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Do No Harm

Medicine is craft, art and science. It is old, the first evidence of surgery, trepanations, dates back more than 8000 years. With the renaissance science started to change medicine. In 1543 Andreas Vesalius (1514-1564) published De Humani Corporis Fabrica Libri Septem (On the Fabric of the Human Body in Seven Books), one of the great contributions to medicine. It contained anatomical knowledge of unprecedented precision. The start of scientific medicine was slow, but once it really started, in the last century, the body of medical knowledge soon outgrew the capacity of individuals.

Due to that, as well as the fact that knowledge in scientific medicine is nowhere as sharp as in the physical sciences, the aspects of art and craft remain significant. We are far too complex to be grasped scientifically. And then there is medical ethics. And then there are some very bad stories.

The Vedas have a warning, ahimsa, Sanskrit for not-harm, a-himsa, nonviolence, a core concept of Buddhist life also. This warning has an occidental colleague in primum non nocere, latin for first, do no harm. The origin of the wording is uncertain, but as a concept it belongs to the Hippocratic Corpus of the 5th century BCE.

OK, here we have double agreement on what is relevant, but how does medicine heed this, how do we practice? There is a range. Let’s look at six physicians.

Shiro Ishi (1892-1959)

Director of Unit 731 in Manchuria during WW2. This unit committed incredible atrocities including vivisection of pregnant women. When it comes to cruelty this unit is hard to beat. Shiro Ishi never had his day in court.

Josef Mengele (1911-1979)

Doctor and SS captain in Auschwitz, Angel of Death. When it comes to cruelty also hard to beat. Josef Mengele never had his day in court.

Ernesto „Che“ Guevera (1928-1967)

Idealist physician and revolutionary seeking justice for all by violence. Che saw injustice as a sickness where greed and cruelty of the few is the cause of suffering of the many. He saw the pathological process in the wielding of power. Because the few exercised power without reluctance, he saw in violence the only cure. It backfired and cost his life. It puts him in the line of idealists paying for taking extreme positions. Che has to be respected for what he tried.

Andreas Vesalius (1514-1564)

Founder of modern anatomy, his contribution saved uncountable lives. He received help and was subjected to harm. He died in poverty.

Li Wenliang (1986-2020)

He sensed bad news early and tried to warn about a viral disease, SARS-CoV-2. The authorities did not like it. He contracted the disease himself and died.

Janusz Korczak (1878-1942)

Jewish pediatrician with an orphanage in Warsaw. The Nazis came in the beginning of august 1942. He knew the fate. He walked ahead, holding the hand of one child, followed by a long column of twos, holding hands. He had the orphans dressed in their best clothes, all carried a knapsack with their favorite book or toy. It is recorded that he and all his children boarded the train, never to be seen again.

What Janusz Korczak did is incredibly heroic: He tried under hellish conditions to do the best for his children, and when the inevitable had to be faced he protected them, also from their fears, as much and as long as he could. He was a bodhisattva. I heard the story for the first time when my daughter’s school put it up as a play. I had tears then, I have tears now.

All six were academically trained men, all also educated in medical history, a history illustrating incredible suffering, and medical ethics. The spread is enormous. We better take note and be careful with judgement. Many of us have cozy lives, many of us are not tested.

Most physicians I know are somewhere in the middle. They feel their patient’s misery and give their best to help. Finding something disturbing they try to warn, finding something new they want colleagues to know and to examine such that improvements are possible.

Do no harm bridges orient and occident, it is very important advice. Doing harm not only means to harm others but also to harm yourself. Burdening karma is added, the day comes when it will ripen. Altruism is the egoism that makes sense.

Mindfulness and Meditation as Therapy

The Eightfold Path is a form of therapy, in particular mindfulness and meditation. Mindfulness is knowing what you are doing and meditation is a form of doing, the self doing something with its own self. I, self and mind are in need of clarification here.

