Ministering to the Sick
and the Terminally Ill

On another occasion the Buddha discovered a monk whose body was covered with sores, his robe sticking to the body with pus oozing from the sores. Unable to look after him, his fellow monks had abandoned him. On discovering this monk, the Buddha boiled water and washed the monk with his own hands, then cleaned and dried his robes. When the monk felt comforted the Buddha preached to him and he became an Arahant, soon after which he passed away (DhpA.i,319). Thus the Buddha not only advocated the importance of looking after the sick, he also set a noble example by himself ministering to those who were so ill that they were even considered repulsive by others.

The Buddha has enumerated the qualities that should be present in a good nurse. He should be competent to administer the medicine, he should know what is agreeable to the patient and what is not. He should keep away what is disagreeable and give only what is agreeable to the patient. He should be benevolent and kind-hearted, he should perform his duties out of a sense of service and not just for the sake of remuneration (mettacitto gilanam upatthati no amisantaro). He should not feel repulsion towards saliva, phlegm, urine, stools, sores, etc. He should be capable of exhorting and stimulating the patient with noble ideas, with Dhamma talk (A.iii,144).

Here it is noteworthy that the nurse is expected to be efficient not only in taking care of the body by giving proper food and medicine, but is also expected to nurture the patient's mental condition. It is well known that the kindness of nurses and doctors is almost as effective as medicine for a patient's morale and recovery. When one is desperately ill and feels helpless, a kind word or a gentle act becomes a source of comfort and hope. That is why benevolence (metta) and compassion (karuna), which are also sublime emotions (brahmavihara), are regarded as praiseworthy qualities in a nurse. The sutta adds another dimension to the nursing profession by including the spiritual element in a nurse's talk. Sickness is a time when one is face to face with the realities of life and it is a good opportunity to instill a sense of spiritual urgency even in the most materialistic mind. Further, the fear of death is naturally greater when a person is ill than when well. The best means of calming this fear is by diverting attention to the Dhamma. A nurse is expected to give this spiritual guidance to the patient in his or her charge as a part and parcel of a nurse's duty.

In the Anguttara Nikaya the Buddha describes three types of patients (A.i,120). There are patients who do not recover whether or not they get proper medical attention and nursing care; there are others who recover irrespective of whether or not they get medical attention and nursing care; there are others who recover only with appropriate medical treatment and care. Because there is this third type of patient, all those who are ill should be given the best medical treatment available, agreeable food and proper nursing care. So long as a patient is alive, everything possible should be done for his recovery.

According to another sutta (A.iii,56,62), illness is one of the inevitables in life. When faced with it, all resources available to one, even magical incantations, should be utilized with the hope of restoring health. Here the question of whether such performances are effective or not is not discussed. The point seems to be that at the time of a crisis there is no harm in trying out even methods traditionally believed to be efficacious, but in which one does not necessarily have faith or belief. Of course, such methods should not clash with one's conscience. If, in spite of these efforts, death does occur, then one has to accept it as a verdict of kamma with equanimity and philosophical maturity.

Here we are reminded of an episode (MA.i,203) where a mother who was critically ill needed rabbit meat as a cure. The son, finding that rabbit meat was not available in the open market, went in search of a rabbit. He caught one but was loathe to kill even for the sake of his mother. He let the rabbit go and wished his mother well. Simultaneously with this wish, the power of the son's moral virtue brought about the mother's recovery. The Buddhist tradition seems to hold that under certain circumstances moral power has healing properties that may work even in cases when orthodox medicine fails.

The Medicines Chapter of the Vinaya Mahavagga (Vin.i,199ff.) shows that the Buddha relaxed a number of minor disciplinary rules to accommodate the needs of sick monks. Though a strict disciplinarian, the Buddha has shown great sympathy and understanding to those who are ill. The value of health has been fully realized and it is even recognized as the greatest gain (arogyaparama labha, Dhp.204).

The Buddha teaches that the patient too should cooperate with the doctor and the nurse in order to get well. Such a good patient should take and do only what is agreeable to him. Even in taking agreeable food he should know the proper quantity. He should take the prescribed medicine without fuss. He should honestly disclose his ailments to his duty-conscious nurse. He should patiently bear physical pain even when it is acute and excruciating (A.iii,144).

