Donation, education, and bodies in Taiwan
Silent mentors are positive role models who have given so much to the study of medicine, without even uttering a word… . Even in death they teach medical students what it means to give, to love, and to learn. Their decision is a great act of altruism. What they do for others and the world remains immortal. – Sou-Hsin Chien, superintendent of Dalin Tzu Chi Hospital
In the mid 1990s, teaching hospitals on the island of Taiwan suffered a severe shortage of cadavers for the education of students in basic anatomy. As a now well-known story goes, in 1995, a Ms Lin (林蕙敏) from Changchun, a small town near Hualien on the mountainous east coast of Taiwan, donated her body to the Mahāyāna Buddhist Tzu Chi Hospital so that it could be used to teach its students. Her donation was the first to a programme fostered by the Buddhist Compassion Relief Tzu Chi Foundation (慈濟, Tzu Chi Foundation hereafter), a nongovernmental organisation with bases in forty countries, active in medicine, environmentalism, education and international aid relief. During its first decade, this programme has gathered from the public more than thirty thousand pledges to donate. It is called the ‘Silent Mentor programme’ and, lauded in terms like those in the epigraph above, has reconfigured anatomy training in a way antithetical to methods of medical pedagogy familiar in the West. Not only do students know the identity of their cadavers but they also research their lives, meet their families, and in Buddhist ceremonies mourn with them. During anatomy classes, digital presentations detailing the Silent Mentor’s life play on screens above the trolley and, in the teaching hospital, posters with photographs and biographies of past Silent Mentors line corridor walls.
This article places the Silent Mentor programme in the context of established medical pedagogy, focusing on growing discussions about anonymity in donation, detachment in medical training, and new regimes of accountability in the pedagogical relation between students and cadavers. It emerges from research conducted in Taiwan in the summer months of 2010, [note 1]The research upon which this article is based was made possible through support from the Economic and Social Research Council International Science and Bioethics Collaborations grant RES-062-23-0215.
while I was undertaking a separate project focused on the work and improvement of biomedical ethics review committees (Douglas-Jones 2012, 2015). As I researched, spoke, and wrote about ethical review with clinicians, committee members, and administrators, I became interested in the responses that bureaucratic, procedural ethics was eliciting from trainees: they were being challenged to think about the kinds of doctors they were, and the bearing this had on the clinical researchers they wanted to be. Similarly, the Silent Mentor initiative is a rich resource for anthropological thinking, challenging the idioms through which the corporal gift is to be understood. It further affirms that bodily donations need to be understood within the different cultures of death and disposal in which they arise, the ‘thanatologies’ of this special issue (see also Davies and Rumble 2012; Copeman and Reddy 2012). In the context of the Tzu Chi Foundation’s broader work, statements by dying donors calling their donation a ‘last act of recycling’ align body donation provocatively with the foundation’s extensive Taiwan-wide plastic recycling initiative (Lu 2011; Lee and Han 2015). This reference to ‘recycling’ invites reflection on the way the foundation foregrounds ‘use’ across its diverse voluntary practices. It brings forward the ‘use’ value of bodies (offering knowledge, education) and plastic (for aid blankets, disaster relief), as well as the practices that transform bodies (cutting, stitching, mourning) and plastic (unwrapping, cleaning, melting, reconstituting) into ‘useful’ things after the end of their lives. The Silent Mentor programme challenges anthropologists to draw together the separate literatures on religious movements with anatomists’ accounts of medical pedagogy, to revisit circular economies as modes of reshaping accountabilities and the ethics of consequence (Lu 2011; Chang 2016). Given this breadth of possible engagements and framings, the present article cannot do justice to each dimension, but I want nonetheless to draw out some key questions for discussion in relation to ‘new immortalities’.
The questions the Silent Mentor programme prompts in me are inspired by the original framing of the research through which I encountered it: ethical review and the formation of ethical subjectivities. In linking the Silent Mentor programme to my studies of biomedical ethical review processes and bringing it under the heading of ‘new immortalities’, I work through three themes of particular relevance to this special issue and the concerns laid out in its introduction. First, I am interested in the refusal of anonymity and its effects on ideas and practices of medical pedagogy. Described by programme designers as a ‘hidden curriculum’, the lack of default anonymity inverts the doctor–cadaver relationship from one of the dominance of medical knowledge over organs and tissues to one of subservience to the cadaver as person, in which the integrity of the material body is preserved as an index, material trace, or indeed, presence of the person themselves. Second, since the pedagogical dimension of the programme and its design fosters radically different relationships between students and cadavers, I use the notion of detachment to work through how ideals of relating become inscribed in biomedical training. Third, I draw out alternative genealogies of accountability to the dead that pre-date the audit-based practices I was in Taiwan to study. Together, the sections that follow remain close to the material that sparked – and continues to inspire – my curiosity about the ambition to make better doctors and the forms of pedagogy and accountabilities to the living and the dead that this involves. First, however, some background to the programme, the organisation out of which it emanates, and an empirical discussion of how I came to know about it.
About Tzu Chi
The Tzu Chi Foundation provides the frame for the emergence of the Silent Mentor programme, and I briefly review here some of the particularly relevant dimensions of extensive scholarship on the Foundation’s history and philosophies. [note 2]The Tzu Chi Foundation has been studied from a range of disciplinary perspectives including the sociology of religion, area studies, women’s studies, communications studies, and the medical humanities. Studies of its role as ‘the latest modern reincarnation of the regime of civic morality’ (Huang 2015c) are particularly relevant for their bearing on death as didactic (Copeman and Reddy 2012).
Founded in 1966 by a nun called Master Cheng Yen, the Tzu Chi Foundation grew significantly – along with Taiwan’s own financial successes and the lifting of martial law during the 1980s – to become the internationally active NGO it is today. Its origin stories, wrapped in the charisma of Master Cheng Yen’s childhood experiences and visions for a Buddhism that could act in this world for the relief of human suffering, are widely recounted and, at times, disputed (Huang 2006). Today, Tzu Chi is predominantly known for four areas of activity: its origins and work as a medical charity and hospital network, its contemporary work in disaster relief, its cultural contributions in TV and publishing, as well as its ambitious environmental programme focused particularly on plastic recycling. [note 3]Jones (2009) notes that both Huang (2009) and Laliberté (1999) refer to these activities as ‘footprints’.
