Maryland's Tuskegee Experiment, 2016

According to the 2016 Maryland Medical Assistance Program guidelines,* Medical Assistance (Medicaid) patients with hepatitis C were denied insurance coverage for the treatment of their disease if they were early stage (stage 0 or stage 1). Only patients with stage 2 or higher, in most cases, were approved for treatment. Patients with stage 0 or stage 1 had to progress to stage 2 or higher before the Maryland Medical Assistance Program would approve treatment.

      The demographics of hepatitis C were such that there were thousands of patients in Maryland, many of them in Baltimore, many of them African-American, who needed treatment for hepatitis C. Maryland's denial of insurance coverage to a significant subset of these patients bore similarities to the infamous Tuskegee Experiment, a research study conducted by the U.S. Public Health Service between 1932-1972, in which African-American men in Macon County, Alabama were denied treatment for syphilis, even after penicillin became available as a cure for the disease.

      In 2016 there was an available cure for hepatitis C (ledipasvir/sofosbuvir had a cure rate of greater than 95% in patients infected with genotype 1), but the state of Maryland, because of budgetary considerations, denied treatment to the subset of patients with early-stage disease, even though their disease was easily curable. Hepatitis C, if untreated, can cause a variety of serious and potentially fatal complications, such as cirrhosis, liver failure, and liver cancer. Thus, treatment for hepatitis C can be lifesaving.

      Basically, physicians in Maryland were being told to say to some of their patients, "We can't treat you for hepatitis C, even though it's a serious illness that could cause you to have long-term health problems, including a risk of severe liver damage and liver cancer. You have to get sicker before we can treat you." This is not the way that physicians treat patients with other chronic, significant health problems.

      Of course, the denial of treatment to patients with hepatitis C was not just a problem in Maryland; in California, Washington, and Florida the denial of treatment to patients with hepatitis C by insurance companies had already become a subject of litigation. According to a study by Edlin, et al. (Hepatology, Aug. 25, 2015), in 2016 there were at least 3.5 million people in the United States who were infected with hepatitis C. Physicians who treated hepatitis C often had to file appeals on behalf of their patients when approval of treatment was denied by public or private insurers.

      According to the 2016 guidelines provided by the American Association for the Study of Liver Disease (AASLD) and the Infectious Diseases Society of America (IDSA), "Treatment is recommended for all patients with chronic HCV (hepatitis C virus) infection, except those with short life expectancies that cannot be remediated by treating HCV, by transplantation, or by other directed therapy," and "clinicians should treat HCV-infected patients with antiviral therapy with the goal of achieving an SVR (sustained virologic response), preferably early in the course of chronic HCV infection before the development of severe liver disease and other complications" (www.hcvguidelines.org).

      Of course, there were, and still are, a number of factors that have to be considered regarding the cost of treatment and the likelihood of treatment benefit. Which patients are likely to benefit the most from treatment? Certainly, the stage and activity of the disease in patients must be considered in deciding who will benefit the most. But looking at the patient population most likely to be denied access to treatment, the impact of Maryland's budgetary constraints fell most heavily on the poor, on those who were most economically disadvantaged.

      Moreover, the denial of insurance coverage for treatment of hepatitis C by public and private insurers wasn't justified by medical or scientific opinion concerning treatment of the disease; it was based solely on cost considerations. Insurers could not therefore rightfully claim that denial of treatment was based on considerations of medical necessity. According to AASLD/ISDA guidelines, hepatitis C treatment is recommended for nearly all patients with the disease.

      This issue still needs to be discussed further in the public sphere, and there needs to be greater public awareness that "health care rationing" has become a part of our health care system. There needs to be wider public discussion of the ethics and management of health care rationing, and there needs to be wider discussion of the measures that can be taken to utilize our health care resources more efficiently and equitably, as well as wider discussion of the steps that can be taken to control costs, increase affordability, remove barriers to access, encourage innovation, and achieve other aspects of health care system reform.

ADDENDUM:

On Friday, May 27, 2016, U.S. District Court Judge John C. Coughenour ruled that Washington State's Medicaid program must cover treatment for all patients with hepatitis C, regardless of the stage of their disease. In his ruling, Judge Coughenour said that untreated patients are likely to suffer irreparable harm, and that under Title XIX of the Social Security Act (which establishes federal guidelines for state Medicaid programs), patients cannot be denied access to medically necessary care.

*Maryland Medicaid finally lifted its coverage restrictions in 2020 to allow treatment of hepatitis C for all patients, regardless of the stage of their disease.

The Moral High Ground

There were a variety of celebrity feuds in 2015 (Donald Trump vs. Megyn Kelly, Floyd Mayweather vs. Ronda Rousey, Drake vs. Meek Mill, Taylor Swift vs. Katy Perry) in which one or another of the disputants was alleged to have sought to end the feud by “taking the high road,” that is to say, by refusing to respond to some disparaging remark made about him or her and thereby at least temporarily allowing the dispute to be put to rest.

      Similarly, there were several occasions during the early months of the U.S. presidential campaign in 2015-2016 when Democratic and Republican candidates "took the high road" by refraining from personal attacks against one another. For example, Sen. Bernie Sanders, during a debate with Sec. Hillary Clinton on Oct. 13, 2015, refused to attack her for her use of a private email server to access classified email communications while she was U.S. Secretary of State from 2009-2013. Sanders said, "Enough of the emails. Let's talk about the real issues facing America." Sen. Ted Cruz, on Feb 22, 2016, said that he was “taking the high road” by firing his communications director for having posted a video on Facebook that falsely accused Sen. Marco Rubio of having insulted the Bible. Gov. John Kasich, on Mar. 14, 2016, said, "I will not take the low road to the highest office in the land." Unfortunately, there were also many occasions during the campaign when the candidates did indeed engage in scathing personal attacks against one another.

      What then does it mean to “take the high road” or to “claim the moral high ground”? A variety of explanations may be proposed: taking the high road means being fair, just, kind, and forgiving, and being guided by one’s better and more virtuous impulses. It means treating others as one would like oneself to be treated, rather than as one has been treated by others (although if one has been treated kindly and generously, then one may have a duty to reciprocate).

