- Ann Boyd, Pinit Ratanakul*, Attajenda Deepudong*
Biology Dept., Hood College,
401 Rosemont Ave, Frederick, Maryland 21701-8575, USA
*Center for Human Resources Development, Mahidol University,
45/3 Ladphrao 92 Bangkapi, Bangkok 10310, THAILAND
Eubios Journal of Asian and International Bioethics 8 (1998), 34-37.
Thailand, like most countries in Asia, has experienced rapid changes in this century including the incorporation of Western paradigms of scientific research and medical practice. Physicians educated in Western Universities return with different perspectives which create cultural and ethical dilemmas about the allocation of resources, priorities of health care, biomedical research, and the manner in which care is given. Universally, bioethics considers allocation of scarce resources, financial and personal priorities in research funding, care for the poor vs. the wealthy, emergence of extraordinary technologies, and their accompanying denial of the just distribution of goods. Ethics attempts to guide decisions about what priority ought to be given to the principles of autonomy over paternalism, truth telling over deception, social justice over consumerism, beneficence and nonmaleficence over inertia. The search is a philosophical quest for "good" in terms of human moral agency and practical application. The dialectic between theory and application is dynamic in every culture. More can be done than is done. New biomedical techniques provide the ability to improve the quality of life for the few who can afford them and threatens to override a commitment to a basic/minimal standard of health care for all members of a society.
Academic conflicts surface between justice and autonomy, and beneficence and nonmaleficence regarding what is the "good" action in a given situation. Furthermore, there is no universal agreement on whether the four principle ethics (justice, autonomy, beneficence, and nonmaleficence)provides the best platform for applied ethics. As intellectually stimulating as the academic debate is, individuals and governments are faced with competing and compelling claims upon which they must act. For example, a government that decides to fund telemedicine rather than build enough rural clinics to provide equitable healthcare has given priority to one need and allocated resources accordingly. What principle or standard can guide academic debate and give wisdom to those who decide the "good" action in health care?
The global epidemic of HIV/AIDS is an opportunity for pluralistic dialogue set in the context of pressing and universal need. This issue has the potential to fuel discussion everywhere about the just allocation of health care resources. The AIDS epidemic in Thailand presents a poignant case study. The explosive nature of the HIV epidemic is illustrated by the fact that within six months the rate of infected women in the sex industry rose from 2% to 40% (Beyrer, 1995; Nelson, 1996). Considering the fact that HIV infection leads to AIDS and death in five to ten years, it is expected that one in every eight men in the 20 to 40 year-old group, and one in every twenty women in Northern Thailand will die within the next two decades leaving thousands of orphans in the care of grandparents, foster parents, or state institutions(Beyrer, 1995). The economic, cultural, social, and spiritual ramifications are unprecedented in Thailand's history. The "100% condom use" campaign shows positive results in terms of a 50% decrease of HIV infection among Northern Thai male army recruits within the past two years (Nelson,1996).
This paper suggests that compassion is the philosophical "good"
in Thailand. Compassion is endorsed by the prevalent Buddhist
philosophy adhered to by the majority of the population. Compassion
is the essential element that motivates non-governmental organizations
to provide home-based care through outreach ministries of the
Church of Christ in Thailand in Chiang Mai. Compassion motivated
the creation of an AIDS hospice at a Buddhist Wat in Loburi.
These two examples serve to establish a hypothesis: that compassion
is the prima facie duty of an ethical response to the compelling
human needs associated with HIV/AIDS.
Religion and Ethics
Buddhism is the fundamental basis of moral education in Thailand. It directly influences how the average Thai citizen ethically evaluates a case study (Boyd, 1997). More than 90% of the population follow the Dhamma, Buddhist teachings. This fact provides an insight into how religious belief affects ethical thought. The doctoral program in Religious Studies at Mahidol University began in 1996 with eleven international students. During the first semester of the program, a course entitled "Science and Religion: Bioethics" was offered by a visiting professor from the United States (Boyd, 1997). The students analyzed four case studies during the semester, one of which described the AIDS epidemic. Their case analyses invariably included reference to Buddhist, Moslem, or Christian sacred texts in order to defend or prescribe a "good action." Attempts to evaluate the right action on the basis of a four principle ethics approach, or one of several ethical standards were trumped by religious perspectives.