Within Taiwan and scholarship on modern Buddhism, it is recognised amongst other large Mahāyāna Buddhist movements of the island nation, particularly Dharam Drum Mountain (Fagushan) and Buddah’s Light Mountain (Foguangshan) (Madsen 2007; Schak and Hsiao 2005). Based on its orientation towards public service, social activism, and voluntary work as core activities, scholars of Buddhism, particularly sociologists of religion, describe Tzu Chi as a form of ‘engaged Buddhism’ or humanistic Buddhism (人間佛教, ren jian fo jiao, literal translation: ‘Buddhism of/for humanity’) (Gombrich and Yao 2013, 240; Yao 2012; Watts and Tomatsu 2012; Queen and King 1996).
Two dimensions of this ‘engaged Buddhism’ are particularly salient for my discussion of the Silent Mentor programme: Tzu Chi’s treatment of death and the character of what could be termed ‘ethical action’ within the movement. Scholarship deliberating ‘Buddhist approaches’ towards body donation has been quick to point out the variety of attitudes held in contemporary Buddhist communities towards the body and its treatment after death. In her comprehensive, literary review of tales in which bodies are gifted in Indian Buddhism, Ohnuma (2006) relates the logics of self-sacrifice that appear in sutras and parables about the Buddha’s life. In these, giving the body has come to demonstrate a cultivated detachment, communicating transcendence from the world and one’s earthly life (Sutra of Immeasurable Meanings). Though written prior to the practical possibility of body or organ donation, these tales have shaped organ and body donation programmes in Buddhist settings. Subasinghe and Jones (2015) note, however, that there remain a variety of attitudes towards donation among the strands of Buddhism, including concerns with the extension of suffering (Chiu et al. 2012), preoccupation with rebirth (Winkelmann and Güldner 2004), compassion towards others (Ajita and Singh 2007), and the conduct of good deeds (Simpson 2004). Simpson’s account of eye donation in Therevāda Buddhist Sri Lanka elaborates on one of these tales prominent in Sri Lankan donation narratives, the Jātaka, involving an incarnation of the Boddhisattva as the North Indian King Sivi (Simpson 2004, 844). Dissatisfied despite great generosity, he promises to give something that is part of him, and is challenged to do so when asked by Sakra, king of the gods, in the guise of a sightless Brahmin (Simpson 2004, 844; drawing on Cowell  1990, 4, 251). Giving his eyes as a gift, the Bodhisattva can say, ‘There is not a single human gift that has not been given by me’ (Ohnuma 2006, 8). [note 4]This is also a test, what Ohnuma (2006, 9) calls an ‘unnatural addiction to generosity’.
It has perhaps been beneficial for the Silent Mentor programme that within Tzu Chi there is arguably no ‘systematic work of doctrine’ (Gombrich and Yao 2013, 252), allowing the charismatic leadership of Cheng Yen [note 5]Described most thoroughly by Huang in her detailed organisational ethnography Charisma and Compassion (2009) and ongoing work (Huang-Lemmon 2013). See also Huang 2006 for a discussion of the absence of critique around Cheng Yen herself.
to set the terms for engagement. As Yao (2014, 153) argues, within Tzu Chi, ‘Death is not regarded primarily as an occasion for mourning, but is given a comparatively optimistic interpretation’. Indeed, for members of Tzu Chi, such as the philosopher Rey-Sheng Her (2013, 47), Cheng Yen’s ‘Great Body Donation’ initiative ‘changes the conception of death from one of gloom, decay, destruction and abandonment to one of purity and dignity, sanctified beneficence and an enhancement of the value of life by means of helping others’. In widely circulated statements from Cheng Yen herself, this positive emphasis comes largely from presenting the use value of the corpse, and de-emphasising ownership: ‘We do not own our lives. We only have the right to make use of them… . Turning the useless corpse into teaching materials is a liberating experience from life and death as well as the wisdom of knowing how to teach selflessly’ (cited in Jodo Shu Research Institute 2008). [note 6]See also Chen et al. 2008.
At other times, Cheng Yen links the giving of the body directly to the Buddhist sutras. In her introduction to a booklet entitled ‘The Useless vs. the Great Use’, about body, organ, and tissue donation in Tzu Chi, she recounts the sutra in which ‘the Buddha in a past life had sacrificed himself to save lives’:
One time, the Buddha saw a starving mother tiger who had several cubs to feed. To get enough nutrition to nurse her cubs, the only option she had left was to eat one of her cubs. But how could she bear to do that? Understanding her terrible dilemma and predicament, the Buddha offered himself to the mother tiger. As a Buddhist, we should emulate the Buddha’s spirit of selfless compassion. Let us aspire to help others by donating our organs or donating our body to medicine after our death. (Cheng Yen, n.d., 12) [note 7]The parallel between this parable and body donation is also drawn by Ohnuma (1998).
Within the ‘engaged Buddhism’ that fosters the Silent Mentor initiative then, donation becomes a natural extension of a ‘practice-oriented version of the Buddhist vision’ (Madsen 2007, 24–25), a point I discuss further below.
The Silent Mentor programme
The Silent Mentor Programme has become extremely popular, and it is part of the narrative Tzu Chi tells about itself, both at home and internationally (Lin 2006). [note 8]A great deal of the available resources about the programme are by the Foundation itself, or scholars who are now or were attached to it. As a result, I treat carefully the repeated narrative that appears not only as part of the organisation’s account of itself but also within biomedical literatures, such as the British Medical Journal (Lin, Hsu, and Fan 2009).
According to the organisation’s own sources, Tzu Chi’s medical college received its first pledge in January 1995, the year after the college was founded. The donor, Ms Hui-min Lin (林蕙敏) from Changhua died the following month, and in June 1996 her body was used in the first trainings. On 17 September, at the completion of the course, the university held the first Silent Mentor commencement ceremony. The scheme did not necessarily emerge without prior referent, however. [note 9]Acknowledging the difficulty of finding ‘origin stories’ for the Silent Mentor programme, Huang notes that as a latecomer to the landscape of medical schools in the 1990s, it was not going to be easy for the new Tzu Chi hospital and training school to get access to national networks of cadavers for training.
Rey-Sheng Her, who has trained as a philosopher in Beijing and who works within Tzu Chi itself as the director of humanistic development, as well as the sociologist of religion Yao, have drawn links between the Silent Mentors initiative and the Japanese Shiragiku-kai Ehime, or ‘White Chrysanthemum Society’, established in 1971 [note 10]Shiragiku-kai Ehime is referenced from time to time in academic articles as the source of bodies used in research (see for example Kobayashi et al. 2006).