      Taking the high road also means being mindful, considerate, and understanding of others’ thoughts and feelings. It means turning the other cheek, being tolerant of others’ faults and transgressions, and showing forbearance and self-restraint.

      To take the high road is also to refrain from responding to spiteful and hateful personal attacks against one’s motives, conduct, character, or reputation by launching the same kind of spiteful and hateful personal attacks against those who have initiated them (“taking the low road”). It is also to refrain from pettiness, vindictiveness, revenge, dirty tricks, ad hominem attacks, and attempts to suppress free speech. It is not to descend to the level of those who will use any means at their disposal, no matter how callous, cruel, or heartless, to promote their own personal advantage.

      To claim the moral high ground is not to indulge in “tit for tat.” It is to refrain from always having to have the last word. It is to understand that one may not always be able to change the attitudes and opinions of those with whom one disagrees. It is to accept the fact that there may always be differences of opinion between individuals, and that some individuals’ opinions may be difficult to change.

      To claim the moral high ground is also to be scrupulous about the means that one chooses to advance one’s own ends. It is to keep in mind the needs of those who are disadvantaged and suffering, and to defend the rights of those who have been abused, victimized, stigmatized, discriminated against, or oppressed. It is not to actively or passively condone moral injustice or social oppression. It is to appeal to people’s unselfish and altruistic impulses, and not to surrender to the politics of fear. It is also to promote political, economic, and cultural pluralism, and to encourage peaceful means of conflict resolution.

      To take the high road is also to do whatever is morally right, regardless of any personal inconvenience or disadvantage to oneself. It is not to merely do whatever is expedient in order to solve a problem or settle a conflict. It is also not to engage in devious practices or underhanded quid pro quo transactions.

      Sometimes when people are angry, it may be helpful to let them vent their feelings in order to defuse their anger. “Taking the high road” may mean simply listening to them and not trying to make them understand one’s own feelings of being unfairly subjected to their complaints and criticisms.

      Robert H. Frank (1996) asks the question: at what personal cost (or at what level of personal disadvantage) will we still be willing to take the moral high ground? What kinds of sacrifices, if necessary, will we be prepared to make? Frank argues that various kinds of social and economic choices may be significantly influenced by unselfish motives. For example, the career choices of individuals may be influenced not only by financial incentives, but also by social incentives provided by opportunities to help others and contribute to society. The ability of a corporation to attract new employees may depend not only on its ability to offer attractive financial compensation, but also on its ability to demonstrate social responsibility. Employees may require much higher salaries before being willing to switch to less socially responsible employers.¹

      While taking the high road may be praiseworthy insofar as it is motivated by the desire to act virtuously, it may also be unpraiseworthy insofar as it is motivated by self-righteousness, arrogance, and condescension. Telling others that one is taking the high road may be self-serving. It may be a means of praising and congratulating oneself about one’s own level of self-restraint, even when one has engaged in needless arguments and petty disputes. It may also be a means of allowing oneself to say that one will not descend to a certain level of debate, thus expressing scorn or disdain for whomever is deemed to have engaged in that level of debate. Telling others that one is taking the high road may also be a method of saving face, and may represent a fallacy of relevance whereby the superiority of one’s own motives or intentions is asserted in order to establish the truth and validity of one’s beliefs or opinions.

      If a particular set of moral rules or principles is said to characterize a moral high ground, then what makes that ground higher than other grounds?  Is it because those moral rules or principles are somehow higher, more far-reaching, and of greater priority than others, or because they reflect a higher set of moral values?

      A ground for something may also be a reason, explanation, or justification for that thing. The sufficiency of a ground may thus be its reason-giving ability, its foundational or justificatory capacity, and its explanatory power. The more sufficient the ground, the greater may be its justificatory capacity and explanatory power.

      Paul Bloomfield (2003) explains that the concept of a moral high ground may generate a theoretical topology of normative ethical positions whereby some moral positions are higher or lower than others in terms of their normative consequence or theoretical validity. The notion of a level playing field of normative positions (or the notion that no normative position is higher than others in terms of its consequence or validity) may lead to a form of moral relativism (or the view that all normative positions are equally valid, and that their normative consequence or theoretical validity depends merely on the subjective viewpoint of the observer).²

      Taking the high road may require one to act from a position of strength rather than weakness, since one may not be able to take the high road if one is desperate to make use of any means at one’s disposal in order to gain advantage in a dispute or controversy. At the same time, the taking of the high road or the claiming of the moral high ground may itself bestow strength upon the taker or claimant. The high road or moral high ground is to some degree a path to, or a position of, moral power and authority.

FOOTNOTES

¹Robert H. Frank, “What Price the Moral High Ground?” in Southern Economic Journal, Vol. 63, No. 1 (July, 1996), pp. 1-17.

²Paul Bloomfield, “Is There Moral High Ground?” in The Southern Journal of Philosophy, Vol. XLI (2003), pp. 511-512.

WIlhelm Vossenkuhl's The Possibility of the Good

Wilhelm Vossenkuhl is a German philosopher who was born Dec. 11, 1945 in Engen, Germany. He is the author of many books, essays, and articles, and has taught at many universities, including Bayreuth (1986-1993), Halle-Wittenburg (1990-91), Freiburg, Krakow, Lodz, and Ludwig Maximilian University of Munich (1993-2011). He is currently professor emeritus of philosophy at LMU Munich. His writings have included Ludwig Wittgenstein (1995), Philosophie für die Westentasche (Philosophy for the Vest Pocket, 2004), Die Möglichkeit des Guten (The Possibility of the Good, 2006), Solipsismus und Sprachkritik (Solipsism and Language Criticism, 2009), Philosophie: Basics (2011), and Die Grossen Denker (The Great Thinkers, with Harald Lesch, 2012). His research has centered on epistemology, ethics, the history of philosophy, action theory, and the philosophy of language, and he has explored the work of such philosophers as William of Ockham, Immanuel Kant, Henry Sidgwick, Rudolf Carnap, and Ludwig Wittgenstein. 

      Vossenkuhl appeared with Harald Lesch, the German physicist, astronomer, and philosopher, on the television series, Lesch & Co. (2001-2006), and Denker des Abendlandes (Thinkers of the Western World, 2008-2014). Lesch is currently professor of theoretical astrophysics at LMU Munich, and professor of natural philosophy at the Munich School of Philosophy.