If ethics is defined as an individual reasoned response to a situation in which a person seeks to do the "right" or "good" thing, then individuals with a priori religious education may subjugate to religious precepts of "right" and "good." Kantian ethics asserts that human moral virtues are determined by reason because people can think and thereby know the "good" and act accordingly. The standard of Respect for Persons is based on the equality of persons in the universalization principle and the dignity of each person in the means-end principle (Kant, 1785). The realization that religious perception influences rational logic and visa versa occupied much of the latter years of Kant's scholarship in Religion within the limits of reason alone (Kant, 1934).
The philosophical foundations of ethical thought rely on principles
and standards in which what is "good" is defined according
to the philosophy of what it means to be human. How an individual
actually decides about the right and "good" may harmonize
with a religious precept or a philosophical standard, but it is
unclear how much either foundation influences the individual's
actions. Persons in heavily influenced religious cultures are
taught what is right and "good." The point is not to
argue that moral logic depends on religion, rather, that belief
and religious ethics overlap with moral reasoning at the personal
level. It is difficult to suspend all memory of religious experience
and knowledge when evaluating a case study by any one of several
ethical theories. Perhaps one of the appeals of principle-based
ethics is the provision of a framework for analysis and a tentative,
if not explicit, definition of what is "good." It is
the opinion of these authors that many people have some religious
instruction, while fewer are skilled in ethical literature and
principle-based logic. Therefore, this paper proposes that an
interrelationship exists within the mind of religious persons
between the moral and the ethical. Morals and ethics differ academically,
but at the existential level, religion influences individual choices,
thoughts, and actions perhaps as much as principle or standard-based
The Buddhist concept of compassion is one of loving kindness which embraces the ethical principles of beneficence, nonmaleficence, and justice. Justice is the social form of compassion. Compassion exceeds justice in basic equality and human rights to the point of self-sacrifice voluntarily given for the benefit of another. When a patient voluntarily gives up or refuses medical attention, even if it means death, so that his family does not suffer, it is compassion. Nurses and doctors who give up sleep and family time to be with suffering patients demonstrate compassion. To pursue the ideal of compassion is to transcend the language of justice and to be unconcerned with getting what one deserves, or being treated fairly, or securing one's rightful claims on the behavior of others (Ratanakul, 1988).
Justice, in Buddhist philosophy, means impartiality, equal treatment, giving to each their due. Although people differ in circumstances, they are equal as moral agents. Justice means providing available health care for all - the poor and the rich -and equal quality of health care to include the manner in which they are treated.
Christian ethicist, Paul Ramsey, proposes an agapÇ command in order to reveal a certain deontological basis for knowing the "good" in any situation. It provides a way to determine the right action that is revealed by the most loving action possible in a given circumstance (Ramsey, 1950). The following quotation from Paul Ramsey's Deeds and Rules illustrate his position (Ramsey, 1967).. "a proper understanding of the moral life will be one in which Christians determine what we ought to do in very great measure by determining which rules of action are most love-embodying, but that there are also always situations in which we are to tell what we should do by getting clear about the facts of that situation and then asking what is the loving or the most loving thing to do in it."
Rigorous biomedical ethical debate often leans in favor of standards and principles that provide a plumb line for defining a "good" action; whereas the four principles of justice, autonomy, beneficence, and nonmaleficence provide an ethical compass for evaluating action (Beauchamp and Childress, 1979).
