Meditation is widely believed to offer many benefits for mental and physical health, but the very premise of Buddhism, known as the first noble truth, is the inevitability of sickness, old age and death. In this panel discussion, four Buddhist health practitioners talk about how relaxing our hopes and fears about health can lessen our suffering and help us recognize that whatever happens, our true nature is always healthy.
Lion’s Roar: Overall, we’re trying to find out what Buddhism has to say about health. Perhaps we could start by talking about physical health. Yoga, for instance, and some other types of spiritual practice are often connected with physical health, longevity and vitality. Is that something that Buddhist practice offers?
Jan Chozen Bays: Jon Kabat-Zinn has done very good research on many types of illness and shown that mindfulness meditation does have an effect on physical health and well-being. Those studies are published in peer-reviewed journals, so they are pretty credible. There are specific ailments where mindfulness has been shown to be helpful. Kabat-Zinn’s work on psoriasis, for example, is pretty compelling.
Lion’s Roar: How precisely does mindfulness offer health benefits?
Jan Chozen Bays: Mind and body are intimately connected, and if any physical illness causes the mind to be anxious and stressed, that will have a negative impact on the body. However, I don’t think we know by what mechanism mindfulness brings about a given effect.
Mitchell Levy: You could describe mindfulness as a form of preventive medicine. We are often pushing ourselves and ignoring the messages our body gives us. Mindfulness provides the opportunity to see when we are pushing ourselves in a direction that is likely to lead to worsening health.
Barbara Rhodes: The point of Zen meditation is to be attentive, and if you are attentive, mind and body are one. You would notice if there is ill health and do something about it. That might involve getting help from another person or changing your own life. The more attentive you are, the sooner you would be aware of any dis-ease, and that is more healthy in and of itself.
We were taught by my teacher, the Venerable Seung Sahn, to ask each situation, each person, each thing: “How may I help?” When you are doing that, it sends an incredibly healthy message to all your body’s cells. You are living not for yourself, not for your body, but to be a bodhisattva. When you are with someone, you are a part of the whole body of other people, not just the person in front of you. When you help them, you are helping yourself.
Lion’s Roar: How would you characterize Buddhism’s overall view of or attitude toward health?
David Shlim: There seems to be a paradox in the Buddhist view of health. On the one hand, we are taught how precious our human birth is and that we need to take advantage of that. On the other hand, we are taught not to be too attached to our body and to focus on training our mind. Of course it makes sense to take care of the body, yet teachers I have met don’t emphasize it much.
I was taking care of the great meditation teacher Tulku Urgyen Rinpoche, who died in 1996. The first time I met him he was having a heart attack. This was back in the eighties when the Type A personality’s relationship to heart attack was first being bandied about. So my partner asked him, “Why are you having a heart attack? What stress do you have if you practice so much meditation?” Tulku Urgyen said that there are in fact yogic practices that can have a strong impact on health and longevity, but you have to work at them pretty hard and in the end your body dies anyway. So he felt he would rather use his time to work on stability of mind.
Jan Chozen Bays: You take care of your body to the extent you can, but still there is illness. The Buddha himself had illness. He suffered from back pain and dysentery, at the very least. He got old and said to Ananda at one point, “This old cart is barely held together.” He died at a normal age, in his eighties. He didn’t seem to use supernatural powers to prolong his life. He did say at various points that he thought it would be advantageous for people he was working with if he lived a little longer.
Barbara Rhodes: It can be quite dangerous when people think that by being psychically clear and physically fit that they should be disease-free. The point is not so much whether a person is sick or healthy, but how they work with illness. If they do get cancer, let’s say, and are able to stay with it and do what they can without the hindrance of being frightened, perhaps they can die gracefully. Your body is not healthy but you are not afraid and you do what you can.
Mitchell Levy: People can fall into the trap of thinking you can use practice to avoid and circumvent health concerns. Yes, meditation can help you work with your health better, but there is a real trap in thinking that a good practitioner is going to be physically healthy by definition.