The suttas show that the Buddha exercised great will power and composure on occasions when he fell ill. He experienced excruciating pain when a stone splinter pierced his foot after Devadatta hurled a boulder at him. He endured such pain with mindfulness and self-composure and was not overpowered by the pain (S.i,27, 210). During his last illness, too, the Buddha mindfully bore up great physical pain and with admirable courage he walked from Pava to Kusinara with his devoted attendant Ananda, resting in a number of places to soothe his tired body (D.ii,128,134). The Maha-Parinibbana Sutta also reports that the Buddha once willfully suppressed a grave illness in Beluvagama and regained health (D.ii,99).

It seems that those who are highly developed mentally are able to suppress illness, at least on certain occasions. Once Nakulapita visited the Buddha in old age, and the Master advised him to remain mentally healthy even though the body is feeble (S.iii,1). There is physical and mental pain (dve vedana kayika ca cetasika ca). If, when one has physical pain, one becomes worried and adds mental pain too, that is like being shot with two arrows (S.iv,208). One who is spiritually evolved is capable of keeping the mind healthy proportionate to his spiritual development. As an Arahant is fully developed spiritually, he is capable of experiencing physical pain only, without mental pain (so ekam vedanam vediyati kayikam na cetasikam, S.iv,209).

A number of suttas advocate the recitation of the enlightenment factors (bojjhanga) for the purpose of healing physical ailments. On two occasions, when the Elders Mahakassapa and Mahamoggallana were ill, the Buddha recited the enlightenment factors and it is reported that the monks regained normal health (S.v,79-80). It is perhaps significant to note that all the monks concerned were Arahants, and had therefore fully developed the enlightenment factors. The Bojjhanga Samyutta also reports that once when the Buddha was ill, he requested Cunda to recite the enlightenment factors (S.v,81). The Buddha was pleased at the recitation and it is said that he regained health. On another occasion, when the monk Girimananda was very ill (A.v,109), the Buddha informed Ananda that if a discourse on ten perceptions (dasa sañña) is delivered to him, he might get well. The ten perceptions are the perception of impermanence, egolessness, impurity of the body, evil consequences (of bodily existence), elimination (of sense pleasures), detachment, cessation, disenchantment with the entire world, impermanence of all component things, and mindfulness of breathing. Ananda learnt the discourse from the Buddha and repeated it for Girimananda and it is reported that he recovered.

Once the Buddha heard that a newly ordained monk who was not very well known among his fellow monks was very ill (S.iv,46). The Buddha visited him. When he saw the Buddha approaching him he stirred in his bed and tried to get up, but the Buddha cautioned him not to rise. Having taken a seat, the Buddha inquired after his health, whether the pains are decreasing and not increasing. The monk replied that he is feeling very ill and weak, that his pains are increasing and not decreasing. The Buddha then inquired whether he had any misgiving or remorse. The monk replied that he had plenty of misgiving and remorse. The Buddha then asked whether he reproached himself for breach of virtue. He said no. Then the Buddha asked why he felt remorseful if he was not guilty of any breach of virtue. The monk replied that the Buddha does not preach the doctrine for purity of virtue, but for detachment from lust (ragaviragatthaya). Greatly pleased, the Buddha exclaimed Sadhu Sadhu in approbation.

The Buddha then went on to preach the doctrine to the monk. He explained that the sense faculties are impermanent, unsatisfactory and egoless, therefore they should not be considered as "I" and "mine." Understanding their true nature the noble disciple becomes disenchanted with the sense faculties. When this explanation of the Dhamma was being given the vision of truth (dhammacakkhu) dawned on the monk; he realized that whatever has the nature of arising necessarily has the nature of cessation. In other words he became a sotapanna, a stream-enterer.

According to the Sotapattisamyutta Anathapindika was once very ill, and at his request the Venerable Sariputta visited him (S.v,380). On being told that the pains are excruciating and increasing Sariputta delivered a discourse reminding Anathapindika of his own virtues. Sariputta explained that the uninstructed worldling who has no faith in the Buddha, Dhamma and Sangha and who has not cultivated virtuous moral habits goes to a state of woe on the destruction of the body. But Anathapindika has unshakable conviction in the Buddha, Dhamma and Sangha, and has cultivated noble moral habits. Sariputta told him that when these noble qualities are mindfully appreciated the pains would subside.