(Her 2013, 5; Yao 2014, 154). Important distinctions remain, given that the White Chrysanthemum Society emphasised the removal of ‘all religious connotations’ and made no connection between donation and the alleviation of grief. In contrast, Tzu Chi materials directly address and involve the bereaved, relying on their consent to and engagement with the process of donation and subsequent student education.
Laid out in a series of seven steps, Tzu Chi materials describe the process associated with the receipt, treatment, and commemoration of the donated body. Before the class begins, students will meet with the donor’s family members and find out more about the donor’s life. After an opening ceremony the dissection or ‘simulated surgery’ (described below) begins, and students are encouraged to look for the life lived as evidenced in the body. In the lab, a screen displays an image with a photograph and name of the Silent Mentor, in strong contrast to the didactic media of the body. Afterwards, the body is stitched back together, dressed in white fabrics, and placed in a coffin. The bodies, accompanied by the students, travel through volunteer-lined streets to the crematorium. A memorial service follows, where the students present their stories, read poems, and sing in the presence of the families. After cremation, some of the ashes of the Silent Mentors are placed in glass urns in the shape of the Hall of Still Thoughts, and then put in the university’s Great Giving Hall. [note 11]As Huang (2015) rightly notes, this is an extended period of waiting time for families, with the ‘wait’ for bodies to be used in gross anatomy classes up to three years, and the wait for the more frequent simulation surgery training between two months and one year.
The steps described here refer to bodies used in the Simulation Surgery described below, which takes place over a four-day period, but the order of the process is similar for the longer lasting Gross Anatomy classes. [note 12]For a more detailed account, see Chang 2016.
The recruitment success of the programme in Taiwan has led to more bodies being pledged than can be used by Tzu Chi’s teaching hospitals (Chen et al. 2008), and a range of initiatives and collaborations both within and beyond Taiwan are underway. In the Asian region, news of the programme’s success travelled, leading to cooperation between the University Malaya Medical Centre in Kuala Lumpar, and Tzu Chi in Hualien in 2012. [note 13]The collaboration also includes the bereavement and funerary care service provider Xiao En Group. At the time, twenty-five bodies had been pledged to the programme, with 160 others expressing a wish to be a part of it.
Since then, the intervening years have seen three key developments within the Silent Mentor initiative: a period where donations were made to other medical schools, provided they followed the ceremonial protocol (Chen, Chang, and Yu 2011); a broadening of uses for cadavers beyond undergraduate anatomy; and the use of the programme to train and initiate the medical faculties of other countries in this form of donation. By 2002 the Anatomy Department of Dalin Hospital (Hualien) developed a ‘simulated surgery’ programme, which uses donated bodies as trial patients and upon whom trainee surgeons practice techniques in conditions closer to those they will face in live surgery. Made possible by technologies that freeze the body rapidly to -30 Celsius, cadavers are made available for subsequent defrosting and warming to almost living temperatures, thereby retaining elasticity in their muscles and vessels (Yang and Wu 2013, 21). Over the course of up to four days, students can simulate clinical treatments and develop surgical skills such as ‘basic skin suturing, advanced skin suturing, laparoscopy suturing, bowel anastomosis, gastrointestinal anastomosis … facial nerve separation, grafting of pulmonary valves to aorta, excision of prostate cancer’ (Tzu Chi, n.d., 105). Tzu Chi’s own television channel DaAi (Great Love), for example, regularly covers the opening and closing ceremonies as part of its mission to ‘bring about a society characterized by peace and harmony’ (DaAi 2016), and students from universities and hospitals in many countries visit the simulation centre to practice techniques. [note 14]Although it is beyond the scope of this article, the creation of the Silent Mentor programme as a ‘model’ for other universities and hospitals around the world deserves academic attention. The degree to which the Buddhist ceremonial dimension needs to be maintained is open to question, particularly the place of meditation on a person’s death, over a corpse or in a crypt, as the practice moves to Malaysia and Singapore. The approach by some academics to date has been quite formalistic. Indonesian researchers Atmadja and Untoro (2012, 35) report, for example, that the Faculty of Medicine at the University of Indonesia sent delegates to Hualien in 2007 to learn about the Surgery Simulation centre and ‘develop the Standard Operational Procedures of SMP [Silent Mentor Program]’.
By 2008 Tzu Chi had established a Medical Simulation Centre to host these new techniques, a series of rooms with eight teaching operation tables with ‘a fully functioning simulation line, independent cleaning units, concealed gas supply piping, surveillance monitors and robotic arms for the operating table’ (Tseng 2009, under ‘Unreserved Giving of Love’. In addition, as Tseng notes in the ‘The Useless vs. Great Use’ booklet, ‘Every operation table is equipped with a large LCD screen, which broadcast[s] the life history of the mentors so as to remind trainees of the mentors’ loving kindness and unreserved giving’ (Tzu Chi n.d., 59). The ceremonial dimensions of both the Silent Mentor and simulated surgery program, despite their now regular occurrence, continue to be treated with headline status.
The international attention the Silent Mentor initiative has received is extensive, both in popular media and within academic journals on medical pedagogy. The movement regularly points to coverage received in 2009, when American journalist Ian Johnson wrote about the program for The Wall Street Journal. Understandably, the program is also drawing broad anthropological and sociological attention, mentioned in Yao’s (2012) book on engaged Buddhism, based on her fieldwork conducted in the mid-1990s, and anthropologist Chang has recently read the Tzu Chi Foundation’s activities through the work of French theorist Michel Foucault (Chang 2016; Foucault 1991). While considerable care must be taken to consider the specific, historical state–citizen formations out of which Foucauldian thought arose, and its applicability to the activities of a Buddhist charity, Chang’s (2016, 135) import of Foucault’s governmentality framework to contemporary Taiwan does permit her to bring out the rapid uptake of the donation program as a form of discipline, pointing to the extension of Tzu Chi’s construction of a ‘giving ideology’ into fields as distinct as environmentalism and medicine) . Similarly, C. Julia Huang (2015a) has recently returned to her own encounters with the Silent Mentor program during her earlier fieldwork of 1999, addressing the motivations of donors and those who are ‘dying to give’. I now introduce the context in which I came to understand and think about the program, relative to my ethnography of ethical review.