Persons who define right actions according to consequences, utilitarians, often do so in order to justify an action that does the most good in contrast to the harm that results from doing nothing. That is to say, that one normatively decides the most good that can be achieved in an action recognizing that absolute "good" is often impossible to achieve. Many medical schools and hospitals in the West elect a utilitarian calculus in order to act and avoid the inertia that an absolute rule of obedience to a divine will, like agapÇ command, might impose. Joseph Fletcher attempted to baptize utilitarian thought with an agapÇ overlay in Situation Ethics (Fletcher, 1966). He proposed that the greatest "good" in any given situation is based on what is the most loving thing to do. Thomas Aquinas derived a standard from revelation of natural laws which prescribe right actions based on the natural inclinations of all persons, life, sociability, procreation, and knowledge, Natural Law (Denise and Peterfreund, 1992). This standard has influenced thinking in most Roman Catholic hospitals throughout the world. Such a standard allows forgoing extraordinary care/treatment to obtain a death with dignity, or to spare family members extreme pain and sacrifice. This is similar to the compassion described in Buddhist philosophy.
A visit to two AIDS care facilities in Thailand revealed that
compassion provides an interesting ethical standard. The element
of compassionate care observed in each AIDS care facility is one
that expresses individual virtue. The suggested ideal is more
than a principle of justice expressed as equality, it is an expression
of self-sacrifice. Giving with no hope of return, gain, recognition,
or payment in order to care for those whose needs are greater
than theirs: this is compassion (Pinit, 1988).
A Buddhist Hospice for AIDS Patients
Wat Phrabatnampu is just outside Lopburi, about 120 km north of Bangkok. This is the first and largest AIDS hospice care facility in Thailand. Phra Ajohn Alongkot is the resident abbot and founder of the facility. His inspiration for the facility was derived from an American psychologist who taught him hospice care philosophy and techniques. What began as a care facility for 20 AIDS patients in 1991, now accommodates 200 AIDS patients, with a waiting list of 6,000.
Standing at the gate looking into the compound, one sees a large building on the left where funerals are performed. Behind it is the modern crematorium, a small stream of smoke emanating from the top, signifying the cremation being done and the daily reality for all residents and volunteers. Beside the crematorium is another large building used for counseling, out-patient services, and offices. The abbot's office is filled with slides and preparations made for seminars. He travels constantly to promote education aimed at prevention, self-protection, awareness, and fund-raising. The budget for the facility is two million baht a month, and all is raised from private donations.
On both sides of these larger buildings are rows of small houses where the patients live and help with the work of the center, cooking, cleaning, and laundry. New construction is in progress to expand the capacity to care for more patients as the demand escalates. Near the back of the compound is the emergency care unit, which serves as a hospital for those who are dying. The hospital unit provides both traditional and modern medicine. Anti-viral and anti-microbiological drugs are used to treat the opportunistic infections all AIDS patients experience. A treatment of herbs containing a mixture of camphor, ginger, and lemon grass is also used. The abbot says that the herbal mixture provides nutrition and has some healing effects.
Two infants occupy beds among the adults. All are terminal. A small 18-month-old girl sits between two stuffed animals, eating a cookie. Both of her parents have died of AIDS, and she is HIV positive. She is quiet, content with her cookie, and does not notice visitors. The reality is stark. The patients who are in the emergency care ward are in the final stages and will die within a matter of days or weeks. The staff of volunteers provide care for their physical and spiritual needs. Death is a daily occurrence here. It is accepted calmly, with the knowledge that appropriate medical care was given and each person dies with dignity, surrounded by a caring compassionate community.
All the monks who live and work here are HIV positive, except for the abbot. Counseling is offered to prospective patients and out-patient service is provided until room is available. 90% of the patients receive no family support or contact. The abbot explains the objectives of the program as follows:
"Provide caring, compassionate care, in a village-type environment for people with AIDS. Provide a center for training and education, to increase community acceptance and active support. Provide a place where Buddhist practice and philosophy are integrated with counseling and give practical and spiritual support to persons with AIDS. Increase the knowledge and awareness for family members and friends who care for people with AIDS. Provide a temporary respite care facility to relieve family members of the full burden of care as well as medical assistance" (Dramaraksaniwesana Project, 1996).
The Buddhist ideal of compassion demonstrated in this Wat means
recognition of the great suffering AIDS patients experience.