Further, Sariputta pointed out that uninstructed worldlings reach a state of woe on the disintegration of the body as they have not cultivated the Noble Eightfold Path. But on the contrary Anathapindika has cultivated the Noble Eightfold Path. When attention is paid to them and the noble qualities are appreciated the pains would subside. It is reported that the pains subsided and Anathapindika recovered from that illness. So much so, that Anathapindika got out of bed and served the Venerable Sariputta with the meal that was prepared for himself.

The Sotapattisamyutta records an account of another occasion when Anathapindika was ill (S.v,385). The Venerable Ananda was summoned to the bedside and he delivered a discourse. Ananda explained that uninstructed ordinary people who have no faith in the Buddha, Dhamma and Sangha and who are given to immoral habits are seized with trepidation and fear at the approach of death. But the noble disciple who has deep conviction in the Buddha, Dhamma and Sangha and who has cultivated moral habits does not experience trepidation and fear of death. Anathapindika then confessed unshakable conviction in the Buddha, Dhamma and Sangha, and declared that he is endowed with the spotless virtue of a householder. Ananda exclaimed that it is indeed a great gain that Anathapindika has disclosed the attainment of the fruit of stream-entry. It is, however, not reported whether Anathapindika recovered straight away.

The Buddha recommends that a monk should not relax his energy and determination for spiritual progress even when he is ill (A.iv,335). It is possible that the illness might deteriorate, and before that happens care should be taken to advance spiritually as much as possible. After recovering from an illness, too, one should not be negligent, because, should there be a relapse, the chances of gaining higher spiritual attainments diminish.

The Buddhist method of ministering to the sick, as is evident from the canonical texts cited above, attaches great importance not only to proper medical and nursing care, but also to directing the mind of the patient to wholesome thoughts. There seems to be a belief that attention paid to doctrinal topics, especially the recitation of virtues which one has already cultivated, is endowed with healing properties. In the case of the Buddha and Arahants the recitation of the bojjhangas has restored normal health. In the case of the monk Girimananda, who was probably not an Arahant at the time of his illness, it was a discourse on the ten perceptions that restored his good health. Anathapindika was a sotapanna and a discussion on the special qualities of a sotapanna was instrumental for his speedy recovery. It may be that when one is reminded of the spiritual qualities one has already acquired, great joy arises in the mind. Such joy is perhaps capable even of altering one's bodily chemistry in a positive and healthy manner.

Here we are reminded of a relevant episode contained in the Papañcasudani (MA.i,78). A monk while listening to the Dhamma was bitten by a snake. He ignored the snake bite and continued to listen. The venom spread and the pain became acute. He then reflected on the unblemished purity of his virtuous conduct (sila) from the time of his higher ordination. Great joy and satisfaction arose within him when he realized the spotless nature of his character. This healthy psychological change acted as anti-venom and he was immediately cured. These episodes seem to reveal that when attention is drawn to one's own spiritual qualities at times of serious illness, and pious joy wells up in the mind thereby, health-promoting factors become activated in the body, perhaps by way of the secretion of health-restoring hormones. That may be the mechanism by which spiritually advanced individuals regain health when appropriate suttas are recited.

There is much material in the Pali Canon on counseling the terminally ill. Speaking about death to a terminally ill patient is not avoided as an unpleasant topic. On the contrary, the reality of death and perhaps its imminence are accepted without any pretense and the patient is made to face the prospect of death with confidence and tranquillity.

