A Heart Full of Great Compassion
Originally published on Jan. 29, 2020
Note: The following was written as a contribution to a forthcoming book by Elisa Rossi on “The Therapeutic Encounter in Acupuncture.” Images generously provided by Paul U. Unschuld. For more, see his chapter on “Medicine, Healing, and Popular Religion. The Tang Period Physician Sun Simiao, from Healer to Medicine God,” in Unschuld, Medicine in China. Historical Artifacts and Images, Prestel, 2000)
Introduction
Image courtesy of Paul U. Unschuld.
Image courtesy of Paul U. Unschuld
Known in China and abroad as the “King of Medicinals,” Sun Simiao 孫思邈 is one of the most celebrated figures in the long history of Chinese medicine. He is also the author of China’s first – and still relevant – essay on medical ethics and professional cultivation, which is included in countless oaths of TCM schools worldwide. Despite Master Sun’s elevated status in both China and the West as one of its greatest practitioners, however, an official biography composed several centuries after his death and other historical documents offer not a single hard fact about his professional practice as a physician. To appreciate the significance of this fact, we need to look both at the context of medical practice in early China and the content of Sun Simiao’s teachings. With this understanding, we shall be prepared to read his famous essay “On the Sublime Sincerity of the Eminent Physician,” which I have translated below. The relevance of this information to the topic of the present book on “The Therapeutic Encounter in Acupuncture” will quickly become obvious.
First, let us briefly review Sun Simiao’s life and work. Based on historical accounts, we know that he was an honored consultant to the emperor of the Tang dynasty in 674 CE, at which point he was already far advanced in age. Beyond this fact, the official biographies describe him as a brilliant member of the literate elite who already stood out in his youth for his deep understanding of the philosophical and religious teachings of his time, including Buddhism, which had only arrived in China a few centuries earlier. He was so highly principled that he refused an invitation from an immoral ruler to join his court but chose to hide out in the mountains until the Tang dynasty restored the “mandate of heaven” in the early seventh century, at which point he responded to a personal invitation by the emperor to join him in his new capital. Sun Simiao was an accomplished calligrapher, astrologer, and author of wise sayings, stunned even the emperor with his longevity and youthful appearance, which demonstrated his accomplishment in the arts of “nurturing life” (yangsheng 養生), was an active practitioner of both religious Daoism and Buddhism, and authored books on a range of religious and medical topics. Many of his contemporaries considered him “one of the highly accomplished immortals of ancient times,” as his official biography put it. We would not be wrong to think of him as a sort of medieval Chinese miracle worker and sage characterized by outstanding longevity or even immortality, based on his deep understanding of the Dao and high level of personal cultivation. After decades of service at the imperial court, where he mentored a number of illustrious figures of the high Tang elite, he retired and lived out the rest of his life in seclusion. And this is where the historical facts end. According to later mythology, he retired to the mountains and lived for decades or centuries as a recluse in a cave in the company of a tiger and a dragon, tasting herbs in pursuit of immortality, and, depending on the account, either practiced religious rituals aimed at alchemical transformation or selflessly shared his medicinal and cosmological knowledge with the peasants in the surrounding villages, until eventually leaving his mortal shell behind in this grave in the form of a staff.
Image courtesy of Paul U. Unschuld
So what is the connection between such a mysterious figure and the famous treatise on medical ethics translated below? Why is this murky miracle worker, who according to historical facts never treated a single patient, held in such high regard in contemporary Chinese medicine? What could a consultant to the emperor, member of the literate high society, poet, calligrapher, astrologer, and Buddhist and Daoist practitioner of self-cultivation possibly have to teach us modern humans about medical ethics and the therapeutic encounter? Why would such a person compile a multi-volume encyclopedia on “Essential Formulas to Prepare for Emergencies Worth a Thousand in Gold” (the English translation of his famous Beiji qianjin yaofang 備急千金要方)? And what might the contents and structure of this masterpiece of Chinese medical literature tell us about Chinese medicine and the values and goals of its elite practitioners in early medieval China?