      Honors that Vossenkuhl has received include the International Prize for Philosophy from the Margrit Egnér Foundation (1998), honorary membership in the Sokratischen Gesellschaft (Socratic Society) since 2009, and fellowship at the Centre for the Study of Democracy (Queen’s University, Kingston, Ontario, 2004-2011).

      In 2010, Asteroid no. 210174 was named “Vossenkuhl” by the International Astronomical Union (IAU) in Paris and the Minor Planet Center at Harvard University, at the suggestion of Rolf Apitzsch (Wildberg Observatory, Wildberg, Germany), who discovered the asteroid.¹

      As of 2016, Wilherlm Vossenkuhl’s major writings have not yet been translated into English. Philosophie für die Westentasche has been translated into Dutch, Italian, and Korean, and Die Möglichkeit des Guten has been translated into Polish. Lexikon der Ethik (2008, co-edited by Otfried Höffe, Maximilian Forschner, Christoph Horn, and Wilhelm Vossenkuhl) has been translated into Italian, Spanish, and Chinese.²

      In Die Möglichkeit des Guten: Ethik im 21. Jahrhundert (The Possibility of the Good: Ethics in the 21^st Century), Vossenkuhl describes ethics as a practical science that seeks to answer two basic questions: how “the good” is possible, and how the good, in the form of “the good life,” can be actualized. He says that these two basic questions are inseparable, and that the clarification of the possibility of the good is actually the first step toward the actualization of the good life.³

      The clarification of the possibility of the good involves both a theoretical and a practical commitment. The theoretical commitment to internal and external consistency in our ethical judgments must underlie a practical commitment to coherence. We cannot find the best solutions to ethical problems (those solutions that enable the best possible life, under the given conditions, to be actualized for all human beings) unless our ethical judgments are coherent. Such judgments should enable the actualization (or contribute to the actualization) of the best possible life for all human beings, even when moral, legal, or political conflicts between different individuals or groups cannot be resolved. Without the theoretical commitment to consistency and the practical commitment to coherence, our ethical judgments can make no claim to objectivity.⁴

      Vossenkuhl explains that in every judgment that something is good or bad, we employ a basic standard of what is good or bad. This standard may be moral, ethical, aesthetic, technical, or functional in nature. But within certain limits, the good or bad may change, and thus within certain limits, our standards of what is good or bad must also change.

      The pivotal point of any ethics, according to Vossenkuhl, is the issue of human freedom. Ethics not only presupposes human freedom, it also offers the possibility of promoting and ensuring it. The possibilities of the good increase or decrease with the possibilities of human freedom.⁵

      Two problems for ethics arise from (1) the fact that there may be a scarcity of goods to be allocated to different individuals or groups, and (2) the fact that it may be difficult to determine how unquantifiable normative claims to goods are to be matched to quantifiable shares of distributable goods. These two problems are the source of what Vossenkuhl calls “the basic methodological problem of ethics,” i.e. the problem of how manifold and diverse goods are to be integrated into a whole, whereby a good life becomes possible for all members of society. He proposes a “maxim method” as the solution of this problem, and he explains that this method provides a means of answering both the question of how the good is possible and the question of how the good, in the form of the good life, can be actualized.

      In considering the relation between ethics and morality, Vossenkuhl says that ethics presupposes morality, and that ethical judgments are always in some way connected to moral presuppositions. Ethics therefore has only a limited independence from morality, and must rely on basic moral norms in order to justify its judgments. Such norms include “moral facts” (sittliche Tatsachen), e.g. the fact that killing human beings is wrong, and the fact that human dignity should be respected. These facts are basic and foundational to ethics, and they do not require further explanation.

      Ethics, on the other hand, seeks to explain why actions are right or wrong, good or bad, and thus it attempts to achieve objective validity for its judgments. Criteria for the objective validity of ethical judgments include truth, understandability, verifiability, relevance, and revisability in light of new facts or knowledge. These five criteria of objectivity are not proposed as absolute or final, but they indicate how ethical validity (ethische Geltung) may be distinguished from moral justification (sittliche Rechtfertigung).

      At the same time, the scientific authority of ethics presupposes the natural authority of morality. Ethics, on the one hand, can have scientific authority only if its foundations are independent of morality, but on the other hand, it would have no scientific authority if it were not rooted in morality.⁶ Ethics can therefore criticize morality only by deriving its truth claims from morality. This kind of critique is possible only if moral facts can change or be replaced by new moral facts.

      Vossenkuhl explains that conventional morality is usually recognized and accepted as long as it fulfills its customary functions and is supported by regular social practices. It becomes problematic only when it gives good reasons to mistrust regular social practices, and when it puts its own validity into question on ethical grounds.⁷

      Kant claimed that subjective principles of volition can become objective principles of reason if they comply with the "categorical imperative," which is to act only in such a way that the principle according to which an action is performed can be taken as a universal law of morality. Universal moral commands, such as “keep your promises,” “tell the truth,” “have compassion for others,” and “help the needy as much as you can” correspond to what Kant would describe as objectively valid principles of morality. Vossenkuhl, however, questions whether universality is a meaningful methodological requirement in ethics, and he argues for a situational ethics whose requirements are objectively founded for determinate problems under determinate conditions. He says that every ethics is in some way situational, because it contains elements that characterize the particular individual and collective context of action.⁸

      Vossenkuhl also describes “ethical normality” (ethishe Normalität) as a conflict-free condition in which there is, for a given moral problem, only one rule that must be followed in order to solve it. Other criteria for ethical normality include: the rule to be followed in a situation must be morally valid, and there are no other rules or obligations that conflict with the rule. If the criteria for ethical normality are not all fulfilled, then there are at least three kinds of problems that may occur: (1) there may be moral conflict when more than one rule or obligation holds in a situation and only one can be fulfilled, (2) there may be moral disagreement over the interpretation of moral facts or the application of ethical principles to particular situations, and (3) there may be "normative overloading"(normative Überforderung) if multiple moral duties or norms cannot all be complied with simultaneously. In the case of (1), two kinds of moral conflicts may occur: those that can be resolved, and those that cannot (moral dilemmas).⁹