When AIDS is diagnosed here, no judgment is made; only unconditional
love and support are given. Monks and laity of the Buddhist tradition
are greatly respected in Thai society. Therefore, their exemplary
lives of compassion and concern for AIDS patients will, hopefully,
inspire others to follow their example.
Christian Compassion in Chiang Mai
The Church of Christ in Thailand (CCT) AIDS Ministry (CAM) is a non-governmental organization (NGO) located in a small building across the street from the School of Theology of Payap University. CAM was founded in 1991 with a mission to help provide a vision and support system for local churches as they work to respond to the needs of people living with HIV/AIDS. The organization has four active components: a health promotion group, education and training team, speakers for outreach to churches, and a team that solicits financial donations. The inspiration for the mission is based on a perspective that "All humanity is created in the image of God and has inherent dignity and value and as such the right to a life of quality and meaning. God's love for all humanity, including people with HIV/AIDS, compels us to reach out to others with compassion" (CCT AIDS Ministry).
CAM provides home-based care services, counseling at the center, and a staffed clinic. The Reverend Sanan Mutti allowed us to observe as the team met to review their cases. The theme of home-based care is "from heart to heart, from life to life." The team promotes a positive attitude among care givers and volunteers, characterized by the dignity and value of life, love and acceptance, useful and hopeful living, care of health and self. "We do AIDS ministry because of our consciousness of 'Metha-Tham,' or compassion-care and mercifulness." Established networks with informal education connect schools with churches and temples, and women's groups with community health services creating an embracing circle around the HIV/AIDS patients. One of the volunteers offer the visiting team the following case study to help us understand CAM.
"Tip" was a nurse in Chiang Mai, a bright, dedicated, Christian, professional woman. Tip was married to Dee, a Buddhist man who worked for the municipal water department. Tip and Dee were a happily married, devoted couple who decided to have children three years after the marriage. Blood tests revealed that Tip was two months pregnant and that both she and Dee were HIV positive. With this news, they took a few days off from work, spent time together, laughed, cried, talked, and, on the third day, went home and ate rat poison together. Tip died immediately, but Dee went into a coughing spasm and fell to the floor wakening his parents, who rushed him to the hospital where he was revived. Family and friends stayed nearby, offering encouragement, counseling, and loving support.
Ten days after Tip's funeral ceremonies were completed, Dee
went into his room, turned on his music, and drank insecticide.
When his family found him, he was dead. Nearby lay a letter
Dee had written, wishing all his family and friends peace, and
pleading for their forgiveness and understanding. At the end
was a section addressed to God: "Great God Almighty, I am
a Buddhist, but my wife was a Christian. If you have taken her
spirit to be with you in your eternal home, please grant this
my petition and release her to come down and receive my spirit
as well, so that I can help her take care of our child. We should
all be together, the three of us...I love them so much, and I
miss my wife so badly. O God, why did you let this thing happen
to such a good person as my wife? But, I don't blame anyone except
myself. I could have stopped her. I tried to change her mind
when she first suggested doing this, but when I saw she had made
up her mind, I went along, out of love for her. I know everyone
is trying their best to cheer me up, but it's no use. I'm sorry...."
(CCT, Case Study)
The poor who acquire HIV cannot afford traditional medical care and the family dynamics are tremendous. As the disease progresses, the patient can no longer work and requires virtually full-time care, meaning that some other family member's job becomes one of care giver, with the concomitant loss of income. Neighbors, friends, and family are often fearful and neglect the HIV-infected person leading to isolation, loneliness, and depression. Isolation and desperation may lead to suicide. As the decade comes to a close, scientists estimate that Thailand has at least 700,000 HIV-infected persons, and that by the year 2000, approximately 100,000 persons will die of AIDS every year until the epidemic runs its course (Breyer, 1995).