To answer these questions, we need to first look at the realities of medical practice in early China, which is far more difficult than it might appear. And here I must warn you, since what follows is contrary to the impression that most Westerners practitioners have of medical practice at that time: Eminent contemporary practitioners in both China and the West praise and emulate the beloved figure of the traditional Chinese “scholar physician” (ruyi 儒醫 in Chinese), a physician who successfully combines an active clinical practice with a lifelong dedication to ever deepening studies in medical, cosmological, and philosophical literature. While such a scholar-physician’s studies must be rooted in the classical texts from the Han dynasty on and it is so easy and tempting to paint Sun Simiao as a representative of this ideal, medical practice as an acceptable and honored profession for a member of the educated elite did not actually become a historical reality until many centuries after Sun Simiao’s life. During his lifetime, it simply was not acceptable for a member of the elite to make a living by professionally practicing clinical medicine and curing patients in exchange for material compensation. Like many of his literate contemporaries, Sun Simiao studied, collected, and transmitted medical texts and wrote about and discussed medicine and “nurturing life” with his contemporaries and students. Given his elevated status and all the information we do have about his life, it is highly unlikely that he ever cured a single sick person, because it certainly would have made it into the historical record.
Having said that, I am not suggesting that we ignore his contributions to Chinese medicine or even regard them as any less relevant. Quite to the contrary, I ask you to consider the broader implications of this fact that Sun Simiao, as one of the most celebrated figures of Chinese medicine, did not practice medicine in the modern sense of the word. If he did not treat sick patients, then what were his connections to medicine and medical practice and why did he care enough about this topic to write one of the most celebrated texts in China’s medical history?
Perhaps his own words, as recorded in his official Tang biography (Jiu Tang shu 舊唐書) in response to a disciple’s question about the “principles that the famous physicians employ to cure illness,” can suggest an answer:
“I have heard that if one is skilled at talking about Heaven, one must substantiate it in the human realm; if one is skilled at talking about humans, one must also root it in Heaven. In Heaven, there are four seasons and five phases; and winter cold and summer heat alternate with each other. When this cyclical revolution is harmonious, it forms rain; when it is angry, wind; when it congeals, frost and snow; when it stretches out, rainbows. These are the constancies of Heaven and Earth.
Humans have four limbs and five internal organs. They alternate between being awake and sleeping. In exhaling and inhaling, spitting out and sucking in, essence and qi come and go. In their flow, they constitute provision and defense (i.e., yingqi 營氣 and weiqi 衛氣), they manifest as facial complexion, and they erupt as sound. These are the constancies of humanity.
Yang employs the form, and yin employs the essence. This is where Heaven and humanity are identical. When [the constancies] are lost, if [qi and essence] steam upward, they cause heat; if they are blocked, they cause cold; if they are bound, tumors and excrescences; if they sink, abscesses; if they scatter wildly, panting and dyspnea; and if they are exhausted, scorching and withering. Their symptoms arise on the face, and their transformations move around in the body.
Extending this analogy to apply it to Heaven and Earth, it is likewise. Thus the waxing and waning of the five planets, the irregular motions of the constellations, the eclipses of the sun and moon, and the flight of shooting stars, these are Heaven and Earth’s symptoms of danger. Unseasonable winter cold and summer heat are the ascent or blockage [of qi and essence] in Heaven and Earth. Uprighted boulders and thrust-up earth are the tumors and excrescences of Heaven and Earth. Collapsing mountains and caved-in ground are the abscesses of Heaven and Earth. Scattered winds and violent rains are the panting and dyspnea of Heaven and Earth. Dried-up streams and parched marshes are the scorching and withering of Heaven and Earth.
An excellent physician guides [qi] with medicines and [lancing] stones and rescues with needles and prescriptions. A sage[ly ruler] harmonizes [qi] to perfect his power and uses this as support in order to manage the affairs of humanity. Thus, the human body has illnesses that can be cured, and Heaven and Earth have calamities that can be dispersed.”