The advice given by Nakulamata to Nakulapita is extremely valuable in this connection (A.iii,295-98). Once Nakulapita was seriously ill and his wife Nakulamata noticed that he was anxious and worried. She advised him thus: "Please, sir, do not face death with anxiety. Painful is death for one who is anxious. The Buddha has looked down upon death with anxiety. It may be you are anxious that I will not be able to support the family after your death. Please do not think so. I am capable of spinning and weaving, and I will be able to bring up the children even if you are no more. Perhaps you are worried that I will remarry after your death. Please do not think so. We both led pure wholesome lives according to the noble conduct of householders. So do not entertain any anxiety on that account. It may be you are worried that I will neglect attending on the Buddha and the Sangha. Please do not think so. I will be more devoted to the Buddha and the Sangha after your death. Perhaps you are worried that I will neglect keeping to the precepts. Please do not have any doubts on that account. I am one of those who fully practice the moral habits declared for the laity, and if you wish please ask the Buddha about this matter. Perhaps you fear that I have not gained inner mental composure. Please do not think so. I am one of those who have gained inner mental composure as much as a householder could gain. If you have any doubts about this, the Buddha is at Bhesakalavana, ask him. Perhaps it occurs to you that I have not attained proficiency in the Buddha's dispensation, that I have not gone beyond doubt and perplexity without depending on another. If you wish to have these matters clarified ask the Buddha. But please do not face death with anxiety, for it is painful and censured by the Buddha." It is reported that after Nakulapita was thus admonished by Nakulamata, he regained his health, and gone was that illness never to recur. Later on this whole incident was narrated to the Buddha, who commended Nakulamata for her sagacious advice.

The Sotapattisamyutta contains a valuable discourse on the question of counseling the terminally ill (S.v,408). Once Mahanama the Sakyan inquired from the Buddha how a wise layman should advise another wise layman who is terminally ill. Here it should be noted that both the counselor and the patient are wise lay Buddhists. The Buddha delivered a whole discourse on how this should be done. First, a wise layman should comfort a wise layman who is terminally ill with the four assurances: "Be comforted friend, you have unshakable confidence in the Buddha, Dhamma and Sangha, that the Buddha is fully enlightened, the Dhamma is well proclaimed, and the Sangha is well disciplined. You also have cultivated unblemished virtuous conduct which is conducive to concentration." Having thus comforted the patient with the four assurances, he should ask him whether he has any longing for his parents. If he says yes, it should be pointed out that death will certainly come whether he has longing for his parents or not. Therefore it is better to give up the longing. Then, if he says he gives up his longing for his parents, he should be asked whether he has longing for his wife and children. With the same reasoning he should be persuaded to give up that longing too. Then he should be asked if he has any longing for the pleasures of the senses. If he says yes, he should be convinced that divine pleasures are superior to human pleasures, and should be encouraged to aspire for divine pleasures. Then he should be gradually led up the scale of divine pleasures and when he comes to the highest heaven of the sense sphere, his attention should be diverted to the Brahma-world. If he says he has resolved on the attainment of the Brahma-world, he should be admonished that even the Brahma-world is characterized by impermanence and the rebirth personality. Therefore it is better to aspire for the cessation of the rebirth personality. If he can establish his mind on the cessation of the rebirth personality, then, the Buddha says, there is no difference between him and the monk who is liberated.

This, no doubt, is the highest form of counseling that can be given to a highly advanced person who is terminally ill by an equally spiritually advanced person. It is very clear from the discourse that the patient must be one who is as advanced as a stream-enterer, as the four assurances or the consoling factors mentioned at the very beginning of the discourse are identical with the qualities of a stream-enterer.

The Cittasamyutta contains an interesting episode of the death of a spiritually advanced learned lay disciple (S.iv,302). Citta the householder was a non-returner (anagamin, A.iii,451). When he fell critically ill, a group of sylvan deities invited Citta to set his mind on becoming a universal monarch (cakkavattiraja) because the aspirations of the virtuous come to pass. He refused, saying that that too is impermanent. Though lying on his deathbed he admonished his relatives, who had assembled round him, on the importance of cultivating faith in the Buddha, Dhamma and Sangha, and on the importance of charity, then he passed away.

According to the Sotapattisamyutta the Buddha once visited the bedside of Dighavu the lay disciple who was terminally ill (S.v,344). The Master advised him to fix his attention on unwavering confidence in the noble qualities of the Triple Gem and to will that he be endowed with spotless virtuous conduct. Dighavu replied that these qualities of a stream-enterer are already found in him. Then the Buddha advised him to be established in those virtues and develop the six qualities conducive to understanding, namely, the perception of the impermanence of all component things, the unsatisfactoriness of all that is impermanent, the egolessness of what is unsatisfactory, the perception of elimination, detachment and cessation. Dighavu replied that these qualities too are found in him, but he is concerned that his father will be sad when he dies. Then Jotipala, his father, advised him not to be worried on that account, but to pay heed to what the Buddha says. The Buddha, having admonished him, left and Dighavu died soon after. Later the Buddha declared that Dighavu passed away as a non-returner.