Ethical review meets cadaver donation
How did research on the establishment and standards of biomedical ethics review committees lead me to discussions with members of Hualien’s Silent Mentor program? As part of multisited research into the work of a capacity-building NGO, the Forum on Ethics Review Committees of Asia and the Pacific (FERCAP), I regularly attended workshops, training sessions and conferences (Douglas-Jones 2015). It was at one of the large annual conferences in 2009 in Chiang Mai, Thailand, that I met Dana, an ethics committee secretary from Hualien. We had breakfast together one morning before the training sessions of the day were about to start, and she invited me enthusiastically to visit her committee if my research plans allowed. The following year, as I pursued the NGO on its training and surveying circuit around the region, I emailed Dana and asked if she would be able to show me her committee and its offices, and help me meet and interview some of her colleagues. That June, I took the train from Taipei along Taiwan’s mountainous east coast to the Buddhist Tzu Chi General Hospital in Hualien where Dana worked. During the course of my two-week visit, Dana used her position to help me arrange interviews with members of her committee, both faculty and doctors. It was during one of these interviews that I first heard about the Silent Mentor programme, and in the section that follows, I draw on that and subsequent interviews with Tzu Chi staff involved both in ethical review and in the Silent Mentor programme. The interviewee – who had a role as a practicing clinician on Dana’s ethics committee – lamented about the quality of research that he saw coming through the committee. He thought the doctors were well intentioned, and the science wasn’t bad, but he reflected that the proposals seemed to show the investigators as ‘quite thoughtless’ when it came to patient comfort and safety. Folding his hands and leaning forward to me, he nodded decisively: ‘Some day we will produce better doctors. Our Silent Mentor programme will help with that’.
I initially took this use of ‘Silent Mentor programme’ to refer to training that the ethics committee members would undertake. In the discussion that followed, I asked some follow-up questions, mostly pursuing my interest in the relationship between ethics review and how researchers are regarded. But as we walked across campus afterwards, I asked Dana about this ‘Silent Mentor programme’. Seeing my interest, she arranged a visit to the unit and meetings with several of the programme coordinators for the following day. Tzu Chi, like many prominent NGOs, has established procedures for handling international guests, and the performative greeting I received followed the pattern described in many accounts one can read related to Silent Mentor activities (Lin, Hsu, and Fan 2009; Johnson 2009). As Dana and I hurried across the drizzly open campus that morning, we could see the waiting representatives under their stylish umbrellas. Both were sharply dressed in navy blue and white, [note 15]In her analysis of the power relations in making volunteers, Chang (2016, 12) adds the pleasing detail that new volunteers wear ‘the blue polo shirt, white trousers, and white shoes of the “blue sky and white cloud” (lántiān báiyún) uniform, which represents a breadth of mind as wide as the sky and action as white as the clouds’. The uniform is discussed by Cheng Yen (2011) in a lecture entitled ‘The Robe of Gentleness and Forbearance’. For an extended discussion on the meanings of the uniform, see Huang 2009, 165–76.
Tzu Chi logos on the left breast, and they greeted me in English, with a handshake and wide smiles. The tone was professional; I was a welcome international guest, who had come to find out about Tzu Chi and its innovative cadaver donation programme. The first objective of the tour was to immerse me in the story, and a DVD had been prepared for that purpose. In a darkened room off the ‘Occidental’ section of the two-storey library, I watched as the history of the programme was explained. Set to emotional string music in a minor key, subtitles told me that everyone was going to die, but in death – the music became more uplifting – they could turn their ‘useless body into a valuable cadaver’. The representatives watched the film, and watched me as I took notes, seeming faintly disappointed that I had not cried.
Our next stop was the hospital’s second floor. We walked the bright, empty perimeter corridors slowly, looking at posters and poems, statements by donors and letters from students. Sam, the lead guide, was keen to emphasise to me that the architectural choices, lighting, displays and positioning of the storage facilities above ground were in strong contrast with his understandings of basement morgues of ‘the West’, where he didn’t think the dead were treated with much respect, based on stories of bodies hung on hooks: ‘Our way is different’, he said seriously. ‘It is on the second floor because we feel the meaning of life is to be respectful and open, to teach students that death is natural but very important. This is a bright part of anatomy that we let all students learn’.
As I noted above, since 2000, students have been responsible for making a visit to the families of the Silent Mentors and learning about the donors’ lives (Ye 2012). In their review of 109 students who took part in Tzu Chi’s training between 1996 and 2001, Chen and colleagues (2011, 445) write that ‘an important step in the procedure of requiring that medical students show respect to the dead body they dissect is to write a letter to the silent teacher at the end of the semester’ addressing them directly. The letters long outlive the direct engagement between student and cadaver, serving first as a demonstrable link of care between students and their ‘silent teachers’ when witnessed by the families of the deceased at the memorial service, and later when Tzu Chi publishes these letters, many online, and displays printed versions in its hallway. Encouraging a relationship with the family of the deceased is a further dimension of the programme, in which the cadaver is referred to as the students’ first ‘teacher’ rather than ‘patient’. The students, cadavers, and families are brought together at a ‘memorial blessing ceremony’, photographs and videos of which appear in Tzu Chi’s materials, both online and in printed form. ‘The body is open so that the family can take a last look’, Sam told me as we looked at the pictures. He continued, ‘You hear the crying and mourning. At the time, students face great pressure’.
When I talked about the programme with Dana later that afternoon, she told me she had not yet decided whether she was going to volunteer her body to become a Silent Mentor. She was seriously considering it, she said, since she had no family to object, but she was not yet sure it would be the right thing to do for her. She would have to think more about it, she said, explaining that donating required a change in ‘how people thought about life, death, and after’. We were sitting at her desk, waiting for her colleagues to come back from lunch, and she looked away from me, picking up a photo frame containing a photo taken on an ethics committee training trip to the United States. She explained, ‘Because we have some forbidden part – after you die, the family can’t touch you, move your body, for eight hours, we have to pray for eight hours, so the soul will leave the body and go to heaven and have fun – so there is some resistance [to donating]’. As I spoke with other Tzu Chi volunteers and ethics committee members, ‘resistance’ to the programme, particularly from grieving families, was referenced in passing. Again, in the introduction to the booklet ‘The Useless vs. the Great Use’, Master Cheng Yen (n.d., 15) acknowledges that ‘For the body donors, it was not easy to make the decision to donate their body. They must be able to see past traditional Chinese beliefs about keeping one’s body whole and intact after death’. These ‘traditional Chinese beliefs’ are frequently referenced as an ‘obstacle’ because they involve the period of time after death where the technical demands of body preservation overlap with what socially and ritually surrounds death. [note 16]The context of this critique implicates Taiwanese, Chinese, and Tzu Chi relationships of secularity, medical science, and claims to modernity. I do not have space to do justice to the politics here, but C. Julia Huang’s unpublished papers on making Tzu Chi’s medical mission Buddhist (2011) and the secularization of death rituals (2015c) address the issue in more detail.
