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Volume 12, Number 2

Special Article
Loving Kindness- The Essential Buddhist Contribution to Primary Care

Steven K.H. Aung, MD

Loving kindness (metta), a traditional Buddhist concept, implies acting with compassion toward all sentient beings, with an awareness and appreciation of the natural world. The giving of metta, an integral part of Buddhist medicine, has the potential to enhance modern primary health care. Metta must be given with selflessness (saydana), compassion (karuna), and sympathetic joy (mudita). For the believer, Gautama Siddhartha, the Buddha, is the Supreme Healer. His ancient but timeless message of metta is alive and well today, The Dalai Lama being its key proponent. The Buddhist system features several techniques, such as the Noble Eight-Fold Path and the metta meditations, to keep physicians moving toward metta. One does not have to be a Buddhist to practice metta, or more humane medicine, and the notion of "tender loving care" is spreading in biomedical circles.

No matter what the circumstances, no matter what kind of tragedy I am facing, I practice compassion. This gives me inner strength and happiness.... I myself you see am the devoted servant of compassion. This is the way I really feel.
-The Dalai Lama1

Loving kindness, metta, is a traditional Buddhist concept. The giving of metta is an integral part of Buddhist medicine that has the potential to enhance modem primary care.

Loving kindness is a traditional Buddhist notion. It implies acting with compassion toward all sentient beings within the context of awareness and appreciation of the natural world. It is a general Buddhist ethical precept rather than a specific medical concept, but it has a direct and powerful application in primary health care. In November 1990, in a private session, I asked The Dalai Lama: "What is the essential difference between Buddhist medicine and Western medicine?" He replied that Buddhist primary care physicians must always provide a blessing as part of their diagnostic and treatment protocol. Thus, a Buddhist physician providing a dietetic, herbal, or other remedy such as acupuncture will also bless the patient quietly or silently with metta.

With Loving Kindness
Fig. 1 The Dalai Lama presenting-with metta-a small medicine Buddha statue to Dr. Steven Aung.

 

With metta (with loving kindness) implies "may you and all sentient beings sharing this natural world of ours be blessed with peace, happiness, and good health." The phrase reminds the physician-and the thought of loving kindness is its function2-that his or her therapy must be safe, reliable, and effective, and that it must be competently administered in full consideration of the special needs and concerns of each patient. The word, metta, derives from the Pali term mitta, which may be translated as "a true friend in need."

The practice of loving kindness requires considerable discipline from the physician. It must be given with: Saydana (selflessness), signifying that one must serve others without any expectation of reward; karuna (compassion), implying gentle, warm, open, and intelligent communication; Mudita (pure joy) at the good fortune of others.

Thus, the "pill" that is included in every Buddhist healing act is comprised of loving kindness, selflessness, compassion, and sympathetic joy. These are among the most unusual and, indeed, the most humane "drugs" in any preventive or treatment program, because they must be synthesized from within the body, mind, and spirit of the physician.

The Discipline of Loving Kindness

Inherent in the practice of metta is the realization that physicians must first heal themselves, that they commit themselves to attain and sustain attitude of genuine, heartfelt, loving kindness. Also, they acknowledge that the most difficult patients are the best teachers.

These ideas are evident in the teachings of Gautama Siddhartha, the Buddha: Protecting oneself, one protects others; protecting others, one protects oneself.

And how does one, in protecting oneself, protect others? By the repeated and frequent practice of meditation.

And how does one, by protecting others, protect oneself? By patience and forbearance, by a nonviolent and harmless life, by loving kindness and compassion.3

No matter what medical tradition they represent, physicians who are unhealthy are unlikely to maintain peak performance. It will be difficult to focus their attention on enhancing the wellbeing and quality-of-life of patients. Buddhist physicians cultivate total health by various breathing, concentration, meditation, and still or moving posture techniques, collectively termed anapanasati.4'5

The four basic anapanasati breathing exercises are long breath, short breath, mindful inspiration, and mindful exhalation. These awareness and concentration exercises calm the mind and generate a feeling of being in touch with and having a measure of control over one's own vital energy, the fountainhead of good health. The exercises are the foundation for preparing the whole person for the cultivation of loving kindness.

In traditional Chinese medicine, similar practices are known as qigong. Their goal-relaxation, harmony, health, and eventual enlightenment-is virtually impossible to achieve without loving kindness. Qigong students, for example, are taught to smile both outwardly and inwardly, while radiating love and blessings outward to all.6

Getting and keeping a spirit of true loving kindness demands constant attentiveness. According to Buddhist principles, it may take several individual lifetimes to achieve. The ordinary person's fragile sense of metta is threatened constantly by such stressors as disease, pain, old age, bereavement, and so on. Every working day, physicians are subject to substantial overexposure to the effects by way of their patients.