The brahmin Dhananjani was an unscrupulous tax collector who exploited both the king and the public (M.ii,184-96). The Venerable Sariputta met him once and exhorted him on the evil consequences of an unrighteous life. Shortly thereafter Dhananjani was seriously ill and Sariputta was summoned to his bedside. On being inquired about his health, Dhananjani informed Sariputta that he has an unbearable headache. Sariputta then engaged him in a conversation gradually drawing his attention from lower to higher realms of existence as far as the Brahma-world. Having thus diverted the attention of the near-death patient to the Brahma-world, Sariputta went on to explain the path leading to the attainment of the Brahma-world, namely, the full development of the brahmaviharas -- loving kindness, compassion, altruistic joy and equanimity -- to suffuse all quarters. At the end of the discourse Dhananjani requested Sariputta to convey his respects to the Buddha. Sariputta departed and shortly afterwards Dhananjani died. It is reported that he was reborn in the Brahma-world. Later when the matter was related to the Buddha, he found fault with Sariputta for not having led Dhananjani further on the spiritual path.

This sutta shows that a man who had been unscrupulous in his dealings could also be guided to a happier rebirth by counseling during the crucial period just prior to death. It is highly doubtful whether any and every evil doer could be thus guided towards rebirth in a happy realm. Perhaps Dhananjani's good qualities outweighed his evil deeds (Dhp.173) and that may be the reason why it was possible to lead him to rebirth in a happy state by counsel offered by a noble Arahant at the hour of death.

That this may have been so can be inferred from the facts reported in the sutta (M.ii,185). Sariputta made it a point to inquire about Dhananjani's spiritual zeal, soon after inquiring about the Buddha's health, from a monk coming from Rajagaha, when he himself was touring in the far away Dakkhinapatha. It is very likely that Dhananjani was a faithful patron of the Sangha when his first wife, a lady full of faith, was alive. His second wife was a faithless woman. When Sariputta heard that Dhananjani was negligent he was dismayed, and made up his mind to talk to Dhananjani should the occasion arise to meet him.

Another important noteworthy feature in this discourse is that the Venerable Sariputta starts the discourse from the lowest state of existence, and works upwards as far as the Brahma-world. Perhaps he started from the hells because Dhananjani had deteriorated to that level. Sariputta may have helped to remind him of his former good deeds, and also may have drawn his attention to a relevant Dhamma discourse Sariputta had delivered to him, perhaps only a few days prior to his illness. Thus by drawing on the spiritual potential that was hidden in him, Sariputta may have been able to help Dhananjani attain a happy rebirth by last minute counseling.

Here we are reminded of the episode of young Mattakundali (DhpA.i,26). When he was lying on his death-bed the Blessed One appeared and Mattakundali, being greatly pleased, generated much faith in the Buddha. Dying soon after, he was reborn in a celestial realm.

A sutta in the Sotapattisamyutta (S.v,386) maintains that when an uninstructed ordinary person at the threshold of death sees that he has no faith in the noble qualities of the Buddha, Dhamma and Sangha, and that he has led an immoral life, great fear of death and trepidation arise in him. But a person who has deep unwavering faith in the noble qualities of the Triple Gem, and who is spotlessly pure in his conduct, experiences no such fear of death and trepidation. It seems to be the guilty conscience that causes much anguish at the moment of death. When there is fear and anxiety at this crucial moment rebirth must take place in a sphere that is proportionate and commensurate to that experience of anguish.

It is appropriate to record here a relevant discussion Mahanama the Sakyan had with the Buddha regarding the fate of one who meets with a violent death (S.v,369). Mahanama tells the Buddha that when he comes to the serene atmosphere of the monastery and associates with pious monks of noble qualities, he feels quite calm and self-possessed. But when he goes out into the streets of Kapilavatthu, busy with constant traffic, he feels frightened over the future birth that would await him should he meet with a violent death in a traffic accident. The Buddha assures him that a person who has cultivated moral virtues and led a righteous life need not entertain such fears. He explains the situation with the help of a simile. If a pot of ghee is broken after being submerged in water, the potsherds will sink to the riverbed, but the ghee will rise to the surface. Similarly, the body will disintegrate, but the cultured mind will rise up like the ghee.