The wishes of donors, as quoted by Tzu Chi, press a transition from recognisable Buddhist practices as well. In an account of the ‘making’ of a Tzu Chi surgeon, we find the story of Shi Qing-xiu (施清秀), a Tzu Chi volunteer from Kaohsiung, who is reported as having:
told his family again and again: ‘When I pass on, don’t bother chanting “Amitabha” for eight hours [as many Buddhists do to comfort the soul of the deceased and help send it to the Pure Land of the West]. Instead, rush me to Hualien so my dream of becoming a silent mentor can come true. Many people undergo surgery so they can live. I’ll undergo surgery when I die so, hopefully, many others can live’. He was in the terminal stage of lung cancer. He wanted to make sure that his body got into Tzu Chi’s simulated surgery program. (Chen 2008, under ‘Body donors’)
Watts and Tomatsu (2012), in their account of a ‘good death’ for Chinese Buddhists in the context of the development of Buddhist palliative care at the National Taiwan University Hospice and Palliative Care Unit, describe ideal practices upon death. They quote from Yutang Lin’s (1997, 94) article ‘Crossing the Gate of Death in Chinese Buddhist Culture’, which explains that in addition to a deathbed ceremony (臨終行儀) involving chanting of Amitabha Buddha’s name to aid transcendence,
the body should not be disturbed (in some cases not even touched or moved) for at least another eight hours after it has gone cold. The part of the body where warmth lingers until the rest of the body has become cold is called the Gate of Death in the sense that the consciousness finally leaves the body through this spot. Its relative position on the body is believed to indicate to which realm the consciousness has migrated. In general, higher spots on the body such as the crown of the head indicate heavenly realms while lower ones such as the feet indicate unfortunate realms. (Lin 1997, 94)
As Watts and Tomatsu (2012, 125) go on to note, ‘This spiritualization of death is incomprehensible in a public medical facility’, yet in Tzu Chi, the two are brought closer together through the ceremonial treatment of bodies within the hospital and their interim preservation. [note 17]This tension is also handled in the recently released (March 2017) documentary The Silent Teacher, made by Chen Zhinhan (陳志漢), which follows widower Lin Hui-Zong (林惠宗) after the death of his wife, who had donated her body to the Silent Mentor programme. The documentary filmmaker stays with him and his family as they make trips to visit the deceased, participate in the Tzu Chi ceremonies, and eventually bury her remains. An interview and trailer can be found at https://tinyurl.com/m4jlhtv.
Back in the corridor in Hualien in the company of Sam, I stood beside curtains covering a window to a central room, and as he tugged gently on a tasselled pulley I was given a view of the darkened space in which bodies, wrapped in white, rested on narrow metal shelves. There was an extended moment of reverent silence as we gazed in; then, not looking at me, Sam closed the curtains again. I was led quietly around the corner, and shown into the Great Body Teacher Memorial Hall. As the doors opened, the lights came on automatically, illuminating row upon row of small, glowing crystal boxes, crafted in the shape of the Hall of Still Thoughts (靜思堂), the ‘spiritual fortress of Buddhism’. ‘After cremation, ashes of Silent Mentors are placed here. Students sometimes come and visit them’, Sam told me. ‘They come to visit the Silent Mentors and thank them; some tell me that they confide their difficulties and feel that the Silent Mentor will continue to look over their shoulder as they work’.
Returning to my research on ethical review, I note that in an interview with the clinical director of the Silent Mentor programme, he explained some of the reasoning behind the programme to me in this way:
There are two parts to being a doctor: one part is a healer, the other is being a professional. It’s based on a social contract, between medical society and the whole society, that is medical professionalism… . The base of medical professionalism has three points. To practice with skill, knowledge, and with morality to service others. However, morality and service are becoming weaker and weaker. How do you design a curriculum to help students learn morality and service to others?
He was speaking to me with an eye to the research proposals that crossed his desk regularly, proposals to investigate a wide range of issues. Both he and May, the committee’s layperson, complained in our interviews about the ‘atmosphere’ between ‘medical people and patients’. May, an information manager for Tzu Chi, explained that she saw the relationship as ‘commercialized’: ‘I pay you, you use me. It used to be friends, family doctor. Master [Chen Yen]wants to recall those good spirits for medical work. So [we] have to change the relation – doctor, nurse, patient, family. They should be friends, like family’. May attributed these changing relations in no small part to research practices: ‘Our doctors think [research] should be more cold blooded, more science style, more powerful’. In the Silent Mentor programme, the clinical director said, was a ‘hidden curriculum’, designed to help students learn ‘morality’, expressed predominantly, though not exclusively, through a Buddhist frame. ‘We need more good doctors, not more famous or fame-making doctors. So we want to train the student to respect [patients], not just by lecture or television, but by this kind of role model’. The role model was the Silent Mentors themselves. Towards the end of an interview with one of the programme coordinators, a passing comment drew me back to the reason I was in Hualien at all: ethics committees. The coordinator had been showing me a presentation designed for an international audience to help me understand how he saw the relationships among the Silent Mentor programme, spirituality, and modern medicine. ‘To study medicine is a kind of spiritual practice’, he said. ‘So physicians have to reflect on how to contribute to society. If every physician can learn this, there is no need for the ethics committee. I’d like to use the surgical department; I really wish we can, by this foundation, train more and more good surgeons and serve the society and thereby make ethics committees unnecessary’. Instead of seeking a committee to conduct a bureaucratic check on doctors who might design or conduct ‘bad’ research, the coordinator was seeking to relocate ethics within the subjectivity of the doctor.
