In Buddhism, compassion is the central moral ideal that all are asked to practice toward people everywhere and at all times. Due to his special concern for the suffering, pain, and illness of his fellow human beings and animals, and because of his desire to relieve their suffering, the great Buddhist King Ashoka of the third century BCE decreed, "Let healing be brought to man and beast." By the beginning centuries of the common era, vast halls of medicine and medical universities had been established under Buddhist influence and patronage throughout India and Southeast Asia. The Buddha himself had manifested concern for the health of his followers. He said to his disciples, "If you will not take care of each other, who else, I ask, will do so? Brethren, he who would wait on me, let him wait on the sick." The Buddha also remarked on the qualities needed by those who would care for the sick. A good nurse or physician, he went on to say, is one capable of prescribing the proper remedies for sickness--one who can distinguish between which treatments are fit and which are unfit. Equally important, the good nurse is one who cares for the patient, not out of greed, but out of compassion, and is capable of cheering, encouraging, and comforting the sick. Medical knowledge and skill by itself, then, is insufficient; without proper motivation and the ability to form a caring relationship with the patient, the Buddha stated, one is "of no use as a nurse."

Out of his compassion for human suffering, the Buddha commissioned his disciples to "go forth for the well-being and happiness of all mankind." Since that time, compassion has been given a central place in Buddhist ethics. This spiritual ideal is of great importance, particularly in cases where people are the most vulnerable to pain and suffering--in infancy, in early childhood, in sickness, in disability, and near death. In these conditions people are least likely to be able to act for themselves, to be self-sufficient. They rely upon, are dependent on, are at the mercy of, other human beings to help them and care for them. This caring and assistance is sometimes a matter of life and death. Without the active concern and efforts of others, vulnerable people cannot survive or can live only a minimal existence. Compassion then has a special application in medicine, where one is dealing with vulnerable, weak, helpless, and dependent people.

Compassion and Health Care

In health care, compassion implies two obligations that health care providers have toward their patients. One is to do everything in their power to enhance the health and well-being of patients. The second is to do no further harm to those already experiencing the harm of pain and helplessness, disease, disability, and dying. In this case, compassion implies that one is to seek to prevent harm (ill health and death) if it is within one's power to do so; if one cannot prevent harm or pain and suffering, then one ought to seek to remove it (cure the disease, restore to health); and if one cannot remove it, one's obligation is to alleviate it or lessen it, that is, relieve the suffering, care for and comfort the dying, and maintain as best one can those beyond one's capacity to cure. This practice of compassion in health care can involve self-sacrifice on the part of health care providers. It means giving time and energy and reversing priorities, even at the expense of one's own comfort and benefit. This practice of compassion, however, has its limits in relation to the needs of patients. The limits are set when the expectations of patients go beyond the professional capacity of the health care providers or against their ethical convictions. For example, a request for open-heart surgery cannot be met by a physician who is not a heart surgeon. A physician may also refuse to act on a patient's request, for example, in the case of abortion or suicide, when such a request is against the physician's professional or personal ethics.

Similarly, in the case of a patient in a persistent vegetative state, health care providers may refuse to prolong the treatment indefinitely when such treatment is futile and inordinately overburdensome to the patient and the relatives. Provision of such services should be considered in terms of fairness to other patients' needs. Compassion embraces justice. To render justice is a social form of compassion by recognizing the other as a moral equal and giving and claiming what is due a fellow human being. Without justice, compassion is sentimental; without compassion, however, justice can be rigid and heartless.

In some cases, compassion may mean permitting patients to meet the end naturally without futile prolongation of treatment. This "allowing to die" is believed to be different from the act of killing, even if it is mercy killing. Whether this is against the first precept is still being debated among Buddhists. However, it is clear that Buddhism is against euthanasia--the quick, supposedly merciful ending of life to relieve pain. The Buddhist objection to the experience of unbearable pain as the reason for euthanasia is justified. The hospice movement has shown that we already possess the means to control suffering and the knowledge to maintain people without severe pain.