The point Sun Simiao is sharing with his student here is that knowledge about the human body is relevant not just for treating disease but for our understanding of the processes that govern the macrocosm and, through cosmic resonance, other microcosms, most notably the ruler’s realm of human society. In Chinese, the character that means “to treat” zhi 治 also means “to rule” and has the most basic meaning of “to put things in order,” by restoring harmony and healthy flow. And in both the medical and the political realm, the key principle is to “treat disease before it arises” ( zhi weibing 治未病), which Sun himself describes as the key to nurturing life. For this purpose, both the ruler and the medical practitioner must cultivate the ability, as demonstrated by the ancient sages, to align themselves with the Dao, to conform to the constant changes of the cosmos, which are knowable and predictable through the cycles of yin-yang and the five agents (i.e., “elements”). The cultivation of such a penetrating insight allows the practitioner to assess the state of any micro- or macrocosm, to diagnose disorder when it is still “tiny as autumn down,” and then to restore harmony and balance with minimal invasive action before it erupts as a problem. This principle is expressed throughout Sun Simiao’s writings and is perhaps best expressed in English by the term “cosmic resonance.”
From what I have present so far, Sun Simiao’s teachings are squarely in the tradition of the teachings expressed in the “Yellow Emperor’s Inner Classic”(Huangdi neijing 黃帝內經) and similar early medical classics. What makes Sun Simiao stand out as a medical author and provided the stimulus for the eventual rise of the scholar-physician as an honored member of the elite is the addition of the Buddhist notion of compassion. Even though it took several centuries from Sun Simiao’s writing of his famous essay on medical ethics for his vision to become reality, I argue that his vision of the “eminent physician” (dayi 大醫) laid the foundations for a fundamentally different way of thinking about medical practice in China, as emphasis shifted in elite literature from self-cultivation under the umbrella of “nurturing life” and preventative practices to the treatment of sick patients in the Buddhist-inspired attempt to “rescue all sentient beings indiscriminately from their suffering.”
What we can perhaps read as an intermediate step in this process, the first extension of care from one’s own body to that of others is reflected in the structure of Sun Simiao’s most famous work, the Beiji qianjin yaofang: After the introductory volume, the next three volumes cover “formulas for women.” Recognizing that women are “ten times more difficult to treat” than men because of reproductive process, Master Sun emphasized that “specialists in nurturing life should particularly instruct their sons and daughters to study these three volumes of methods for women until they comprehend them thoroughly. Then what would there be to worry or fear even in the face of a harvest of unexpected surprises?” Following this theme, the next major section covers pediatrics. As Sun himself explains, “The present collection of treatments is arranged by placing the treatments for women and children first, and those for men and the elderly afterwards. The significance of this structure is that it venerates the root.” Whether it was conscious or unconscious, I suggest that Sun Simiao’s compassionate concern with alleviating suffering, arguably a Buddhist concept, is what led him to the radically innovative notion of prioritizing the care of women and children as an extension of “nurturing life” beyond one’s own body to the larger body of one’s family. And from this concern with the collective body of the family, it was only a logical step further for the government and leading medical authors in the Song dynasty several centuries later to argue for the need to provide consistent high-level medical care also for the social body of the population as a whole. As a result of this altruistic concept of the government as being in charge of healthcare for its people, just like the gentleman in a traditional extended elite family was seen by Sun as charged with the care for the members of his family, the government actively became involved in medical education and healthcare. As a result, it recruited medically-inclined members of the literate elite as well as members of traditionally lower-class medical families to formally study medicine in the new ideal of the “scholar-physician”; sponsored the research, publication, and distribution of standardized print editions of all major classics; compiled extensive official formula compilations; and established a network of imperial pharmacies to dispense both patent and individualized prescriptions. While these changes initially only affected a tiny percentage of China’s population, they were the foundation for what we today tend to associate with the term “traditional Chinese medicine.” For this reason, the significance of Sun Simiao’s essay that I have translated below, actually extends far beyond the historical fact that it is the first formulation of medical ethics in China. I hope you read it slowly so that it may inspire you too to “develop a heart full of great compassion and empathy,” to “pledge your desire to rescue all sentient beings indiscriminately from their suffering,” and to “develop a sense of purpose marked by conscience, sympathy, and loving care.” In this way, your medical practice can truly become the perfect vehicle for the manifestation of the twin Buddhist ideals of wisdom and compassion.