Jan Chozen Bays: Genuine health arises from how we hold the inevitable experiences of pain, aging and death in our hearts and our bodies. It is mind that adds the suffering to it, for example, through anxiety about the past: if only I had had a colonoscopy or a mammogram or if I hadn’t smoked. Then, there is fear about the future: will I be in pain or will I be alone when I die? If we can just be present with the experiences and not personalize them, we can remove what Buddha called the second arrow. The first arrow is the sensation and then there’s what the mind adds to it. If we remove that second arrow, the suffering is reduced greatly. With the mind out of the way, the body has amazing resources that can reduce the pain and sometimes heal the body. But there are no guarantees.
Lion’s Roar: It is interesting that Buddhism has much to say about working with ill health, suffering and dying, but apparently little to say about good health.
David Shlim: In Tibetan medicine, all illness goes back to the three mind poisons: attachment, anger and indifference. So long as those are present in the mindstream, a being will suffer some physical illness. It also considers the karmic causes of illness that relate to conditions prior to one’s birth. So, it doesn’t take the position that at birth everybody has equal potential to be healthy and if you just practice and eat a certain way you will be without illness. That may be one reason why good health as a prime objective is not a central feature in the Buddhist conversation about health.
Jan Chozen Bays: Buddhism doesn’t say much explicitly about good health but if you look, it is there. The Buddha’s basic teaching on health was the four foundations of mindfulness. It starts with full awareness of the body, and many people are unconscious of their bodies. All of us, in fact, separate from our bodies somewhat while sleeping and we have to bring the mind’s awareness back into the body in the morning when we get up.
The second foundation is full awareness of the feeling tone with which we approach life—positive, negative or neutral. It is very important to detect negative feelings toward our body and mind, as well as the bodies and minds of others. Doing so can certainly improve our health.
Then, we have the third and fourth foundations—full awareness of the ground of mind itself, and awareness of mind objects. When we can hold awareness of the clear, bright, huge mind and only think when necessary—maybe ten percent of the time—we are healthy. We don’t really need to think so much.
Part of being healthy, according to the Buddha, also has to do with love, having a good heart and a kind attitude toward everyone. We are healthy when we can be at ease in the body and enjoy arising sensations.
Mitchell Levy: The four foundations are another expression of a kind of preventive medicine. We deepen mindfulness and so we can pay attention to our body-mind. The mindfulness practices have nothing to do with helping one to live forever, though. We all seem to be saying that Buddhist health is not really about being physically healthy. Along with that we have the belief that when we are spiritually healthy, it does permeate our body and allow us to pay more attention and avoid things that are likely to make us sicker. But practice is not a cure.
Lion’s Roar: It might be instructive to consider health in terms of Buddhism’s two truths: absolute and relative truth.
Mitchell Levy: In fact, we have been talking about that already. From a relative health point of view, we’ve been saying in various ways that Buddhism’s view of health is to encourage us to begin to accept the inevitability of old age, sickness and death. It means looking at your habitual patterns and seeing where you worsen your dis-ease. But from a relative point of view we can’t really avoid illness. It happens.
On an absolute level, however, there is a fundamental state of mind that is open and natural and healthy. It is possible even in the midst of intense illness and the dying process to contact this fundamentally pure and wholesome state of mind. However, many people confuse contacting that fundamental healthy state of mind with using it to avoid disease, as opposed to letting it allow you to feel better about the illness that inevitably happens.
Lion’s Roar: Practice may not be a cure, but can it give you a different relationship to physical pain, perhaps lessen it?
Jan Chozen Bays: When I was first beginning Zen practice, several Zen teachers had died of cancer, Suzuki Roshi and Katagiri Roshi among them, and that puzzled me. Apparently Suzuki Roshi said about the cancer at one point, “Well, it wants to live too.” His untroubled state of mind about having cancer saw cancer as a form of life. It was just cells that had gotten out of control. Perhaps when you don’t separate from the cancer, you suffer much less.
I have had students who have had experiences of great pain, but when the mind is very quiet, time seems to stretch and things are moving very slowly, so the moment of sensation and the discomfort are separated by empty space. Each one is experienced discretely. As a result, the usual experience of pain is not there. The sensation of pain comes from connecting all those moments. When they are not connected, when the mind is open and spacious and experiences are separate, it isn’t pain anymore.