Buddhism provides comprehensive guidelines for attaining and sustaining loving kindness. The Noble Eight-Fold Path7 is a moral framework comprising right understanding, right mindedness, right speech, right action, right living, right endeavour, right attentiveness, and right concentration. Each is a valuable practical guideline for physicians. Right speech, for example, entails telling the truth, avoiding abusive or crude language, and avoiding vain talk, boasting, speaking at the wrong time, wordiness, etc. Right action entails not harming or killing another sentient being, not stealing from anyone, and avoiding illicit sexual intercourse.

The key theoretical premise behind these and other Buddhist guidelines is that the world is led by the mind. The ancient Buddhist classic, the Dhammapada, begins: "All that we are is the result of what we have thought: it is founded on our thoughts, it is made up of our thoughts."8 A few lines later it introduces loving kindness: "Hatred does not cease by hatred at any time: hatred ceases by love-this is an old rule." Buddhists still follow this timeless rule.

Buddhism also features specific techniques for cultivating and nourishing loving kindness. These metta mediations were taught by the Buddha as a way of alleviating existential fear- loneliness, despair, and a sense alienation from other human beings and the natural world.9,10 A simple metta meditation-which physicians can perform anywhere-is to repeat the following silently:

May I be free from enmity
May I be free from ill-will
May I be free from distress
May I keep myself happy11

It is a beneficial exercise to recollect past words and actions that have involved metta, to practice developing metta toward a highly respected person such as a teacher or mentor, to practice developing metta toward a close friend, to practice developing metta toward an acquaintance or stranger, and to practice developing metta toward a hostile individual. In the Buddhist view, such a disciplined way of thinking helps to transform a physician from a mere technician into a genuine healer.

Another useful technique is based on breathing: relax and rest your mind; inhale warmth, darkness, and heaviness (sense of staleness) and exhale coolness brightness and lightness (sense of freshness); inhale what is not desirable in your daily experience (hatred, anger, fear, etc) and exhale what is desirable (love, joy, courage, etc). This discipline is based on the physician's sincere willingness to recycle pain and suffering.12-15 Buddhist physician may attempt to absorb the pathogenic factors, to cleanse or eliminate them, and to radiate pure health back to the patient- and to the world.

Finally, Buddhist physicians believe that the most difficult patients are the best teachers, that they are a constant source of continuing medical education. They challenge physicians' egos and force them to be modest and admit their ignorance, at least in these particular cases. This should encourage physicians to broaden their medical knowledge and sharpen their diagnostic and therapeutic skills.

Difficult patients challenge the physician's ability to manifest loving kindness, because these patients often are filled with anger, hatred, hostility, fear, anxiety, sadness, and other forms of "emotional pollution." Thus, it is difficult for caregivers to relate to them and to appreciate their fundamental worth as sentient beings.

Physicians interested in learning from their difficulty cases can use the following metta meditation, written by a Tibetan Buddhist monk 1000 years ago.

I will learn to cherish being...Pressed by strong...sufferings...As if I had found a precious... Treasure very difficult to find.'6

Indirectly, difficult cases were responsible for facilitating the acceptance of acupuncture in Alberta. In 1980, when I was a resident in the Department of Geriatric Medicine at the University of Alberta, the chairperson asked me to perform acupuncture on patients with cancer pain, osteoarthritis, and other conditions that had not responded well to biomedical treatment. The results were so impressive to the patients and to my medical colleagues that I was appointed a consultant in medical acupuncture at the university.

Tender Loving Care

Increasingly, Western medical commentators use the term tender loving care to describe the needs and wants of their patients. This indicates that loving kindness is once again, after several centuries of scientific reductionism,17 becoming part of the Western biomedical tradition. After all, the Oath of Hippocrates alludes to loving kindness when it states, for example, that the competent and caring physician will "give no deadly medicine to anyone" and will "abstain from every voluntary act of mischief and corruption."

In the 17th century, Thomas Sydenham, the English Hippocrates, insisted that "whoever takes up medicine.. .must render to the Supreme Judge an account of the lives of those sick men who have been entrusted into his care18 Agape, the classical Greek and Christian concept of loving one's neighbour-spiritually rather than sensually-is analogous to Buddhist loving kindness. In modern primary care settings, agape implies metta: (tender loving care) "Care for others without qualifications.... Simply based on their existence, we owe other persons our regard, our love."19 In a different religious tradition, Jesus, like Buddha, is considered to be a supreme healer.20

Buddhists are not the only ones capable of a compassionate approach to medicine. Although the biomedical system continues to downplay compassion in favour of technical expertise, many Western physicians are adopting a more caring attitude toward the patient as a whole person.21,22

Concluding Remarks

Metta has a deep and complex meaning. It is not easy to practice metta with its associated virtues of saydana, karuna, and mudita, unless the physician realizes that one's whole attitude to life must change. To attain and sustain proper metta is a discipline that requires through cleansing-from the inside out-especially getting rid of emotional pollution and avoiding self-centeredness.