It is the same idea that is emphasized in suttas such as Sankharuppatti, (M.iii,99) Kukkuravatika (M.i,387) and Tevijja (D.i,235). Rebirth usually depends on the thoughts that are most often entertained during a life-time. If one entertains thoughts and dispositions that are suitable for an animal, for a dog or a cow as given in the Kukkuravatika Sutta, then it is likely one will be reborn among these animals, i.e. among beings who have similar dispositions. If, on the other hand, one has entertained thoughts and dispositions comparable to those among the Brahmas, by the cultivation of sublime emotions such as universal love and compassion, one has a good chance of being reborn among the Brahmas. Therefore preparation for death really has to be done while living. Even to be guided in thought to a higher rebirth when death is imminent one needs the prior requisite of faith in the ideal of human virtue and understanding -- for this is what is meant by having faith in the Buddha, Dhamma and Sangha -- and the cultivation of moral habits. If one lacks virtue, guidance of thought patterns at the hour of death to a higher level will be difficult to the extent that one is deficient in virtue. But however difficult and effective the actual guidance may be, it is a Buddhist custom to invite a monk to the bedside of a terminally ill patient with the hope that the chanting of certain protective suttas (paritta) will help the patient to develop faith and elevate his thoughts to a higher plane of spirituality.

We are reminded here that, according to the Vinaya (iii,8), some previous Buddhas such as Vessabhu, whose dispensations did not last long, used to instruct their disciples by looking into their minds with telepathic powers and guiding their thought patterns thus: "Think thus, do not think thus, pay attention thus, do not pay attention thus, give this up, develop this," etc. Perhaps this may be the technique used by Gotama Buddha and his eminent disciples to guide thought patterns of amenable adherents at the hour of death. They seem to have mainly used more general techniques with lengthy doctrinal discourses at other normal times in preference to guided meditation with insight into the thought patterns of individuals.

The question may arise of how effective spiritual guidance will be if the terminally ill patient is unconscious. Here what is actually important is that we are really unaware of the patient's mental condition at the hour of death. The doctors and onlookers might conclude that the patient is unconscious because he does not respond to his surroundings and to the questions put to him. His five faculties may have become partly or completely defunct, but nobody can be certain whether or not his mental faculty is active. We certainly do not know what special potentialities the mind harbors on the occasion of death. It is quite likely that the mental faculty is most active at this crucial hour. Perhaps this is the time that one has the most violent mental struggle, yearning for life with the firm habitual resistance and protest against death.

It is our conjecture that yearning for life is greatest when the fear of death is greatest. The fear of death is greatest when one's sense of guilt is greatest, the fear that one has squandered the great opportunity of human life, an opportunity which could have been well utilized for spiritual growth. If, on the other hand, one has well utilized the opportunity of human life for spiritual growth, one can face the inevitability of death with relative calm, contentment and happy satisfaction. One's rebirth seems to be commensurate with one's spiritual potential, which in Buddhist terminology is called kamma.

It is appropriate to conclude this essay by giving thought to what we should do when we visit a terminally ill patient. Our normal attitude is one of sadness and pity, but Buddhism holds that it is wrong to entertain negative thoughts at such a moment. It is my opinion that it would be helpful to the terminally ill patient, and to any patient for that matter, if we radiate thoughts of metta, loving kindness to him. As the dying person's mind may be working at this crucial hour, unencumbered by the limitations imposed by the physical sense faculties, it is possible that the person's mind will be sensitive and receptive to the spiritual thought waves of those around him. If negative thought waves are generated by grief and lamentation the dying person may be adversely affected. But if gentle thoughts of love and kindness are extended, such thoughts may function as a subtle mental balm that allays the distress and anxiety brought on by the approach of death and envelops the dying person's mind in a warm protective cloak of consoling peace.

Abbreviations

A ..... Anguttara Nikaya
D ..... Digha Nikaya
Dhp ..... Dhammapada
DhpA ..... Dhammapada Atthakatha
M ..... Majjhima Nikaya
MA ..... Majjhima Nikaya Atthakatha
S ..... Samyutta Nikaya
Vin ..... Vinaya Pitaka

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