Having given an overview of my encounter with the programme and provided a frame for its emergence, in the remainder of this article I want to draw out three points mentioned in the introduction. The first concerns the changing place of cadaver anonymity within medical pedagogy and its relationship to respect. Second, I use the term ‘Silent Mentor’ to return to the question of ongoing relationships students are prompted to develop with their cadavers and families, and the degree of detachment – or otherwise – that is seen as desirable. Finally, I discuss the reconfiguration of the relationships of behavioural accountability medical researchers find themselves in, by reflecting on what is meant to endure. In my conclusion, I return to the centrality of the notion of ‘utility’ as a linchpin holding together biomedical and Buddhist framings. It does not seem that what the philosopher Rey-Sheng Her (2013, 55) calls a ‘Benthamite’ frame fits Tzu Chi’s descriptions of its practice. Might we then consider this part of international donation movements’ efforts to remake utilities in a broader range of forms?
The historical cadaver of Western biomedical gross anatomy education has been anonymous. As the recently published ‘Recommendations of Good Practice for the Donation and Study of Human Bodies and Tissues for Anatomical Examination’ note, this remains the default: its ‘normal practice is to retain donor anonymity’ (International Federation of Associations of Anatomists 2012, Recommendation 5). The reasons for accepting and continuing with anonymity as a default are again a current topic of discussion within medical pedagogy. Indeed, what will count as good practice is contested and undergoing revision. Jones and King’s comprehensive 2016 review article lays out what they term the ‘virtues of anonymity’, rooted in communitarian values and charity (see Sukol 1995; Murray 1987). They provide a spectrum from nonidentification with low information, through nonidentification with moderate information, to what they call ‘identification, full information’. At this latter end, medical education practitioners and scholars, such as Talarico in the United States and the anatomist Goran Štrkalj in Australia, are making a case for anatomy training to be a site of encounter with grieving relatives, with a view to ‘enhancing the skills and competencies of future physicians’ (Talarico 2013, 162). Štrkalj (2014, 2) writes about ‘humanistic anatomy’: ‘More than a vehicle for learning about the structures of the human body, it is emerging as a medium for the early phases of teaching of, or, perhaps more appropriately, enculturation into medical professionalism’ (see also Pawlina 2006). The growing contrast among approaches is made explicit by Böckers and colleagues (2010, 217), who write in support of this separation, stating frankly in a rebuttal to comments on their piece: ‘The dissection course is not an instrument to develop compassion, because this would be counterproductive for the successful completion of the course’ (emphasis added). [note 18]The place of dissection in medical education is discussed at length in McLachlan et al. 2004 and López and Dyck 2009.
In part inspired by a turn to the medical humanities, the question being posed is ‘If the anonymisation of cadavers services scientific ends, to what extent should this value shape the dissecting room of today’s medical student?’ (Jones and King 2016, 4). Extending this question, I would ask how an increasingly connected, transnational medical profession is going about discussing what the relationship between a teaching cadaver and a medical student should be (Bohl, Bosch, and Hildebrant 2011). In 2010, for example, an editorial in Academic Medicine by the American neurosurgeon and physician-educator Steven L. Kanter (2010, 389) used the Tzu Chi programme as a means to demonstrate the ongoing debates around how doctors are trained: ‘I thank the faculty at Tzu Chi University’s medical school’, he wrote, ‘for reminding us of the need to continually examine and re-examine even what we consider to be our most basic assumptions’. The basic assumptions to which he refers are the ‘great lengths’ to which those responsible for the use of cadavers in medical schools in the United States, and many other countries go to ‘conceal the identity of a cadaver from those who will dissect it’ (ibid.)
In contrast with this ‘Western default’ of anonymity, the Silent Mentor programme thus receives attention within medical pedagogical literature as a relativisation of the assumption of anonymity, making visible what is taken for granted, and presenting a novel formulation. However, it is also evident that a division between ‘hard core science’, ‘Western’ anonymity, and ‘other’ forms of relating to cadavers can be drawn too strongly, as the examples above demonstrate. Olejaz (2015, 20), drawing on historian Bynum, notes that the continuity between self and body has been an ongoing matter of debate since the European Middle Ages, and most ethnographies of dissection labs show that medical students in training are moved by the personhood of their cadaver as much as they are intrigued by its educational properties (Hafferty 1991; McDonald 2014; Prentice 2013). Mackenzie’s (2006) fieldwork amongst Cambridge University undergraduates, for example, found that all the cadavers in her study were named, with students choosing ‘traditional’ names suitable to the era with which they associated the elderly, such as ‘Archibald, Frank, Jenny, Sylvia and Cecile’. She points out that not all students chose to use the names, one stating that she thought it was ‘a bit disrespectful. I have my own name and I don’t expect to be given another one after I die’ (Mackenzie 2006, 26). Mackenzie also observed students apologising to their cadavers: ‘Today when I was cutting I was saying sorry. When I was making the incision, I was saying, “I’m sorry, I’m sorry”’. Others, she writes, ‘were conscious of inflicting physical harm on their cadavers: “I broke the nose of ours by not putting the block under his neck when I turned him over. I feel really guilty”’ (Mackenzie 2006, 28–29). Some literature documents this consciousness as a ‘conflict’, in which students oscillate between ‘perceiving the cadaver as a learning tool versus as a human being’ and suggest ‘[t]his impasse could be resolved if they latently adopted a “perspective switch”’ (Tseng and Lin 2015, 5). Prentice’s (2013) work addresses this same ‘switch’ in the language of the social sciences, terming it ‘ontological duality’, a division that Olejaz (this issue) troubles, noting that it implies a neat partition between people and things that belies the unresolvable ambiguity that is part of the student’s practice-based engagement with the cadaver.
The Silent Mentor programme does not deny the named personhood of the cadaver; indeed, it celebrates it, positioning photographs and accounts of the donor’s life within the space of dissection itself. By refusing anonymity and indeed, celebrating the ‘known’ cadaver, the Tzu Chi method strongly aims to bring the tool/body division together. Tseng Guo-Fang (曾國藩), the head of the Tzu Chi Medical Simulation Centre, recalls the ‘casual atmosphere’ of his training in the United States in the 1980s, something he found disrespectful. However, it seems the transition from casual to ceremonial came slowly: Johnson’s 2009 Wall Street Journal account reports that the elaborate rituals of the Silent Mentor ceremonies were initially alien to Tseng Guo-Fang: ‘I was trained as a hard-core scientist, and this didn’t make sense to me’. Describing how much students already know before a simulated surgery event, for example, Mei-yi Chen writes: ‘The surgeon performs the surgery as if on a loved one. This warmth later radiates from the surgeon outward to future patients. This is yet another example and manifestation of Tzu Chi’s somewhat vague and highly impalpable idea of bringing up not just competent but also loving, surgeons and physicians’ (Chen 2009).