Translation
On the Sublime Sincerity of the Eminent Physician
(Sun Simiao, Beiji qianjin yaofang, volume 1, chapter 2)
Zhāng Zhàn[1] said: “The reason why the methods in the classics are so difficult to grasp in their essence is that they come from such a lofty origin.” Nowadays, there are diseases that are identical on the inside but different on the outside, as well as diseases that are different on the inside but identical on the outside. Therefore, abundance or emptiness in the five zàng and six fǔ organs and the free flow or blockage of blood in the vessels and of yíng Provisioning and wèi Defense are certainly not topics that can just be observed by eyes and ears. They must first be examined by diagnosing signs: At [the three positions of pulse diagnosis] cùnkǒu (inch opening), guān (bar), and chǐ (cubit), for the presence of disorder in terms of a floating or sunken, string-like or tight [pulse]; in the flow at the shù transport points, for differences in whether it is high or low, shallow or deep; and in the flesh, sinews, and bones, for differences in whether they are thick or thin, hard or soft. Only those who apply their heart with sublime subtlety can even begin to talk about this!
Nowadays, however, people pursue matters of utmost sublimity and subtlety with minds of utmost coarseness and shallowness. Is this not dangerous indeed? To add to what is already overabundant or to take away from what is already empty, to penetrate further into what is already flowing freely or to impact what is already obstructed, to cool what is already cold or to warm what is already hot, this only means that you are doubling the disorder. And looking at these patients’ life, all I see is their death! Therefore, the difficulty and sublimity of the technical skills required for the methods of medicine and for divination by means of tortoise shell or yarrow stalks is not something that we receive from the spirits. So how do we grasp their obscure subtleties?
There are fools in the world who have studied the formula texts for three years, and it is said [of them] that there is not a single disease in the world that they can treat. And after treating disease for three years, they finally even become aware that there is not a single formula in the world that they can use. For this reason, students must comprehensively acquaint themselves to the greatest extent with the origins of medicine, tirelessly refining their understanding with diligence. They may not recklessly repeat rumors and then claim that this is all there is to the Dào of Medicine! Deep indeed is their self-delusion!
In all circumstances, when you treat disease as an eminent physician, you must quiet your spirit and fix your intention. You must be free of wants and desires. And you must first develop a heart full of great compassion and empathy. You must pledge your desire to rescue all sentient beings indiscriminately from their suffering. If someone facing disease or disaster comes to you seeking relief, you may not inquire whether the person is of noble or low class, or is poor or wealthy, [or consider their] old age or youth, beauty or ugliness, or whether you detest or like them or whether they are your friend, whether they are Chinese or barbarian, a fool or a sage. You must treat all of them exactly the same as if they were your closest relatives.
Neither must you look to the front while turning around to cover your back, worry about your personal fortune or misfortune, and guard and cherish your own life. When seeing the suffering and grief of others, you must act as if it were your own and open your heart deeply to their misery. You must not avoid dangerous mountains with rugged cliffs, any time of day or night, the cold of winter or heat of summer, hunger or thirst, fatigue and exhaustion. You must focus your heart on attending to their rescue and must not have a concern about hard labor or outward appearances. Acting like this, you can serve as eminent physician for the masses; acting against this, you are a horrid thief to all sentient beings.