      The limits of ethical normality, according to Vossenkuhl, are not the same as the limits of ethics. If there is no single rule that can be used to resolve a moral conflict, then there are still right and wrong responses to that conflict.¹⁰ Moreover, the resolution of moral conflict does not necessarily mean the restoration of ethical normality. In cases of normative overloading, for example, we may be limited to achieving some degree of normative unloading. Such cases of unfulfilled moral duties or obligations cannot simply be resolved like pain is resolved after ingestion of a painkiller. We cannot merely address the symptoms of moral conflict or normative overloading; we must also address the causes of those symptoms.¹¹

      The goal of ethics is the clarification of the question of how the good, in the form of the good life, is possible.¹² Among the presuppositions under which the goal of ethics is achievable are that human beings are capable of acting freely, and that they are capable of accepting moral responsibility for their actions. These presuppositions, however, are not purely moral in character, insofar as the nature of human freedom may be partly determined by political, legal, economic, and social conditions.¹³

      Vossenkuhl says that ethics has presuppositions in a wider, and in a narrower sense. Presuppositions in a wider sense include the importance of respect for human life, the importance of respect for human rights, and the importance of respect for human dignity, and these presuppositions belong to morality. Presuppositions in a narrower sense include the existence of legal jurisprudence, legal protection of civil rights, and legal guarantees of basic human freedoms, and these presuppositions denote the conditions without which ethics could not claim to be a practical science and thus argue independently of morality.

      If the clarification of how the good life is possible is the goal of ethics, and the good life is not of a purely moral nature, then the question of how the good life is possible cannot be answered merely by producing a list of virtues that must be fulfilled or duties that must be complied with.¹⁴ It’s always possible for individual actions to be morally good even though the person who performs them has not always acted morally and does not live in a society that makes the good life possible for all. The morally good is a necessary but not sufficient condition for the good life of an individual person or whole society.¹⁵

      Morally good actions form the “cement” of the individual and collective good life, and they hold together other elements that are necessary for such a life. Morally bad actions do the opposite; they disrupt the good life.¹⁶

      We assume that the good life is possible if a variety of conditions are met, such as when human rights are respected, when no one lives in poverty, when no one is discriminated against, when everyone has equal opportunity for employment, when everyone has access to health care, when everyone can live in peace and security, and when everyone fulfills their duties to one another. Since it seems unlikely that all these ideal conditions will ever simultaneously be fulfilled, we learn to understand the good life as basically incomplete. The good life as a whole is never actually achieved beyond the stage of the possible; its modality is that of a possible actuality.¹⁷

      The basic methodological problem of ethics arises from the fact that the goods we need in order to live a good life are often scarce, and from the fact that these goods frequently have an unquantifiable as well as a quantifiable quality. The successful integration of these quantifiable and unquantifiable goods into a whole is one of the conditions of a good life, and successful integration is possible if we can solve the basic methodological problem of ethics, that is, the problem of how material and nonmaterial, normative and non-normative claims are to be recognized as independent from, but at the same time intertwined with, one another.¹⁸

      The problem of determining how scarce goods can be distributed in the best possible way in order for the good life to be achieved by all members of society is a problem of moral economy.¹⁹ Regional and global markets, with their respective operating mechanisms, do not necessarily guarantee a fair and equitable distribution of goods to everyone. The basic methodological problem of ethics, i.e. the problem of determining how indivisible, incommensurable, and indispensable goods are to be connected to divisible, commensurable, and dispensable goods in order to form a social whole, presupposes that in constitutionally governed, democratic societies there are collectively generated goods that serve the welfare of all members and that can accordingly be justly and fairly distributed. However, the basic methodological problem is only solvable if not only gains in, but also losses of goods are fairly distributed.²⁰

      Vossenkuhl proposes two maxims that can be used to solve the basic methodological problem. The first maxim is: a normative claim is changed when it leads to a distribution of goods that cannot be accepted. The second maxim is: a quantitative distribution of goods is changed when it infringes on normative claims. The first maxim is called the “maxim of scarcity,” and the second maxim is called the “maxim of norms.” The second maxim is an essential correlative to the first, because if the first maxim alone were applied, normative claims would, over the long run, be radically relativized, and would become meaningless whenever conflicts of distribution arise. On the other hand, the second maxim may be difficult to satisfy, because no normative claim contains a clear criterion of its own material infringement.²¹ Both maxims must be simultaneously applied in order for the basic methodological problem to be solved.

      Because inequalities in the distribution of material goods can be arbitrated but not abolished by the two maxims, they must be supplemented by a third maxim, the “maxim of integration.” This can be stated as follows: normative claims and distributions of goods can only be changed when neither absolutely indispensable goods nor the value structure of goods as a whole are thereby compromised.

      Vossenkuhl explains that a good life in a social whole is only possible if the goals of processes of distribution are cooperatively determined. The maxim of integration therefore has political consequences, because it requires that the claims of individuals and groups to indispensable goods be protected against infringement. The maxim of integration also corrects any morally unacceptable restrictions of normative claims and distributions of goods.²²

      The maxim method of solving the methodological problem of ethics may not always make possible the good life; even if the method is correctly applied, the possibility of the good life is neither guaranteed nor exhausted.²³ One reason that the maxim method may sometimes be ineffective is that the integration of goods into a social whole is a necessary condition for the good life, but not a sufficient one. Without a just distribution of goods and burdens, the good life is not possible, Conflicts between various group interests and political ideologies regarding the meaning of “the good life” may underlie failure to achieve just distributions of goods and burdens. Thus, pluralism, political compromise, and social cooperation are necessary.

     

      

FOOTNOTES

¹Prof. Em. Dr. Wilhelm Vossenkuhl: Offizielle Homepage, online at http://www.wilhelm-vossenkuhl.de/vita/

²Ibid., at http://www.wilhelm-vossenkuhl.de/publikationen/.

³Wilhelm Vossenkuhl, Die Möglichkeit des Guten: Ethik im 21. Jahrhundert (München, C.H. Beck, 2006), p. 16.

⁴Ibid., p. 21.

⁵Ibid., p. 30.

⁶Ibid., p. 49.