Mitchell Levy: From a physiological point of view alone, what we see as different pain thresholds probably has to do with the degree to which people are intuitively doing what Jan just described. There is no question that people can exercise a great measure of control over their sensation of pain. That is a little off-message, though, because the more important thing to say to people is not to try to get rid of the pain, but to find a way to work with the pain, to work with the illness. That is the most important message we can give practitioners about the relationship between mindfulness and their illness or their health. We are not trying to avoid or get away from anything.
David Shlim: The Buddha did teach ways to get beyond suffering. We have seen examples of high lamas—I took care of many as I lived in Nepal for fifteen years—who didn’t experience suffering from very severe illnesses, like pancreatic cancer, liver cancer and so on. It shows that the teachings actually are effective. If our goal is to get beyond suffering, which is a different goal from having physical health, certainly Buddhism is extremely effective, if you have good instruction and apply it.
Lion’s Roar: Many Buddhist teachers have let us know that the point is not just to live as long as possible. Yet we clearly have the desire, which seems valid, to maintain our health and not die prematurely. Where is the balance?
Barbara Rhodes: My teacher likened the body to a car. It’s your vehicle and if you just keep it in the garage, it is not doing any good. If you shine it, wax it, wash it, admire it, take photographs of it and never use it, what’s the point? Just get it out there, and if you need to go into a ditch to help someone, you go into the ditch. You need to drive it, and if you forget to change the oil, do it as soon as you remember. The car is not important; it’s where the car is heading that counts.
Mitchell Levy: Chögyam Trungpa Rinpoche used to talk a lot about hope and fear. The thirst for longevity or the thirst for youth is a form of being stuck in hope and fear. If we equate our health or our sanity with being young and good-looking, or, for that matter, living a long time, that distracts us from deeper work. If that work is to discover and deepen mindfulness and awareness, then getting distracted by our hopes and fears around physical well-being prevents us from accessing that fully.
I took care of His Holiness the Sixteenth Karmapa for a period in the latter years of his life. He died before he was fifty. It was clear to everybody that his dying wasn’t a good or bad thing. It was just so. He was giving so much of himself that it wasn’t a tragedy that he was dying young; it was rather a tragedy that he wasn’t going to be able to teach more. That is a different thing, though, from striving for longevity.
Lion’s Roar: What about the average person, who might have children they would like to help to raise and good work they have yet to do? How do they relate to health and longevity?
Barbara Rhodes: Soen Sa Nim was fond of talking about “don’t-know mind.” It doesn’t know if you will be alive tomorrow, which makes you enjoy every minute with your children more, but also have the desire to live longer and be a good parent to your children. There is a story of a dying Zen master. The students go to him and say, “Please give us your words, oh master,” and he whispers to them, “I don’t want to die.” They draw back in horror, thinking his mind must be addled by the illness, but when they come back the next day for some words of wisdom, he says the same thing. He didn’t want to die; he had more work to do.
David Shlim: Many people in the United States and Europe are teaching spirituality aimed at maintaining perpetual good health. The idea of impermanence, that sooner or later these efforts will fail, is not taught. It is a huge disservice to subvert spiritual methods by using them to promote longevity. Seung Sahn used the metaphor of the car. Tulku Urgyen Rinpoche used to talk about our bodies as hotel rooms. We stay there for a while and then we depart. People don’t spend their energy redecorating their hotel rooms. So don’t get too attached. It’s just a body. Any spiritual practice that promotes peacefulness, mindfulness and relaxation will still not extend life to any extraordinary degree, so one ought to be working on being ready to die.
Jan Chozen Bays: That returns us full circle to what Barbara talked about—working with giving up our fear. Maezumi Roshi always said that the greatest gift is the gift of the dharma, because it is the gift of no fear. Fear is what causes people to be in extra pain, unneeded pain—physical, mental and emotional. Practice can reduce that dramatically.