Such language would, I imagine, bring unease to many trained through the tradition of the anonymous cadaver. In her ethnography of anatomy and surgery education, science and technology researcher Rachel Prentice introduces us to two doctors with whom she worked, Drs Chandra and Wilson, for whom the lines between care and objectivity, competence and compassion are hard to draw. Prentice includes their reflections in part because the anonymity of a training cadaver, or its lack of anonymity, is intended to have pedagogical effects. I will take up this point again below, but for now, let us return to Jones and King’s (2016, 4) question about anonymity: ‘If the anonymisation of cadavers services scientific ends, to what extent should this value shape the dissecting room of today’s medical student?’ The Silent Mentor programme, founded in the international move towards ‘medical humanities’, rejects anonymity, both as a value and as a practice. If cadaveric anonymity is the site where, in Western accounts, the person and the body are thought to be detachable from and reattachable to one another, then it is also the site where the detachment and compassion of the medical professional are similarly thought to emerge. While the Silent Mentor’s new ‘connection’ between students and cadavers is praised in English-language, general interest publications, particularly those authored by members of Tzu Chi, it also raises questions about the appropriateness of the insertion of compassion into anatomy teaching, as shown in the literature overviewed above. I turn then, to the cognate issue of detachment that faces both donor and student within the Tzu Chi setting.
Questions of detachment
A key question facing students and pedagogues alike is ‘How much “social relation” is too much?’ in settings of biomedical, especially anatomy, training. The terms traded by the American Drs Chandra and Wilson in Prentice’s (2013, 127) study reveal fault lines in how ‘connections’ may play out, as they search for a good way to ‘construct an emotional stance toward patients consistent with professional care’. Should doctors not cultivate detachment as well (Hildebrandt 2010)? Prentice dedicates significant space in her book to this question, and how doctors balance emotion, rationality, objectivity, and judgment in medical training and practice. She describes Drs. Chandra and Wilson going back and forth in their discussion, contrasting compassion and objectivity, detachment and attachment, and going ‘too far into’ treatment versus working ‘coldly’ (Prentice 2013, 126–30). Their dialogue moves across the divide between sociological and medical literatures, as Prentice points out that the phrase often used by doctors, ‘detached concern’, comes from sociologist Renee Fox’s work, originally published in 1959. Given the emphasis on connection and relation in what we have seen of Tzu Chi’s approach, it is perhaps a little surprising that ‘detachment’ has been integrated into Taiwanese medical pedagogy literature, with Tseng and Lin (2015) using it in the title of their phenomenological study on emotions in cadaver dissection.
Detachment has also recently surfaced in contemporary theory as a response to the primacy of ‘the relation’ in anthropological imaginings since, as the editors argue, it is ‘in a wide range of settings … still socially, ethically and politically valued, and the relationship between detachment and engagement is not simple or singular’ (Candea et al. 2015, 1). The detachment under discussion above, the tie between cadaveric anonymity and the doctors in training, is a ‘Western modernist detachment’ associated with objectivity and knowledge making, an ideal that Candea and colleagues (2015, 4) state encompasses a ‘need for emotional detachment, automatic procedure and methods of quantification’ (see also Olejaz, this issue). ‘Such notions of scientific objectivity’, they continue, ‘entailed a commitment to epistemic forms that necessitated distance from the world through specific forms of critical distance from oneself’ (Candea et al. 2015, 4). The breadth of the forms of detachment they review – process, state, stance, and ascetic – gives entry into the richness of the detached relation.
Within that richness, then, a quite different detachment from that of biomedical training faces those who would become donors: whether to detach from their body, how, and what that would mean. Donors, in their reported accounts, come to see their bodies as useful, a source of future knowledge. We find the language of ‘use’ across Tzu Chi’s own literature, as well as echoed in the statements of donors addressing their new role as teachers, and the aid their body may offer in training doctors to help others. [note 19]For a fascinating comparative description of motivations of donors, and parallel framing of donation through gratitude and help, see Olejaz and Hoeyer 2016.
This utility of the body upon and after death is emphasised by Master Cheng Yen in her statements about donation, arguably reframing the spiritual benefits of detachment, associated with ‘engaged Buddhism’. A donor’s detachment is presented not as an interpersonal detachment from another person, but a personal ‘detachment to’, so to speak, one’s own body. It is most visible in statements made by donors while they still live, relating to their body as already usefully dead. Widely circulated stories of Tzu Chi donors include those who become known for the decisions they take regarding their own medical treatment. The early donor Li He-zhen (李鶴振) became part of Silent Mentor ‘canon’ in 1995 for having refused chemotherapy for his pancreatic cancer, stating:
When I die, I want to give my body to you in its undamaged totality. In your hands, it might help with your studies and do some last good for mankind. The Dharma Master said that a sick body was like a house in need of repairs. Rather than keeping such a house, it would be better to grasp the present moment. I wish to pass away quickly so I can reincarnate soon. (cited in Her 2013, 58)
Tzu Chi’s Master Cheng Yen (2007) noted that Li He-zhen’s message to students was one of turning his body into a device through which trainee medics could practice their skills: ‘You can make hundreds or even thousands of wrong cuts on my body, but please don’t make even one wrong incision on your patients in the future’ (Chen Yen 2007, under ‘Eternal Life with Goodness and Beauty’. The wide use of this statement in material about the donation programme does not detract from the condensed complexity of its self-sacrificial beneficence, emphasising yet accepting – indeed praising – the anticipated bodily harm and transforming it into use. In the words of Cheng Yen (2007, under ‘Eternal Life with Goodness and Beauty’):
Many Tzu Chi people have since signed up to become body donors. They seize every moment of their life to lovingly serve the needy when they are alive, and when they pass away they donate their bodies to nurture future doctors. They don’t stick to the traditional Chinese myth that your soul can only rest in peace when your body has been buried whole. They demonstrate profound wisdom and greatly enhance the value of their lives by letting go of all attachments to life and death.