From ancient times, when the famous sages treated illness, they frequently used living things to rescue those in critical danger. Even though it is said that we should treat animals as humble and humans as noble, when it comes to loving life, humans and animals are the same. Regarding [the practice of] injuring another to benefit oneself, all things suffer identically in their feelings. Isn’t this even more true for humans? To kill life in order to save life, this takes you even further away from life. As such, the reason why the methods that I am putting forth here do not use living things as medicine is derived directly from this. Things like horseflies and leeches, which are available in the market after they are already dead before you use them, are not affected by this rule. In terms of using chicken eggs as a medicinal substance, as long as their content is still mixed and has not yet separated [into a distinguishable chick fetus], in occasions of extreme emergencies, when there is no alternative, use them with restraint. If you can avoid using them, this shows great wisdom but is something that may be unobtainable.
When dealing with conditions like sores or wounds, diarrhea, foul smells, or insufferable filth, which others hate to look at, to develop a sense of purpose marked by conscience, sympathy, and loving care, and to not allow myself to initiate a single thought of resentment in my heart, this is my intention.
Now in terms of the appearance of the eminent physician, present yourself as having obtained a spirit that is clear like settled water and as looking inward, as dignified when observed, as being in a state of bountiful abundance, and as neither too glorious nor too obscure. In discerning disease and diagnosing illness, with consummate intent and your deepest heart, carefully observe the signs on the body, down to the tiniest detail, without missing anything. In the process of judiciously prescribing acupuncture and medicinals, you must not overlook anything or make a mistake. Even though you may say that a condition must be treated with great urgency, you must acquaint yourself intimately with each case so that there can be no doubt. You must attend to every detail and ponder it deeply and may not place anything above [the patient’s] life, hastily showing off your skills with heroic speed and pandering to fame. This is the greatest lack of humaneness indeed! Furthermore, when you arrive at a patient’s home, if you are getting pampered with gorgeous silks to fill your eyes, do not look to the right or left. Where zithers and flutes delight the ear, you must not appear as if you were enjoying yourself. Feasted on delicacies in rapid succession, eat as if they had no flavor. Presented with fancy liquors lined up in a row, look at them as if they did not exist. The reason for this [rule] is that if a single person is left out, the full hall must not be joyful. Even more so in a situation of obvious suffering, you may not stray from this requirement. To have a physician act indifferently, or [even worse] full of joy and delight, haughtiness and self-absorption, this is a disgrace in the eyes of spirits and humans alike and not something a person of utmost cultivation would ever do. This then must be the foundational intention in medicine!
Now concerning the standards of medical practice, you must not speak excessively or tease in jest, chatter and banter boisterously, pass judgment on what’s right or wrong, discuss other people’s affairs, flaunt your reputation, slander other physicians, or brag about your own accomplishments. To have cured a single disease by chance and then put on airs, acting superior to others and stating that you are unequalled in the world, this is the Achilles tendon of physicians! Lord Lao said: “When humans carry out acts of visible virtue, other humans will reciprocate on their own; when humans carry out acts of hidden virtue, the spirits will reciprocate. When humans carry out acts of visible vice, other humans will reciprocate on their own; when humans carry out acts of hidden vice, the spirits will harm them.” Pursuing these two paths, how could the retribution of visible and hidden acts ever be mistaken!
For this reason, as physician, you may not depend on your own greatness and focus your heart on official ranks and material possessions, but you must create a heart intent on relieving suffering. Then, in the midst of experiencing the obscurity of your fate, you will yourself feel blessed in multiple ways. Moreover, you may not take the wealth and rank of others as a reason to prescribe valuable and expensive medicinals, making them difficult for others to seek, and bedazzle others with your own competence. Truly, this is not the path of integrity and reciprocity! Because my intention lies in rescuing and saving [people], I have discussed [medicine] by bending it and breaking it up into bits and pieces. Students must not be insulted by the vulgarity of my words.
[1] A fourth-century scholar, philosopher, and specialist in “nurturing life.”