⁷Ibid., pp. 66-67.

⁸Ibid., p. 84.

⁹Ibid., p. 121.

¹⁰Ibid., p. 132.

¹¹Ibid., p. 140.

¹²Ibid., p. 236.

¹³Ibid., p. 236.

¹⁴Ibid., p. 240.

¹⁵Ibid., p 244.

¹⁶Ibid., p. 250.

¹⁷Ibid., pp. 251-252.

¹⁸Ibid., p. 296.

¹⁹Ibid., p. 346.

²⁰Ibid., p. 347.

²¹Ibid., p. 352.

²²Ibid., p. 377.
²³Ibid., p. 417.

The Vimalakirti Nirdesha Sutra

The Vimalakirti Nirdesha Sutra is a Mayahana Buddhist scripture that dates from the second century CE. It was originally composed in Sanskrit and produced in India, but was later translated into many other languages, including Chinese, Tibetan, Sogdian, Khotanese, Uighur, Mongolian, and Manchu.^1,2 The original Sanskrit text was subsequently lost, and the most influential Chinese translation became that of the Buddhist monk Kumarajiva (406), on which the English translations by Charles Luk (1975)³, Burton Watson (1997)⁴, and John McRae (2004)⁵ are based. Robert Thurman’s English translation (1976)⁶ is based on the Tibetan translation by Chos Nid Tshul Khrims (ninth century CE).  Étienne Lamotte’s French translation (1962)⁷ is based on both Chos Nid Tshul Khrims’s Tibetan translation and Xuanzang’s Chinese translation (650), and was translated into English by Sara Boin (1976)⁸.

      The following summary of the Vimalakirti Sutra is based mainly on Robert Thurman’s translation, which is perhaps the most helpful and rewarding one for beginner students like myself who are interested in Buddhist philosophy. Thurman’s translation is clearly presented, extensively annotated, and beautifully rendered in prose and poetry. It includes a preface, introduction, translated text, and glossaries of Sanskrit terms, Buddhist numerical categories, and technical terms.

      “Vimalakirti Nirdesha” can be translated as “Discourse of Vimilarkirti.”⁹ The setting of the sutra is the garden of Amrapali, in the ancient city of Vaisali, India. Buddha appears before a large assembly of Brahmas (creator gods), Sakras (heavenly kings), Lokapalas (guardian deities), and bodhisattvas (enlightened beings who follow the way of the Buddha, and who dedicate themselves to enabling all beings to attain Buddhahood). The assembly also includes heavenly musicians and various supernatural beings, as well as bhikkus (monks), bhikkunis (nuns), laymen, and laywomen.

      Buddha (whose name in Sanskrit means “Awakened One” or “Enlightened One”) explains that a Buddha-field (buddhakshetra) is a field of skillful means and virtuous application. It is a field of high resolve and total dedication. It is a field in which human beings are freed from all hindrances and afflictions. It is the state of an upright mind, a deeply searching mind, and a mind that aspires to enlightenment.¹⁰

      A Buddha-field (or Buddha land, or pure land) is also a field (or land) of the four immeasurables,¹¹ the four means of unification,¹² the four stations of mindfulness,¹³ the four right efforts,¹⁴ the four bases of power,¹⁵ the five spiritual faculties,¹⁶ the five moral powers,¹⁷ the seven factors of enlightenment,¹⁸ the eightfold path of righteousness,¹⁹ and the thirty-seven aids to enlightenment.²⁰

      Vimalakirti (whose name in Sanskrit means “undefiled fame or glory”²¹) is a wealthy layperson, public servant, and teacher of the Dharma (the teachings of the Buddha, the lawful order of the universe), who lives in the city of Vaisali. He is a model of wisdom, understanding, patience, and generosity. In order to gain further opportunity to teach the Dharma, he makes it appear that he is sick, and a vast multitude of people come to visit him in order to inquire about his health. He teaches them that the body of a Buddha is born of love, compassion, joy, and equanimity. It is born of the knowledge and vision of liberation. It is born of gentleness, kindness, and compassion. It is born of awareness (chitta), quiescence (samatha), and transcendental insight (vipashyana).²² It is born of the four kinds of fearlessness,²³ the six transcendental powers,²⁴ the ten powers,²⁵ the eighteen unshared properties,²⁶ and the thirty-seven factors of enlightenment.²⁷

      Buddha knows that Vimalakirti would like others to take pity on him, but when Buddha asks his disciples to visit the layman and inquire about his health, they all are reluctant, because they are so in awe of his extraordinary wisdom. Each of the disciples recounts an episode that left him awed and astonished by Vimalakirti’s powers of insight and understanding. 

       Maudgalyayana, for example, recalls Vimilakirti’s telling him that the Dharma is like infinite space. Vimilakirti had said that the Dharma is empty of self, and that it cannot be made an object, because it transcends all movements of mind. It is without any coming or going, any beginning or ending.  It is remarkable for its emptiness, signlessness, and aimlessness. It cannot truly be taught, and thus the attempt to “teach the Dharma” is presumptuous.²⁸ Maudgalyayana had been left totally speechless by Vimalakirti’s wisdom, and thus he now is reluctant to visit him in order to inquire about his health.

      The bodhisattva Maitreya (whose name means “Loving One”²⁹) recalls Vimalakirti’s telling him that enlightenment is perfectly realized neither by the body nor by the mind. Vimalakirti had said that enlightenment is the eradication of all signs, and that it is free of all presumptions concerning objects. It is also free of the functioning of all intentional thoughts. It is the annihilation of all convictions, and it is free from all mental constructions. It is without subjectivity, and is completely without object.³⁰ Maitreya had been left totally speechless by Vimalakirti’s wisdom, and thus he also now is reluctant to go see him in order to inquire about his health.

      The bodhisattva Prabhavyuha (whose name means “Light Array”³¹) recalls Vimalakirti’s telling him that the seat of enlightenment is a seat of generosity, morality, patience, and perseverance. It is a seat of meditation and wisdom. It is a seat of truth and understanding. It is a seat of love, compassion, joy, and equanimity. It is a seat of liberation, and a seat of the means to unification. Prabhavyuha had been left totally speechless by Vimalakirti’s penetrating insight, and thus he also now is reluctant to go see him in order to inquire about his health.