An essential goal in humane primary health care is to strive constantly toward loving kindness for the benefit of ourselves, our patients, and, indeed, all sentient beings. Thus, metta is as an integral part of primary care.

Buddhism is not an infallible system. Indeed, many Buddhists, physicians or otherwise, do not live up to the high standards of caring built into the concept of metta. However, the Buddhist system features exercises, such as the Noble Eight-Fold Path and the metta meditations, to keep physicians moving in the right direction.

Non-Buddhist physicians wishing to enhance their practice of the art and science of medicine may begin by cultivating a more positive attitude toward their patients, smiling at them, wishing them well, listening to them, learning from them, and viewing the most difficult among them as "test cases" of one's progress along the path of tolerance and understanding.

References

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  2. Swearer D: Secrets of the Lotus, Macmillan, New York, 1971: 122
  3. Dhammananda KS: What Buddhists Believe, Buddhist Missionary Society, Kuala Lumpur, 1987: 189
  4. Bhikkhu B: Anapanasati Mindfulness with Breathing: Unveiling the Secrets of Life, Dhamma Study-Practice Group, Bangkok, 1988
  5. Rinpoche N: The Breath of Awakening: A Guide to Liberation Through Anapanasati Mindfulness of Breathing, Bodhi Publishing, Kinmount, ON, 1992
  6. Aung SKH: A brief introduction to the theory and practice of Qigong. Am J Acupunct 1994; 22: 335-348
  7. Humphreys C (ed): The Wisdom of Buddhism, (2nd ed.) Curzon Press, London, 1979: 65-70
  8. Muller FM (trans): The Dhammapada. In: The Wisdom of China and India, Yutang L (ed), Modern Library, New York, 1942:327
  9. Thera P: The Psychological Aspects of Buddhism, Buddhist Publication Society, Kandy, Sri Lanka, 1972: 6
  10. Salzberg S: Loving kindness: The Revolutionary Art of Happiness, Shambhala, Boston, 1995: 20-21
  11. Saddhatissa H: Buddhist Ethics, George Allen & Unwin, London, 1970: 91 12. Thera N: The Practice of Loving kindness (Metta), Buddhist Publication Society, Kandy, Sri Lanka, 1964
  12. Trungpa C: Training the Mind and Cultivating Loving-Kindness, Shambhala, Boston, 1993: 46-64
  13. Feldman C: Nurturing compassion. In: The Path of Compassion: Writings on Socially Engaged Buddhism, Eppsteiner F (ed), Parallax Press, Berkeley, 1988: 19-23
  14. Rinpoche LTZ: The Healing Buddha: A Practice for the Prevention and Healing of Disease, Wisdom Publications, Boston, 1994
  15. Tethong TC (ed): Eight Verses of Training the Mind, Tibetan Cultural Society of British Columbia, Vancouver, BC, 1993: 16
  16. Nuland SB: Doctors: The Biography of Medicine, Alfred A Knopf, New York, 1988: xvii-xviii
  17. Browne S: Both knowledge and compassion are needed. B M J 1995; 309: 1657
  18. Mermann AC: Love in the clinical setting. Humane Med 1993; 9: 271
  19. Harper M: Whole again: encountering Jesus the healer. J Christian Nurs 1988; Summer: 10-13
  20. Siegel B: Love, Medicine & Miracles: Lessons Learned About Self-Healing from a Surgeon's Experience with Exceptional Patients, Harper & Row, New York, 1986
  21. Siegel B: Peace, Love and Healing: Bodymind Communication and the Path to Self Healing, Harper & Row, New York, 1989
An earlier draft of this paper was presented as part of the public lecture series of the 3rd World Congress of Medical Acupuncture and Natural Medicine, Edmonton, Alberta, August 8-12, 1995
Clinical Assistant Professor Department of Medicine and Family Medicine, and Adjunct Professor, Faculty of Extension, University of Alberta, Edmonton, Alberta.
Correspondence and reprint requests to: Dr S.K.H. Aung, Alberta Medical Clinic, 9904 - 106 Street, Edmonton, AB T5K 1C4