With regard to the argument that one is seeking to hasten the death of another in order to be merciful or to show loving-kindness, Buddhism considers it a form of paternalism and self-deception. People have different pain thresholds, and various psychological, emotional, and spiritual factors play a great part in how much pain or suffering people can endure. People can endure pain if they find meaning in it. We might think that another is suffering unendurable pain and therefore ought to die. In this, we are paternalistically imposing our values upon the other because we would not want to go on living in such circumstances. But this does not mean that this, even painful life is meaningless to them. In Buddhist psychology, the felt desire to end another's suffering may derive from our own inability to cope with it and our own anguish in watching another suffer.

Actually, we want to save ourselves from further suffering, not the other person. Instead of euthanasia, Buddhist compassion offers a different approach. Compassion toward the dying means giving them special care to enable them to live their last stage of life in the most meaningful way. This special care consists of reducing the pain of the dying without impairing their faculties or clouding their consciousness and assisting them to have wholesome thoughts. Such thoughts in their last moments will, according to the Buddhist view, help inaugurate a new life in an auspicious way.

Monks and Health Care Services

Theravada Buddhism, also known as Hinayana Buddhism, has been considered to be the core of Thai culture since the establishment of the first kingdom (Sukhodaya) in the thirteenth century. The present Thai sangha, the order of Buddhist monks, comprises two sects, namely, the older majority group, Mahanikaya, and the reformed order, Dharmayuttika, founded in the nineteenth century. Within these two groups, there are monks who are labeled "forest monks" or "town/village monks" in accordance with the specific vocation each is pursuing, that is, meditation practice or learning.

A common misunderstanding about Thai Buddhist monks is that they are solely concerned with renunciation of the world and are thus completely indifferent to the ebb and flow of life. In fact, the monks are known among the Thai people for their social work and compassionate service to laypeople. Even the forest monks, who dwell in deep forests practicing meditation for self-perfection, usually, after such spiritual conquest, come out of the forests with enlightenment and compassion, crisscrossing the country, making themselves freely accessible to laypeople of all walks of life. Apart from their actions serving as a "field of merit" in which to sow good karma to benefit their present life, the monks teach their adherents meditation to put them on the right path to total release from all miseries and the endless wheel of life and death. These enlightened monks also use donated money to build secular schools and hospitals or to provide state institutions, which suffer from inadequate budgetary allocation, with needed equipment.

Town/village monks, who reside at temples (wats) in the community, serve the laity as its moral mentor and psychological counselor as well as personal and social advisor, along with following the vocation of learning the Dharma and the ancient Pali language. They also perform various religious rites for people of all societal sectors and teach them the Dharma to stimulate spiritual development in Thai society. In rural areas, many of them are engaged in community development work to relieve the wretched lot of poor villagers. There the monks' social work includes road construction, well digging, and the establishment of village cooperatives. In urban areas, their work for the poor ranges from the giving of free lunches to schoolchildren to the establishment of drug rehabilitation centers and orphanages.

There are numerous monks who live and selflessly work for others, especially to contribute to the health and well-being of the poor and the disadvantaged. One monk, for example, in Nakorn Sridharmarat Province in the south, uses the skills and knowledge gained in his secular life to treat poor villagers' broken bones as well as diseases of the bones. In such healing, he uses the knowledge of herbal medicine gained from the study of ancient medical texts passed down through the ages. The patients who come for his help are not only from villages in that province but also from other provinces, since they do not have enough money to meet the cost of healing at hospitals. Health care given by the monk is accessible, available at all times, and free, without any solicitation for donations.

When asked about his dedicated work, the monk said, "I am very glad to help people and to make myself available to them at all times. I am not tired of this work, even if there are too many patients each day. I have no special office because I like to sit where people can find me easily. I always treat the patients impartially, wanting to restore health to all of them. I am providing them not only free services but also simple food and lodging when needed and available, since these people are poor. Even though some advised me to keep a record of their names and addresses so that when donations are needed the temple may contact them, I refused to do this. This is because, as a Buddhist monk, I am obliged to help all those who are in suffering. Actually, the poor villagers have been providing me with food and other necessities. So why should I ask them to pay for the cost of healing? Besides, the lodging and food that I give them here, when available, are very simple in comparison with what hospitals are offering them.

People also like to come here with their necessities, such as mats, mosquito nets, and pots and pans. I do not want them to feel obligated to give something back to the temple in return. They already spend enough money on bus or boat fares. So I do not want them to spend more for donations. Of course, if I ask them for donations, certainly they will have to borrow money for such donations, and as a result be burdened with debts. That is the underlying reason that I do not want to ask their names and addresses. For me, they are just suffering people who need help, and I am very glad to be helpful to them."