      The bodhisattva Jagatimdhara recalls Vimalakirti’s telling him that the joy in the pleasures of the Dharma is the joy of unbreakable faith in the Buddha. It is the joy of renunciation of the whole world, the joy of helping living beings, and the joy of sharing through generosity, morality, patience, and effort.³² It is the joy of extending enlightenment, the joy of exploring the three doors of liberation,³³ and the joy of the realization of liberation. Jagatimdhara had been left in awe by the superiority of Vimalakirti’s wisdom, and thus he also now is reluctant to visit him in order to inquire about his health.

      Finally, the bodhisattva Manjushri (whose name means “Noble and Gentle One”³⁴) consents to go see Vimalakirti, and the others follow him to Vimalakirti’s house.

      Manjushri enters, and asks Vimalakirti how he is feeling. He also asks Vimalakirti whether he knows what is causing his illness. Vimalakirti answers that his illness is due to ignorance and the thirst for existence, and that it will persist as long as the illnesses of all living beings persist, because for the bodhisattva, the illnesses of all living beings are his own illness, and his own illness can only be relieved by relieving the illnesses of all living beings.³⁵

      Manjushri then asks Vimalakirti why his house is empty, and Vimalakirti answers that his house is empty because all Buddha-fields are empty. All Buddha-fields are devoid of any fixed nature, and they are empty of any differences or distinctions.

      Manjushri then asks Vimalakirit again what kind of illness he has, and Vimalakirti answers that his illness is formless and invisible, and neither mental nor physical, but due to disturbance of the elements of all living beings. The illness can only be eliminated by the elimination of egoism and attachment, which arise from dualistic conceptions of the world. Dualistic conceptions such as self and non-self, mental and physical, internal and external are empty constructions and have no reality.

      Vimalakirti explains that in order for the bodhisattva to liberate others from bondage, he himself must be liberated from bondage. Liberation is attained by the integration of wisdom (prajna) and skillful means (upayakausalya). Wisdom without skillful means is bondage (bandha). Wisdom with skillful means is liberation (moksha).³⁶ The liberation of wisdom with skillful means consists of not only concentration on the development of living beings, but also concentration on the adornment of Buddha-fields, by planting the roots of virtue in them for the sake of enlightenment.³⁷

      The domain of the bodhisattva is the domain of the four immeasurable minds, the four right efforts, the four bases of power, the five spiritual faculties, the five moral powers, the six perfections,³⁸ the seven factors of enlightenment, and the eightfold path of righteousness.

      The domain of the bodhisattva is also the domain of cultivation of the aptitude for mental quiescence and transcendental insight,³⁹ the domain of realization that all Buddha-fields are uncreatable and indestructible, and the domain of the realization of the unborn nature of all things.⁴⁰

      Whoever is interested in the Dharma is uninterested in attachment, even attachment to liberation.⁴¹ Whoever is looking for secure refuge is not interested in the Dharma, but rather in secure refuge. Whoever holds onto things or lets go of things is not interested in the Dharma, but rather in holding on or letting go of things.⁴²

      The bodhisattva generates the kind of love that is peaceful, because it is free of grasping, the kind of love that is serene, because if is not disrupted by afflictive emotions, and the kind of love that is non-dual, because it is involved neither with the external nor with the internal.⁴³

      A goddess in Vimalakirti’s house suddenly makes herself visible to the assembly, and she scatters heavenly flowers over the disciples and bodhisattvas. The flowers adhere to the disciples, but not to the bodhisattvas, because they do not engage in dualistic thinking. To illustrate the teaching that all dharmas (all phenomena) are without determinate characteristics, the goddess transforms her own body into a male body like Shariputra’s, and she transforms his body into a female body like her own. Then she reverses the process, and their bodies return to their previous form. She explains that all dharmas are similarly without occurrence or non-occurrence, existence or non-existence, birth or death. Enlightenment or Buddhahood is not something that is attained; it transcends present, past, and future. To say that enlightenment is, or has been, or will be attained is to say that it is not, or has not been, or will not be attained.

      When Vimalakirti asks all the bodhisattvas to explain how they may enter the Dharma door of nonduality, they each provide an example of a kind of dualistic thinking that must be avoided, e.g. the separation of creation and destruction, the separation of sinfulness and sinlessness, the separation of happiness and misery, and the separation of knowledge and ignorance. Manjushri tells them that they all have spoken well, but that their explanations, by focusing on some particular teaching of the Buddha as distinguished from other teachings, are themselves dualistic. Manjushri therefore tells them that not to say or explain anything is the way to enter the door of nonduality. When he asks Vimalakirti for his response, Vimalakirti merely remains silent. Manjushri applauds, having seen that remaining silent is the way to enter the door of nonduality.

      Buddha later asks Vimalakirti how he would see the Tathagata (the “Thus Come One,” one of the ten honorific titles of the Buddha), and Vimalakirti replies that he would see the Tathagata by not seeing him at all. That is to say, he would see him as not being born from the past, not passing on to the future, and not residing in the present. He would see him as neither present nor absent, neither here nor there, neither this way nor that way, because the Tathagata is neither weak nor strong, neither concentrated nor distracted, neither conditioned nor unconditioned, neither compounded nor uncompounded.⁴⁴ The Tathagata is without equal, and yet equal to the ultimate reality of all things.⁴⁵

      Still later, after the Buddha has explained to the assembly how to investigate, uphold, and correctly teach the Dharma, he transmits his teachings to Maitreya, so that under his protection they may be transmitted to others. Maitreya and the other bodhisattvas vow to transmit the Dharma to the rest of the world. Buddha then bestows upon his disciple Ananda (whose name means “Bliss”) an exposition of the Dharma, and the name of the exposition is “The Discourse of Vimalakirti.”

FOOTNOTES

¹Robert A.F. Thurman, The Holy Teaching of Vimalakirti [1976] (University Park: Pennsylvania State University Press, 2014), p. ix.

²Burton Watson, The Vimalakirti Sutra (New York: Columbia University Press, 1997), p. 2.

³Charles Luk (Lu K’uan Yu), The Vimalakirti Nirdesa Sutra (Boston: Shambhala, 1975).