The parent of the toddler with a temper tantrum in a busy place usually knows: I want this to stop. Wanting and what it is that does the wanting is clear. But this clarity fades. The possibility to identify the I depends on circumstances, here a tantrum. As circumstances change so does clarity. The I looks fuzzy, and so do self and mind. Take this as an assumption for now, but with an agreement, also for now, that the I is contained in the self and the self in the mind. Although plausible, this entails a new problem, the borders. I dress and go to work, sort of I take my body and take my clothes and take my self, and now we all go to work. This implies the self to have some outer limit, perhaps the clothes or the body odor or some limit farther out. But the mind is even more difficult, it can ponder galaxies and thoughts. It looks as if the mind has no limits except its own, and those may be the universe known or the universe total.

In short, the three are fuzzy in concept and borders. Less fuzzy is the suffering from broken heart and broken bone. And this is the quality medicine has to address. It needs physicians with good hearts. See above what can happen if this is not so.

Mindfulness is masterfully expounded by Thich Nhat Hanh (Thây, 1926-) in The Miracle of Mindfulness (1975), and in Present Moment – Wonderful Moment (1990). The first  is available on INTERNET ARCHIVE. Originally published on 1974 as a letter to Brother Quang. It is translated from Vietnamese into English by Mobi Ho. Present Moment – Wonderful Moment is translated by Annabel Laity.

I met Thây. Once my late wife said: There is a Zen Master we can go to as a family. Done, we visited Plum Village in 1991 with our toddler daughter. The evening we arrived, in the kitchen, Sister Chân Không (True Emptiness) came, sat down, and sayed:  “Here we meditate like this, observe your breath.”

   in  –  out

deep  –  slow

calm  –  ease

    smile  –  release

     present moment  –  wonderful moment

For me and my daughter, possibly also for my wife, this was the first meditation instruction ever. It took me decades to realize that this was Thây’s poetic and genius condensation of the Anapanasati Sutta (Mindfulness of Breathing).

It was my very first retreat. At the end, Thây gave us three an interview. This great honor was because of my wife, a sensitive, I am certain. He was the first man of significance I met. I had the fortune to meet excellent teachers in this life, starting with a mathematics teacher in high school. But Thây was very different, he was what he said and so it was with his monastics. Mindfulness was their primary practice and they lived what they taught. Mindfulness is easy and difficult, I certainly fail daily and have to pick myself up daily.

Meditation is the other therapeutic method. It does slow down and it can lessen fear, consequences of stress, severity of physical reactions. It takes discipline to do and it fosters discipline. In order to work it needs to be taught with credibility. Credibility needs experience and experience needs patience. It is a medication but it cannot be prescribed like a medication.

Meditation, I have to want but it is my self that has to do. In Chan, the first step is sitting down, assume a posture and concentrate, for instance on belly breathing. We call this “meditation with object”. At some later stage the object may disappear, then we do “meditation without object”. In meditation the thing that does and the thing that is done on are congruent. This makes it look to differ from science where subject and object are strictly separate. But this is idealized. In both situations there is a quality of the self, an observer, able to look inward, when meditating, and able to look outward, when doing science. Both are processes, both subject to noise, both need practice and practice.

It seems the old Hindus started this, the Upanishads postulate a small, human, self, to differ from a large, divine self. The former is the familiar one with aches and pains. Sit down and they may lessen. You may enjoy this. No need for metaphysical guidance. But from a certain point on guidance is needed. The choice is yours, if it is Buddhadharma then this means trusting Buddha Shakyamuni as the teacher. But he emphasized, trust is good,  control is better. Practicing is the control.

How does it work? There are no known equivalents to pathophysiological mechanisms. Some simply experience fears lessening and stability increasing. Good. Some do not, but teachers may be of help. Good. But meditation can also foster instability, especially for people with personality disorders, depression, psychosis. Already tendencies in these directions can cause meditation to harm badly. Retreats can trigger mental instability and illness.

Most religions have meditative practices. Major Asian Medicines, like Ayurvedic, Chinese and Tibetan have such as supportive practices. In world-medicine, integrating all knowledge on healing, meditation will certainly have its place.

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