As a result of the compassionate work of this monk, patients receiving treatment at the temple also display the tendency to share. One boy--from a poor village in one of the southern provinces--related his feelings and experiences after falling from a truck and breaking his hip and leg. He said, "I do not have enough money to go to the hospital in the city. I went first to a private clinic, where the doctor asked me whether I could pay for the treatment. I said I could not because I have no father and my widowed mother cannot work. When the doctor knew that I did not have enough money, he was reluctant to treat me. I came to the temple on the advice of some friends. Here I am receiving treatment free of charge. And my mother can also be with me and cook for me. Luang Poh [the monk] never asked for my name. He only wanted to know the cause of my pain and suffering. He visits me each day, both in the morning and evening. At the beginning, when my mother first brought me here, I could not move my body. But now I can move it, though slowly, and I am sure that very soon I will be all right. If I had gone to the hospital, my mother would have had to borrow money, and it would have taken months for us to repay it. Here Luang Poh does not ask for any money at all, and I am very happy to be here."

Another patient, a girl from a different province, fell from her house, which is built on stilts, and suffered a bone fracture that makes walking a painful experience. She is also poor, with no father and a mother who lives from hand to mouth. When asked about the reason for coming to the temple, the girl said, "My mother could not take me to the hospital, as we have no money. We cannot borrow money from our relatives, as they are also poor. Here at the temple there is no need for us to pay for treatment. I am now recovering through the help of Luang Poh."

The view of this patient is typical of others who seek help from the temple because they cannot afford health care at hospitals and clinics. It is also very easy for the patients to meet the monk because he is always at the temple to attend to their needs. Even though it is usual for lay Buddhists to pay respect to the monk by addressing him with special language, he does not require any ceremony at all. He only wants to know the cause and nature of the pain so that he can give the appropriate treatment.

There are many similar monks in other provinces around the country who, out of compassion, use their knowledge of herbal medicine to take care of poor sick people without any charge or for a nominal fee. Most of their patients are cured, and treatments are quite successful. Many of the diseases the monks treat are those that rural people regularly suffer from, such as respiratory diseases, bone fractures, allergies, glaucoma, ulcers, high blood pressure, diabetes, back pain, and snakebite. Treatments usually consist of herbal concoctions combined with religious rituals and the practice of meditation. Some monks, such as Phra Lek Pabhasara of Wat Klongsam in Pathumdhanee, even treat cancer patients. A few of these cases have been successfully treated, with the disease controlled or eliminated altogether. Even some physicians from hospitals recommended that their dying patients go to the temple for humane health care. In such cases, the patients are taught meditation to calm the mind and ultimately to accept death in tranquillity. They are also provided a chance to make merit to ensure a good rebirth.

Apart from cancer, another deadly disease in Thailand is AIDS. The Ministry of Public Health estimates that the number of Thais infected with the HIV virus is 750,000, nearly 20,000 of whom have developed full-blown AIDS. The problem AIDS patients have been encountering is that the government cannot provide adequate health care for them. An additional problem is that many health care personnel and members of the general public have hostile attitudes toward these sufferers. Accordingly, AIDS patients may find it difficult to procure treatment at hospitals, and their families and friends may shun them. In addition, when their infection is discovered, their employers usually dismiss them.

Such experiences of rejection make these AIDS sufferers very sad, some becoming depressed to the point of wanting to end their lives, or some reacting aggressively by intentionally seeking to spread the deadly virus. Like the rural poor we have discussed, AIDS sufferers usually turn to the temples as the last resort. The monks, unlike laypeople, cannot turn their backs on these sufferers and try their best to find ways and means to help them. For example, Phra Preecha of Wat Tam Sriwilai in Saraburi near Bangkok uses special herbal concoctions to boost the patient's immune system to resist the virus. The herbs, numbering thirty, used in these concoctions cannot be bought from the indigenous drugstores but have to be collected in the deep jungle.

Along with herbal treatments, the monk prescribes a vegetarian diet, merit making (such as helping others and observance of the precepts), and the practice of meditation. Merit making and meditation are components of the healing process, because the monk believes that healing has something to do with the spirit. Through merit making the patient develops an ability to give, while meditation enables the patient to develop self-control and let go of stresses caused by anger and anxiety.