⁴Watson, The Vimalakirti Sutra, 1997.

⁵John McRae, The Sutra of Queen Srimala of the Lion’s Roar and the Vimalakirti Sutra (Berkeley: Numata Center for Buddhist translation and Research, 2004).

⁶Robert A.F. Thurman, The Holy Teaching of Vimalakirti [1976] (University Park: Pennsylvania State University Press, 2014).
⁷Étienne Lamotte, L’Enseignement de Vimalakirti (Louvain: Institut Orientaliste, 1962).

⁸Lamotte, The Teaching of Vimalakirti, translated by Sara Boin (London: The Pali Text Society, 1976).

⁹Ingrid Fischer-Schreiber, et al., The Encyclopedia of Eastern Philosophy and Religion (Boston: Shambhala Publications, 1994), p. 406.

¹⁰Watson, The Vimalakirti Sutra, pp. 26-27.

¹¹The four immeasurable qualities of mind are love (metta), compassion (karuna), joy (mudita), and equanimity (upeksha).

¹²The four means of unification are generosity (dana), loving speech (priyavadita), beneficial activity (arthacharya), and exemplication (samanarthata).

¹³The four stations of mindfulness are mindful contemplation of the body (kayanupassana), mindful contemplation of feelings (vedananupassana), mindful contemplation of the mind (chittanupassana), and mindful contemplation of phenomena (dhammanupassana).

¹⁴The four right efforts are the effort to avoid unwholesome states, the effort to overcome unwholesome states, the effort to develop wholesome states, and the effort to maintain wholesome states.

¹⁵The four bases of power are: concentration of intention, concentration of energy, concentration of consciousness, and concentration of investigation.

¹⁶The five spiritual faculties are faith (saddha), energy (viriya), mindfulness (sati), concentration (samadhi), and wisdom (prajna).

¹⁷The five moral powers are: the power of faith, the power of energy, the power of mindfulness, the power of concentration, and the power of wisdom.

¹⁸The seven factors or limbs of enlightenment (sambodhyanga) are: mindfulness (sati), investigation of phenomena (dharmapravicaya), energy (viriya), joy (priti), tranquility (passaddhi), concentration (samadhi), and equanimity (upeksha).

¹⁹The eight paths of righteousness are: right views, right intentions, right speech, right action, right livelihood, right effort, right mindfulness, and right concentration.

²⁰The thirty-seven aids to enlightenment include the four stations of mindfulness, the four right efforts, the five spiritual faculties, the five moral powers, the seven limbs of enlightenment, and the eightfold path of righteousness.    

²¹Taigen Dan Leighton, Faces of Compassion: Classic Bodhisattva Archetypes and their Modern Expression (Somerville: Wisdom Publications, 2003), p. 275.

²²Thurman, The Holy Teaching of Vimalakirti, pp. 23-24.

²³ The four kinds of fearlessness of a Buddha are (1) fearlessness because knowledge of all knowledge has been acquired, (2) fearlessness because all afflictions have been eradicated, (3) fearlessness in explaining hindrances that obstruct realization of enlightenment, and (4) fearless in explaining the right path to end suffering (Rulu, Bodisattva Precepts, Bloomington: AuthorHouse, 2012, p. 285).

²⁴The six transcendental powers are supernatural powers that are said to belong to Buddhas and bodhisattvas, and include (1) the power of being anywhere at will, (2) the power of seeing anything anywhere, (3) the power of hearing any sound anywhere, (4) the power of knowing the thoughts of all other minds, (5) the power of knowing past lives, and (6) the power of eradicating all illusions. (Watson, p. 156.)

²⁵The ten powers of a Buddha are: (1) the power of knowing what is right and wrong, (2) the power of knowing the karmic consequences of actions, (3) the power of knowing the various inclinations of living beings, (4) the power of knowing the various realms of living beings, (5) the power of knowing the capacities of living beings, (6) the power of knowing where all paths lead, (7) the power of knowing all stages of meditation, liberation, and concentration, (8) the power of knowing the past lives of living beings, (9) the power of knowing the deaths and future lives of living beings, and (10) the power of knowing the destruction of all illusions. (Thurman, p. 154.)

²⁶The eighteen unshared properties belonging only to Buddhas and bodisattvas include (1) freedom from illusions, (2) eloquence, (3) absence of attachments, (4) impartiality, (5) constant concentration of the mind, (6) insight into all things, and absence of attachment to them, (7) untiring intention to lead beings to salvation, (8) incessant endeavor, (9) consistency of teachings with those of other Buddhas, (10) perfect wisdom, (11) perfect emancipation, (12) perfect insight, (13) consistency of words with wisdom, (14) consistency of mind with wisdom, (15) knowledge of the past, (16) knowledge of the future, and (17) knowledge of the present. (Watson, p. 149.)

²⁷Watson, p. 36.

²⁸Thurman, p. 25.

²⁹Ingrid Fischer-Schreiber, et al., The Encyclopedia of Eastern Philosophy and Religion, p. 217.

³⁰Thurman, p. 35.

³¹Ibid., p. 120.

³²Ibid., p. 38.

³³The three doors of liberation are: emptiness (shunyata), signlessness (animitta), and aimlessness or desirelessness (apranita).

³⁴Ingrid Fischer-Schreiber, et al., The Encyclopedia of Eastern Philosophy and Religion, p. 219.

³⁵Thurman, p. 43.

³⁶Watson, p. 71.

³⁷Thurman, p. 47.

³⁸The six perfections (paramitas) are: generosity (dana), morality (shila), patience (kshanti), perseverance or exertion (virya), meditation (dhyana), and wisdom (prajna).

³⁹Thurman explains that this kind of insight is called “transcendental,” “because it does not accept anything it sees as it appears,” but instead “penetrates to its deeper reality.” (p. 165)

⁴⁰Ibid.,, p. 49.

⁴¹Ibid., p. 50.

⁴²Ibid., p. 51.

⁴³Ibid., pp. 56-57.

⁴⁴Ibid., p. 91.

