Special Section: Spirituality/Medicine Interface Project

Eye on Religion: Buddhism to find the ending of suffering. The Buddha emphasized how
devoting oneself to the practice of mindfulness can ultimately
and Medicine lead end of suffering.2
Mindfulness can provide deep insight and understanding
David E. Arond, MD, MPH
and move one further along the path which ultimately leads to
the end of suffering. Zen Master Thich Nhat Hanh writes,
For those not familiar with Buddhism and seeing Bud-
“Mindfulness is the energy that allows us to look deeply at
dhism as a religion, they might be fascinated by some com-
our body, feelings, perceptions, mental formations, and con-
mon threads that inform both medicine and Buddhism. We
sciousness and see clearly what our real needs are, so we will
will explore both the commonality and differences of empha-
not drown in the sea of suffering.”3 This insight is one of the
sis or perspective.
fundamental components of basic Buddhist teachings, known
Crucial to both Buddhism and medicine is the impor-
as the Eight Fold Path. The Eight Fold Path contains eight
tance of practice. Practice, the repetition of an act, is crucial
practices, each embodying the other and also containing es-
in moving toward perfection. As physicians, we practice
sential practices that will lead to the end of suffering. All
throughout our professional life to acquire and maintain our
involve nonharming. Through mindfulness, one first becomes
skills. Essential to Buddhism, practice is part of learning
adept at focusing and concentrating the mind, and then learn-
through quiet, focused concentration and deep awareness.
ing how to increase the subtlety of one’s awareness. The
Medicine and Buddhism share the ultimate goal, nuanced
outcome is increased insight, deep understanding and aware-
differently, to help relieve the suffering of others. In medi-
ness of inner peace. These insights and the possibility of
cine, there is the famous anonymous saying, “to cure some-
personal transformation uncovered during both meditation
times, to relieve the pain and suffering often, and to comfort
and in bringing the practice of mindfulness into everyday life
always.”1 In Buddhist practice, this refers not only to others
can lead to a profound, “deep understanding” of life. Deep
but also to oneself. From the Buddhist perspective, we must
understanding and personal transformation develops through
simultaneously do this for ourselves while we do this for all
an experimental process, rather than intellectual analysis. In
living beings. In medicine, however, self-care is often over-
Buddhism, “deep understanding” refers to self, other human
looked. How often do we as physicians practice self-care,
beings and one’s total environment.
including self-awareness, as it relates to both caring for pa-
The process of practicing mindfulness helps us “see” the
tients but also in all aspects of life?
past and future in the context of the present moment. From
Buddhism began because of the insights of a person liv-
teaching and personal experience, I have become convinced
ing in Northern India approximately 2600 years ago. Later
that physicians could find significant benefit in learning these
known as the Buddha (translated as one who is “awakened”),
tools irrespective of their religious/cultural perspective. The
this individual was a prince whose father was determined to
question that is often posed is: If we are not living in the
shelter him from all painful aspects of living. It was as a
present moment, then are we truly in touch with life? One
married adult, during journeys outside his royal home, that he
might consider how this would enrich medical practice.
first encountered a corpse, an old man, a sick person and an
Buddhist practice fundamentally has to do with intention,
impoverished person. After these experiences, he left his royal
attention and awareness, which are key components of this
home on a journey to uncover a deeper understanding of the
meditation practice. In medicine, we are familiar with car-
life. These encounters resulted in his seeking to fully under-
diopulmonary resuscitation (CPR). A Buddhist mindfulness
stand suffering and its ending. After many years of concen-
equivalent could be ABC: Awareness (mindfulness); Breath
trated meditation practice, he vowed to continue meditating
(concentration focus); Calm (being at peace). These are the
until he fully deeply understood the nature of suffering. After
basic elements of mindfulness. Kabat-Zinn described this as
the Buddha’s awakening— enlightenment— he began to share
“a coherent phenomenological description of the nature of
what have become the basic teachings in Buddhism, namely,
mind, emotion, and suffering and its potential release, based
the “Four Noble Truths”: There is suffering; there are causes
on highly refined practices aimed at systematically training
of suffering; there is an end to suffering; and there is a path
and cultivating various aspects of mind and heart via faculty
of mindful attention. The contributions of Buddhist traditions
have been in part to emphasize simple and effective ways to
From Division of Public Health Practice, Harvard School of Public Health, cultivate and refine this capacity and bring it to all aspects of
Boston, MA.
life.”4 Mindfulness practices have been formalized in medical
Reprint requests to David E. Arond, MD, MPH, Harvard School of Public
Health, Division of Public Health Practice, 841 Parker Street (Ground research and interventions for a wide range of medical
Floor), Boston, MA 02120. Email: darond@hsph.harvard.edu (asthma, cancer, etc) and psychiatric diseases (Dialectical Be-
Copyright © 2006 by The Southern Medical Association havioral therapy).5 This includes the pioneering work of Jon
0038-4348/0⫺2000/9900-1450 Kabat Zinn, using mindfulness techniques at the University