Encouragement and compassion are needed to provide hospice care
for those who suffer. Thailand has 250,000 monks, 10,000 nuns,
and 30,000 temples. The example of Wat Phrabatnampu illustrates
how Buddhist monks are in a position to offer compassionate humanitarian
care. If the current projections are correct and no new infections
occur, there will be a need for 500 more hospice centers the size
of the one in Lopburi. The efforts of NGO's, like CAM, will also
have to be expanded and replicated in order to offer a Christian
parallel version of compassionate care for HIV/AIDS patients and
their families. These two religious-based efforts are important
examples of how individuals can show compassion and provide care
in a national crisis.
Ethics and Morality
The case study presented here suggests actions based on a principle of compassion that reflects a fundamental Buddhist philosophy. The example illustrates a prima facie duty as an ethical response to a compelling human need. Buddhist philosophy is based in the ethical, metaphysical, and epistemological views of Siddhartha Gautama (Rahula, 1974). The "four noble truths" encompass the meaning of human existence. The fourth noble truth gives the ethics, the eightfold path. These intellectual, social, and meditational virtues promote the overarching moral qualities of clarity, desirelessness, universal friendliness, and compassion (Rahula, 1974)
The ancient Greek Sophists in the fifth century B.C. record some of the first critical questions about the very idea of moral conduct which would be useful human creations to establish customs and conventions that would enhance social existence. Plato's early dialogues portray, though the character of Socrates, a search for definitions of the traditional virtues, temperance, courage, justice, and piety (Cahn, 1977). The theme is that these virtues are good qualities in human beings because they create a good life for those who possess them. Underlying these virtues must, therefore, be some a priori knowledge of what constitutes the human "good." Aristotle employs a similar broad framework in the Nicomachean Ethics in which he asserts that the ultimate end of all human action is happiness. The means to happiness is human reason. Although Plato and Aristotle were theists, their ethics were not based in a religious context.
Medieval Christendom attempted to marry Greek moral philosophy with Christian morality in the Natural Law ethics of Thomas Aquinas. Aquinas' synthesis was based on the idea that through an understanding of human nature the natural purposes proper to human beings could be identified. Aquinas perceived that the natural inclinations of human beings were consistent with the nature of the divine creator and, therefore, harmony was achieved through actions that were consistent with human nature (Honderich, 1995).
Plato asked in the Euthyphro, "is the good because God commands it, or does God command it because it is good?" (Cahn, 1977). If the first condition is true, then morals are no more than an obedience to authority. If the later condition is true, then morality is independent of knowledge derived from the divine or a perception of the deity. The mainstream tradition of ethics in the modern epoch favors the later position and is predominately secular (Honderich, 1995).
The idea of a moral law is central to Kant's moral philosophy. The categorical imperatives prescribe what is to be done regardless of what one may want. The imperative is then a test by which one may determine whether or not one should do what one intends to do. Essentially one ought to act only on those maxims (rules or actions) which would be a universal law for all persons. In brief, the Kantian ethic of Respect for Persons places a premium on individual human worth and dignity, asserting equal treatment, and a direct objection to the rationalization of the most good in a circumstance where competing claims necessitate a choice. The debates about what is the "good," and how human beings decide what action to take in a given circumstance extend the conversations of ancient philosophy into contemporary topics. The main ethical theories appear alive and well in the works of contemporary ethicists. Many represent a modern incarnation of Kant in rights-based theories or of Aristotle in virtue ethics (Pellegrino and Thomasma, 1993; Pellegrino, 1995).
Given the wide variety of opinion about ethical and moral values that exist within and among different cultures and different epochs of the same culture, the meta-ethics question about the human capacity for morality remains unanswered. Actions that are consistent with an ethical standard or principle rely on the interpretation of the actor. If the actor is working from a moral code of a priori knowledge communicated through the religious interpretation of his culture, is he not subject to its influence as he processes the action he ought to take in response to any ethical standard? Can ethical code supersede a moral one? What moral or ethical code has better common ground in the world of human beings than compassion?
This work was supported in part by a Beneficial Hodson Fellowship from Hood College, and the United Church Board of Christian Education in Southeast Asia.