The Lankavatara Sutra

The Lankavatara Sutra is a Mahayana Buddhist scripture that dates from the fourth century CE. The author (or authors) is (are) unknown. The text was originally written in Sanskrit and produced in India. The first Chinese translation was completed in 430 CE, and the second in 443.¹ The second Chinese translation is probably the one given by Boddhidarma (c. 470-543), the first Chinese patriarch of Zen, to his student, Hui-k’o (487-593), the second Chinese patriarch of Zen. The sutra thus had an important influence on the development of Zen Buddhism, as well as on the development of other forms of Mahayana Buddhism in China, Japan, Tibet, and Nepal.

      The Lanka consists of nine chapters of prose and poetry, and an additional chapter, called “Sagathakam” (which means “the one with verses”²), consisting entirely of poetry. The title, “Lankavatara Sutra,” may be translated as “Sutra of the Descent into Lanka” or "Sutra of the Entering into Lanka.”³ The setting of the text is the mythological city of Lanka, site of the castle of Ravana, king of the nature spirits and sea serpents. At an assembly of bhikkhus (monks) and bodhisattvas (enlightened beings), Buddha answers a series of questions posed to him by the bodhisattva Mahamati.

      Throughout their dialogue, Mahamati humbly and respectfully addresses Buddha by his various honorific titles, such as Bhagava (“Blessed One”), Tathagata (“Thus Gone One”), Sugata (“Well Gone One”), Arhat ("Holy One"), Maitreya (“Compassionate One”), and Samyaksambuddha (“Fully Enlightened One”). Buddha kindly and patiently responds to each of Mahamati’s questions, and answers them successively in a very direct, thorough, and systematic way.

      According to Buddha’s teachings in the sutra, all things are devoid of self-nature or self-substance (svabhava), insofar as they are not self-caused or self-existent. All things are unborn, because they are not born of themselves; they are born of causation.⁴ All things are empty of self-nature or self-existence, because their nature or existence is not inherent or self-caused; it depends on causes and conditions other than themselves.

      Self-nature is merely a thought construction (vijnapti). The ego, individual soul, or personal self (atman) is also merely a thought construction. Indeed, the ego or personal self is merely an illusion (maya). Absence of self-nature (or egolessness) is the true nature of all things. Truth (satya) is to be found in emptiness (shunyata), egolessness (anatman), suffering (dukkha), and impermanence (anitya).

      When things are falsely seen as having their own self-nature, wrong discriminations are made among them. Discrimination (vikalpa) arises from attachment (abhinivesa) to the notion that things can be differentiated according to their own self-nature, and that they can therefore be categorized according to their being or nonbeing, existence or nonexistence, individuality or generality.

      When the world is understood to be nothing but mind (chitta), false distinctions among things are no longer clung to. When the egolessness of all things is recognized, wrong discriminations are no longer made. When there is perfect knowledge (parinishpanna), there is no longer discrimination regarding the various appearances of things, and the world is understood to be mind-only (chittamatra).

       Ignorance (avidya) consists in attachment to distinctions among things. Ignorance also consists in attachment to dualistic notions of being (sat) and nonbeing (asat), self (atman) and non-self (anatman), individuality (avalakshana) and generality (samanyalakshana), unity (ekata) and multiplicity (bahulya), sameness (samata) and otherness (anyatya), cessation (nirodha) and continuation (prabandha). In order to see things as they truly are, we must avoid dualistic thinking, and we must remain within the realm of non-discrimination (avilkalpa). When mind-only (chittamatra) is understood to be the true nature of things, discrimination is abandoned.⁵ Non-discrimination is a state of understanding the non-duality (advaya) of mind-only.

      Insofar as all things depend on causes and conditions of existence, they have no self-nature, and they do not exist inherently. They are devoid of self-existence. All things are empty (shunya), unborn (anutpanna), non-dual (advaita), and without self-nature (nihsvabhava).⁶ Things are not born of themselves; they are without self-nature, and thus they are in a constant state of becoming.⁷

      Emptiness itself is devoid of self-existence, and has no self-nature. Thus, it transcends both eternalism (sasvatavada) and nihilism (ucchedavada). Eternalism may be described as the theory that all things are eternal and unchanging, and that there is an eternal and unchanging self. Nihilism may be described as the theory that nothing is eternal and unchanging, and that there is no eternal and unchanging self. Eternalism may also be described as the theory that things exist eternally, while nihilism may be described as the theory that nothing exists at all. Emptiness transcends such dualistic concepts, and is the true nature of things. Thus, it is the middle way (madhyama) between eternalism and nihilism. When things are seen as empty, they are recognized in their suchness (tathata).⁸

      To be enlightened is to be free of such concepts as being (sat) and nonbeing (asat), existence (bhava) and non-existence (abhava), permanence (nitva) and impermanence (anitya), eternity (nityata) and non-eternity (anityata). Being and nonbeing, individuality and generality, and sameness and otherness cannot rightly be predicated of things. When such concepts are abandoned, egolessness (anatman) is attained. The appearance of difference between being and nonbeing is actually a result of maya (illusion).

      The Enlightened One does not engage in dualistic thinking and is able to comprehend the truth of mind-only (the truth that the external world is only a manifestation of mind). Buddhahood transcends discursive reasoning and attachment to the external appearances of things. Perfect knowledge is the essence of the Tathagata-garbha⁹ (the womb of Buddhahood, and the place in which Buddhahood is conceived, nurtured, and matured¹⁰). The Tathagata-garbha is emptiness, non-attachment, non-discrimination, and nirvana.

FOOTNOTES

¹Daisetz Teitaro Suzuki, Studies in The Lankavatara Sutra [1930], (Delhi: Motilal Banarsidass Publishers, 1999, p. 4.

²Daisetz Teitaro Suzuki, The Lankavatara Sutra: A Mahayana Text, translated for the first time from the original Sanskrit (London: George Routledge and Sons, 1932), p.xliv.

³Suzuki, Studies in The Lankavatara Sutra, p. 3.

⁴The Lankavatara Sutra, p. 132.

⁵Ibid., p. 254.        

⁶Ibid., p. 65.

⁷Ibid., p. 67.

⁸Suzuki, Studies in The Lankavatara Sutra, p. 446.

⁹The Lankavatara Sutra, p. 60.

¹⁰Suzuki, Studies in The Lankavatara Sutra, p. 405.