Somebody asked me once to give a talk on what happens after death, and I said I don’t know what happens after death. What I do know is that meditation prepares us to step into the unknown, because when we are sitting with a clear mind, each moment is unknown. Stepping over the threshold we call death becomes just another moment of entering the unknown with curiosity. We can lead a life that’s more at ease, whether it is longer or not. We don’t have complete control over that. In fact, we have barely any control over it.
Lion’s Roar: Do you find that your Buddhist practice helps you in your work as health care providers?
Jan Chozen Bays: I could not do my medical practice without my spiritual practice. I do child abuse work, the kind of work where day by day you accumulate many stories and vivid images of suffering. Right now I am editing videotapes of people caught in the act of abusing their children. As you watch that material, it enters your mind and can cause you to suffer, what we call secondary victimization. Meditation helps to clear the mind every day, every week, so you don’t end up with a heart or mind full of suffering.
I adjust the dose of my practice according to the amount of suffering I encounter during the day. I teach a course for health care professionals on burnout, secondary trauma and compassion fatigue. People tell me what they do to relax and de-stress: gardening, going out in nature, playing with their children or their animals, riding their motorcycle, or doing art or dance or theater. When we’re finished with this very long list, I point out that what is common to all of those is that when you do them you are in the present moment. Your mind isn’t obsessed with the past and anxious about the future. Then I explain that wherever you are, you may not have your golf clubs or your garden or your horse, but you can do meditation. It’s an invaluable tool, especially for keeping our hearts open. Compassion fatigue is more of a problem than physical fatigue in the health care professions.
David Shlim: My years working as a doctor in Nepal helped me to train in compassion and become the physician I had originally hoped to be. That is what led to the idea of having Chokyi Nyima Rinpoche teach directly to a Western audience of doctors and nurses, and eventually I wrote a book based on his teachings.
When I moved back to the United States six years ago and started working on the book, I thought I should become versed in Western ideas of training in compassion. I found there weren’t any. Medical schools teach various techniques for interviewing and eliciting information and responding, but nothing about compassion.
I feel the book is trying to introduce the concept that compassion is a quality that one can be trained in. If you do so, it has great benefit for the health practitioner in making the work more effortless and vast, and it has benefit for the patient, who responds much better when treated with genuine compassion.
Chokyi Nyima talks about conceptual and nonconceptual compassion. Conceptual compassion is the usual kind. We see something and we react to it. It takes energy to react and our reaction is based on good motivation. It is easier when we already like the person and harder when the person is difficult or doesn’t like us.
Nonconceptual compassion, the idea that our natural state is compassion, doesn’t really exist in Western literature. Through meditation we can clear out the obstacles to the free flow of that compassion, so that it becomes our nature and we can apply it wherever we need to. It is also self-rejuvenating. It takes a lot of practice to develop nonconceptual compassion, but we should at least introduce the idea that this type of compassion exists.
Barbara Rhodes: I have never felt fatigued or burned out in my work. Some patients and some situations are very frightening or discouraging or simply hard to watch. Sometimes I don’t know if I am doing everything I could for a patient, so the main practice is to ask, “What is this? How is it just now?” When I can do that each moment, I am able to remain at ease, whether the feeling is pleasant or unpleasant.
We have filters. We feel it ought to be this way or we wish it weren’t that way. But if you just very nakedly touch it as-it-is, the filters dissolve. To see just how something is, one simply asks, “How is it?” Rather than assuming that you know precisely how everything is, you ask, “How is it just now?” Then there is nothing between you and what you perceive, and your intuition can come up with ideas for how to alleviate suffering: calling a doctor and getting the medication increased, or encouraging the patient to go back to bed and helping them to relax, or letting them weep or talk to their spouse. It all appears from your intuition, from your gut, if you relax enough to ask, “How is it just now?”
Sometimes we have an idea of how long something should take or what expectations should be met. But if you take away every idea and just be with it as it is, the patient relaxes, knowing that you are completely there with it. When they know you are really attending, that is the patient/nurse relationship.