Though this particular treatment is still experimental, there are at least two specific cases out of one hundred AIDS patients in the earlier stages who have been declared by hospital physicians to be completely cured. Other patients remain asymptomatic and either stabilize or increase their T-cell count.

Consequently, a large member of patients have come to the temple to seek help from the monk, who, in the absence of any government support, is quite overburdened, particularly when the resources of the temple are very limited. The monk has only two assistants, and he himself has not enough time to rest, having to treat the patients from dawn to dusk. This raises the question of the limits of compassion. "I am very tired," he says, "and my health is in deterioration. At times while treating patients, I have to rush to my lodging to throw up because of overwork and exhaustion. But I have great sympathy for these sufferers who have no other place to go. Of course, I treat them free of charge. But some of their relatives like to donate money to the temple. This enables me to buy more herbs from villagers and to help more patients. The temple has very limited space. I like to advise people to take the medicine home and to come back only if there is no improvement. If they follow my advice on diet, merit making, and meditation while taking the prescribed herbal concoctions, I expect the cure to be effected in one and a half years. Apart from treatment, I encourage all patients to have hope instead of despair, otherwise their condition will become worse. It is not important for me at all to know how they got AIDS and whether they are good people or not. All I know is that they are in great suffering and I have to help to relieve their suffering."

Wat Tam Sriwilai treats AIDS patients only in the earlier, curable, stages. There is another temple that takes care of those in the full-blown stages where no cure is possible. This temple is Wat Phrabat Namphu in Lopburi, another province near Bangkok, and the monk is Phra Alongkot. Moved by compassion for those AIDS sufferers who have nowhere to go for needed care, the monk has transformed his small temple into a hospice. Without professional knowledge about AIDS, he wears no protective clothing when treating these patients. When AIDS patients were initially accepted into the temple, other monks fled, and villagers threatened to stop supporting the temple because of their fear of AIDS. Lacking proper knowledge about this deadly disease, the villagers believed (wrongly) that the disease could be spread easily, for example, through mosquito bites, and as a preventive measure, demanded that the monk keep the patients under mosquito nets at all times.

During this period, Phra Alongkot had to deal with the hostile attitudes of the villagers as well as procure adequate resources to provide proper health care for the AIDS patients. After three years of hard work, he managed to persuade the villagers to develop compassion for these patients and to support the temple's humanitarian work. Gradually the villagers began to follow him, even visiting the patients and helping to treat them. The treatment consisted mostly of traditional herbs, diet, and meditation. Apart from the medicinal treatment, patients are encouraged to form a support group and to enjoy life, however short it may be. At present, the temple has five volunteers from the villages. The monk is now receiving increasing assistance, including financial support from NGOs and the general public. Government agencies are also encouraging other temples to follow the example of Wat Phrabat Namphu.

Even though the patients cannot be cured, the temple is a refuge for them in their final days. At the temple, they are supported and cared for without any charge, and they often live longer. When they do pass away, they let go of their lives peacefully. The provision of free health care adds a burden for the temple, however. Few relatives visit the temple, and when the patients die, their bodies are cremated and their bones kept at the temple because relatives will not receive them for fear of contracting the HIV virus.

The Ministry of Public Health and some NGOs are assisting the temple to initiate a home-care project for AIDS sufferers that will provide a supportive community for them. To implement this project, Phra Alongkot has to work harder to persuade people in different villages to take care of AIDS patients in their own areas and not bring them to the temple. It is not important whether he succeeds, for he has already set an example of translating the high ideal of Buddhism into practice and has contributed, though in a limited way, to the alleviation of suffering in contemporary Thai society. When divorced from action, this moral ideal of compassion is nothing at all.

All of these monks represent only a small portion of Thai monks who do not totally withdraw from the world to pursue their main vocation of following the Buddha's way to liberation from this samsaric existence, or the endless cycle of life and death. Sympathizing with the miseries of the poor and the disadvantaged, these monks selflessly dedicate themselves to the alleviation of their suffering and the restoration of their health. This is an important way of helping people live a creative life, free from suffering caused by illness and disease, thus being able to practice the Dharma as well as follow the Buddha's way to be released from all miseries. Where would society be, where would Buddhism be, were it not for the examples of those who pursue the ideal of compassion by living and working not for themselves but for others?