1450 © 2006 Southern Medical Association


of Massachusetts Medical Center as well as Herbert Benson
(The Relaxation Response)6 and Joan Borysenko’s many con-
tributions, including author of Minding the Body, Mending
the Mind,7 initiating using point focus meditation and other
skills including cognitive behavioral therapy techniques at
Harvard Medical School’s Mind Body Medical Institute and
in teaching hospitals throughout the US.
At the heart of Buddhist practice is its ethical foundation.
This includes the practice of nonharming, nonstealing, sexual
responsibility, mindful speech (which includes not saying
things that one is not certain to be true), and avoiding toxic
ingestion, including alcohol, drugs, and has been interpreted
as extending to TV programs and the like.
Fundamental to Buddhism is the practice of what is trans-
lated as the four Immeasurable minds. They are love, com-
passion, joy and equanimity. These are considered in Bud-
dhism as the four elements of true love: “Happiness is only
possible through true love . . . they are called immeasurable
because if you practice them, they will grow in you every day
until they embrace the whole world. You will become happier
and then everyone around you will become happier, also.”3
The practice of true love is the very nature of an enlightened
person. The four aspects of true love exist within ourselves
and within everyone and everything.8
To develop these immeasurables, one has to listen deeply
so that we know what to do and what not to do to make others
happy and thereby help them transform suffering. “If you
offer your beloved something she does not need, that is not
true love. You have to see her real situation or what you do
might bring her unhappiness. To live in peace we have to be
aware of our tendencies— our habit energies—so we can ex-
ercise some self-control. This is the practice of preventive
care.” Thich Nhat Hanh, Zen Buddhist Master, writes about
how initially he did not understand how the Buddha could not
be disturbed by all the suffering and came to understand that
the Buddha had enough understanding, calm, clarity and
strength to not be overwhelmed by it. “He is able to smile to
suffering because he knows how to take care of it and to help
transform it.”3
By exploring the fourth element of true love—equanim-
ity—we can see how this could positively influence our prac-
tice of medicine. Equanimity is translated from the Sanskrit
by Thich Nhat Hanh as letting go, nonattachment, nondis-
crimination, and evenmindedness.3 If, as physicians, we
would cultivate these practices of true love and could truly be
in the present with our patients, they could experience this
deep caring from our speech and our actions. In equanimity
Southern Medical Journal • Volume 99, Number 12, December 2006
Special Section: Spirituality/Medicine Interface Project
(nondiscrimination), we don’t experience the patient (or any-
thing) as other. But rather we learn to see/experience the
common humanity that is shared by all. We shed all discrim-
ination and see before us an individual who is seeking our
deep understanding of the science of disease and our art of
care for mind and body.
In Buddhism, three other perspectives are essential to
articulate. One, learning to be free from our anxiety, fear and
anger, and other negative states of mind requires us to be
open to ultimately acceptance of everything as it is. It is a way
of living and being that leads to a deeper sense of love of self,
clarity, joy, meaning in life and inner peace. Second, suffer-
ing ultimately comes from our mind (In Eastern psychology,
this includes the heart). How one interprets and then responds
to what one encounters in life—its pain, joy and happiness—is
responsible for our experience of suffering. Mindfulness prac-
tice enables one to begin to transform, ie, let go of our at-
tachments (possessions), anxiety, aversions (fear, anger) and
delusions and “deeply understand” them for what they are. If
we do not acknowledge what is real in the present, how can
one begin to transform suffering? One needs to be truly
present to enjoy the sunshine, our beloved, the rain . . . if not
now, when? Buddhist practice encourages one to accept re-
ality as it is to begin to liberate oneself from suffering. One
can begin to appreciate this by being more mindful in each
moment, of our breathing, walking, smiling, our food . . . the
flowers wherever they are found. Several colleagues and I
have noted that practicing mindfulness have noted that prac-
ticing mindfulness contributes much to the quality and joy of
medical practice and scientific inquiry.
In practicing medicine, when we begin to “see” with
deep awareness, openness of heart, clarity of vision, with
love, joy and nondiscrimination, we can then practice care
and compassion that our patients and we need as part of our
common humanity.
References
1. Anonymous, France 15th century.
2. Dharma Cakka Pavattana Sutta. Samyutta Nikaya V, 420.
3. Hanh TN. Teachings on Love. Berkeley, Parallax Press, 1997.
4. Kabat-Zinn J. Mindfulness-Based Interventions in Context: Past, Present,
and Future Clinical Psychology: Science and Practice 2003;10:144–156.
5. Linehan MM. Cognitive-Behavioral Treatment of Borderline Personality
Disorder. New York, Guiford Press, 1993.
6. Benson H. The Relaxation Response. New York, William Marrow, 1975.
7. Borysenko J. Minding the Body, Mending the Mind. New York, Bantam
Books, 1988.
8. Sutra 744, Tsa A Han (Samyuktagama) Taisho 99.
1451