Mitchell Levy: Much of what I do and much of what I have written about is the end-of-life journey in the Intensive Care Unit. Since most of my patients can’t talk to me anymore, much of my work is done with families. The biggest obstacle I see when I am watching clinicians is their inability to listen, to open themselves up and care deeply. To me, practice is more important for caregivers than for people who are ill, because it teaches you how to tame your mind, open your heart and be able to be fully present with a patient or family when they are most isolated, most alienated and most in need of human contact.
All too often in the ICU what I see is a family who already feels separate and frightened running into a caregiver who is afraid of that—who is afraid of heightened emotions and doesn’t know how to hold their mind properly in a tight room where they are trying to deliver bad news. Practice allows us to tame the mind and experience openness and awareness and communicate that in a compassionate way to patients. In my environment, the most powerful therapeutic intervention I can offer for the family is openness and awareness, so they have a chance to heal in the midst of the dying process, because in the ICU people are very often going to die no matter what I do.
Lion’s Roar: Wouldn’t it be difficult for medical schools to agree to teach techniques in how to develop compassion? Doesn’t that seem antithetical to the objective, scientific definition of the profession?
Mitchell Levy: They would have a hard time understanding it. Often, when I talk to physicians about good end-of-life care, it boils down to teaching them to be decent human beings. In a way you’re asking, would it be strange for a medical school to teach physicians-in-training to be decent human beings?
Barbara Rhodes: We could use that. Medicine today has deteriorated into moving papers around.
David Shlim: Last week I was at the University of California at San Diego and I was asked to give grand rounds in the emergency medicine and internal departments on the topic of medicine and compassion. It was a first for them to have such a talk, but it was well received. What I’ve discovered is that it’s not that doctors and nurses are not compassionate, it is just that medicine has become highly effective in a particular way. If you apply it, it relieves suffering whether you have a consciously compassionate attitude or not. I ended up calling that de facto compassion; it is built into the work.
But it is inherently unsatisfying. The patients don’t feel that you really have focused on them, that you have understood how they are feeling, and you get this feedback from the patients that they are not appreciative. Our medical care is moving along in this mode of de facto compassion. So, to simply help people cultivate a genuine attitude of compassion wouldn’t change the scientific basis of medicine, but it would us get over the hurdle of a kind of compassion that is unsatisfying to patients. That’s what I’ve been encouraging people to think about.
Barbara Rhodes: In meditation every morning, I touch this moment, touch this moment, touch this moment. In the same way, I will literally touch my patients and their families. I’ll hold their hand or rub their shoulders and it is not some contrived technique. Compassion and intelligence can extend into your fingers and your hands, so you can—it sounds like a phone company, I know—reach out and touch someone. I actually did that today with a woman who was really frightened. Her husband could hardly breathe and she was panicked. I just took her hand and at first I know she thought it was odd, because I had only just met her. But after a while she just couldn’t get away from me. She needed that warmth. If you touch the moment, you can feel what is needed, whether it is touching someone or listening to them or reaching out to them in any way that’s necessary.
Barbara Rhodes, R.N. (Zen Master Soeng Hyang) is the School Zen Master of the Kwan Um School of Zen and one of the founders of the Providence Zen Center. A registered nurse since 1969, she works for Hospice Care of Rhode Island.
Jan Chozen Bays, M.D., is a pediatrician specializing in the evaluation of children for possible abuse and neglect. A Soto Zen priest, she teaches at Zen Community of Oregon and at Great Vow Zen Monastery. She is the author of Jizo Bodhisattva, Guardian of Children, Women and Other Voyagers (Shambhala Publications).
David R. Shlim, M.D., is former medical director of the CIWEC Clinic Travel Medicine Center in Kathmandu, Nepal. He is co-author with Chokyi Nyima Rinpoche of Medicine and Compassion: A Tibetan Lama’s Guidance for Caregivers (Wisdom Publications).
Mitchell M. Levy, M.D., is professor of medicine at Brown Medical School and medical director of the Medical Intensive Care Unit at Rhode Island Hospital. He was personal physician to the late Chögyam Trungpa Rinpoche and is an acharya (senior teacher) in the Shambhala Buddhist tradition.