final

aspect of clinical Buddhist chaplaincy offers a compelling perspective of how

modern Taiwanese Buddhist groups understand their role in the end-of-life

experience. The article clearly addresses the fact that Taiwanese end-of-life

patients would like Buddhist otherworldly ceremonies for the dying and

deceased and that modern Buddhist practitioners participate in such rituals as

chanting Amitābha Buddha’s name. However, the article explicitly explains that

these rituals are performed at the request of the family and are meant more

importantly for the benefit of those remaining in this world as opposed to

assisting the deceased in otherworldly experiences.


95

Conclusion

The country of Taiwan has a thriving Buddhist population that is highly

influential in the social arena as outreach groups provide tremendous social

relief and public support programs. The vision of the predecessors of Taiwan’s

Buddhist movement was of a reformed Chinese Buddhism that would prove

itself relevant in modern society through actively contributing to the welfare of

the public. To realize this vision, reformist monks sought to change the public

image of Buddhism from a religion preoccupied with the afterlife and

otherworldly experiences to the neglect of the present life and society, to a

Buddhism that actively contributed to the wellbeing of people in this world. This

reformist vision took root in Taiwan through the leadership of numerous

influential activist monastics who brought ideas for a reformed and prosperous

Chinese Buddhism to life.

Modern Taiwanese reform and prosperity did not only come in the form

of religious movements, in recent years Taiwan has undergone a complete

political, economic and social revolution launching the country into modernity.

Along with modernist thinking, deemed as rationalistic and liberal-minded, one

might assume that Taiwanese ties to religious faith-based belief would dwindle,

but on the contrary the people’s affiliation with religious groups has only

continued to grow. Buddhist groups have developed into an essential part of


96

Taiwanese culture. Activist groups work to directly support the needs of the

public and in the case of healthcare needs, Taiwanese Buddhist groups engaged

in large-scale social relief far earlier and to a much greater degree than

government groups could initially provide.

The central focus of this paper was to examine the interaction between

modern Taiwanese Buddhist groups and their extensive support to bring

medical support to individuals as they approach death. The specific intrigue

behind this topic is that the public service of caring for the dead through end-of-

life and afterlife rituals has been the part of Chinese Buddhist tradition that has

been most prominent over the centuries. Yet this very service was the one treated

with the most distain by reformist Buddhist monks for their preoccupation with

funeral culture and lack of significant contributions to alleviate social problems.

Of all of the modern outreach services, it would appear as though Buddhist and

medical care for the dying would be completely incompatible.

To better understand exactly how Buddhist groups are providing support

to people as they die, this research paper surveyed the types of Buddhist end-of-

life care programs that have been established in Taiwan and how they’ve

developed in light of modern views of death and advances in biomedicine.

Findings showed that the Taiwanese medical community and Buddhist

organizations have made great efforts to work harmoniously in providing end-


97

of-life care that supports various patient needs at this time. Buddhist activist

groups facilitate the widespread provision of medical care, establish large-scale

modern medical hospitals and fund medical research. In turn, the medical

community embraces the religious beliefs of the Taiwanese population through

accepting Buddhist chaplains onto the medical team to provide spiritual support

for dying patients, and allowing for ritual end-of-life ceremonies to be performed

within the medical facility.

As far as medical public health policy, large-scale programs and

infrastructure, it appears as though there is a symbiotic relationship between

modern Buddhist groups and medical care in Taiwan. However after examining

a number of research studies surveying the expressed needs of Taiwanese

terminally ill patients, it became apparent that not all Taiwanese adhere to the

modernist Buddhist beliefs and still rely heavily on traditional Chinese views of

death and the afterlife. In fact, studies revealed that there is still a strong need for

religious ritual practices and guidance for afterlife experiences. Based on these

findings it would seem that Buddhist end-of-life care for the terminally ill that

was solely based on modern reformist beliefs would be inadequate for a great

number of patients. As such, this study looked at the specific services provided

by modern Taiwanese Buddhist groups that work within the medical arena,


98

comparing the objectives of these programs with the needs specified by

Taiwanese end-of-life patients.

What was essentially found was that modern Buddhist groups genuinely

embrace modernist perspectives in the medical arena and use traditional Chinese

Buddhist doctrine as inspiration to overcome modern challenges. In all of the

documentation found explaining the role of the Buddhist chaplain or the

Buddhist doctrine that was useful for end-of-life care, the main focus was on

helping the patient and their families deal with experiences in this life. Even

doctrine that is contextualized in otherworldly attainments was interpreted to

promote modern perspectives on death and referenced as broadly supporting

Buddhist notions of non-attachment to the physical body and the impermanence

of life. In some extreme examples Buddhist doctrine was even used to support

modern, bioethically contentious practices such as DNRs and organ

transplantation.

Throughout this research paper, initial skepticism of how religious

doctrine and practices regarding death could work inside a modern medical

facility were met with rational, practical solutions. For instance, the modern

medical facilities offering reformed Buddhist style care also facilitate ritual end-

of-life and afterlife ceremonies. And Buddhist doctrine is promoted as helpful for

the terminally ill population, but it is only advocated in reference to broad issues


99

of fear of death and learning to let go of this life. In one way, it could be argued

that today’s Taiwanese Buddhist groups are in fact preserving the most

important aspect of caring for the dying and that is affecting the final thoughts of

the patients. Through alleviating the anxiety and fear related with death and

reciting sutras, today’s Buddhist chaplains are indeed adhering to the main

criteria outlined in early texts written on the subject.

Final thoughts of this paper turn to new questions that have arisen and

will remain unanswered in this research paper. Essentially, evidence shows that

Buddhist ritual end-of-life and afterlife ceremonies are desired by the public and

are still widely practiced within Buddhist community. Since these practices are

downplayed in the reformed Buddhist movement in Taiwan they are also largely

ignored in public discourse on the topic and in the literature on activities of

Buddhist outreach groups. Investigation into the modern use of these practices

would make for fascinating future research.


100

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