In the repetition of this framing, and the critique of Chinese commitments around death, the detachment necessary for donation is from both life and the body. It brings to mind early discussions of organ donation in relation to ‘the Bodhisattva ideal’ by Lecso (1991, 38), for example, who writes: ‘One cannot give up one’s body while alive without possible regret unless one realizes the emptiness of the self and the underlying unity of self and other’. Current research shows inclinations continue to be affirmed across Therevāda Buddhism, with the possibility of use again held up as the outcome of detachment. As Simpson (2004, 843) recounts in his article on the ‘impossible gifts’ in Therevāda Buddhist Sri Lanka:
The donation of parts of oneself has become an important aspect of moral and spiritual development which signals a healthy lack of attachment to the body and ultimately to life itself. As one devout and elderly Buddhist man put it to me, ‘I hope I die quickly and cleanly from a brain haemorrhage so that maximum use can be made of all my body parts’.
In contrast with the patriotic ideal through which giving binds Buddhism and the nation in Simpson’s Sri Lankan account, what Tzu Chi offers through ‘engaged Buddhism’ is an emphasis on becoming a bodhisattva in this world, or a rénjiān púsà (Chang 2016). As Huang (2015a) points out, the role of the Bodhisattva becomes a model person: ‘Just as the pure lands became models for society, Bodhisattva became a model for its inhabitants’. This is complex theological terrain, wherein through cycles of reincarnation, Tzu Chi volunteers are choosing rebirth ‘in order to exercise more and more compassion for other sentient beings’ (Gombrich and Yao 2013, 256). That the Silent Mentor is said to become a bodhisattva represents an integration of existing Buddhist notions into a novel biomedical schema. The Silent Mentor is not only presented to medical students as a cadaver with social relations and a lived life: the intention is that those original relationships – both those the student builds with the family and those with the cadaver – extend into the future. The ‘hidden curriculum’ mentioned by the programme’s clinical director is that these relationships will go on to form a basis for how students will treat their future patients, as people with relations.
I turn finally to the intended ongoing relationship students have to the Silent Mentor, the intentional ‘constant reminder’. While it may be that the giving of the body is talked of in terms of detaching from something with no worth (in order, through donation, to give it use and thereby value), there is a parallel attachment that happens as, through the Silent Mentor programme, donors become ‘teachers of doctors’. Their ongoing presence, not only in the canon of medical knowledge in the hands and skills of students who go on to practice medicine but also in the association students are intended to have between cadavers and families, is a reminder that all patients have families. Indeed, as Sam mentioned on our tour of the facilities in Hualien, the Silent Mentor is also intended as someone to whom trainee students can physically return in the Hall of Great Giving, throughout their careers. ‘They come to visit the Silent Mentors and thank them’, Sam said, continuing, ‘Some tell me that they confide their difficulties and feel that the Silent Mentor will continue to look over their shoulder as they work’.
Chang (2016, 6) has addressed the importance of the name ‘Silent Mentor’ for donors, indicating that no small part of the attraction to donate may come from the prospect of teaching doctors, whose societal position has long been elevated despite other forms of social hierarchy in Taiwan. I am intrigued by donors’ sense that their body connects them in relations of accountability to others, and by how students handle the implications of having a Silent Mentor with them throughout their careers. A Tzu Chi (2001) document explains that students will ‘feel that as they pursue their medical careers, the spirits of their “silent teachers” will always remain at their side’. This sense of being observed, watched, and held accountable on the grounds of great sacrifice is at the heart of the hope expressed in the ethnography above: that through this new form of training, ethical review – an external pre-emptive check upon the behaviours of doctors – will no longer be required. Fascinated though I am with how this ongoing presence might be experienced, the degree to which it resonates with a ‘conscience’ or something quite distinct, however, is not a question I can fully answer with the material I presently have. Nonetheless, I want to point to two moments in the Silent Mentor process where the emphasis on relating to the cadaver in this non-anonymous, fully known way brings about new forms of accountability, and challenges old ones, for students, for the programme, and for the donors.
The first way that accountabilities are reconfigured has to do with how the cadaver is itself treated. When students, at the end of a course, prepare the body for the memorial ceremonies, it is reported that they must resuture the body and return the organs to their original places (Santibañez et al. 2016, 1485). However, as a number of ethnographies of dissection laboratories attest, the practicalities of this must be extraordinarily complex in terms of preservation and resuturing (Olejaz 2015). Though it is couched in the familiar language of respect, the resuturing of the cadaver seems perhaps to reference something more. As I noted earlier, the maintenance of the physical integrity of the body is a longstanding Confucian-inspired preference that was until recently widespread in Taiwan. It is ‘out of respect for the ancestors’, writes Chang (2015, 137), that ‘individuals are expected to protect their bodies in an intact condition, as they received it from their parents’, a preference that has given rise to tensions between burial and cremation throughout Chinese history (Ebrey 1990).
How, then, is it that donors and their families come to accept this physical dimension of dissection, even if the aforementioned invitation to become a bodhisattva teacher of doctors strongly appeals? Lu (2011) argues that in addition to reasons of economics and convenience, ‘donors and their relatives accept the damage to the corpses as a result of the “sanctification” of the donors by Tzu Chi’s rituals and narratives’. Not least of these is the process through which donors are ceremonially celebrated, and the placement of (some of) their cremated remains in the Hall of Great Giving, where I saw the rows of small, glowing crystal houses, separated out by a process Tseng Guo-Fan’s slides called ‘urning’. Tzu Chi’s treatment of the body after death, then, has come despite, not because of, existing practices surrounding death. Chang describes this ‘respect for the ancestors’ in the more familiar language of ‘filial piety’, from 孝, xiào, a term in use from the longstanding Confucian text Classic of Filial Piety. However, as Madsen (2007) notes, Cheng Yen’s Three Ways to the Pure Land expands the classical notion of filial piety substantially, addressing the primarily Confucian oriented readership through Tzu Chi’s networks. The ‘best kind of filial piety’, she writes, is to ‘abandon the selfish, temporary love we give only to our relatives and close friends and expand our love to include all living beings’ (Madsen 2007, 25). This reorientation to the breadth of goods possible in the present, as opposed to an ancestrally oriented past, also opens the way to considering one’s future legacies. Through this reworking, it has been possible for Tzu Chi not only to develop distance from preferences for the body to be buried intact but seemingly also for the cremated remains to become separable.
Generating this ‘part’ of the Silent Mentor whom students can, and perhaps do, visit in the Hall of Great Giving during their careers is, then, a negotiation between the accountabilities the dying feel to their parents and other relatives and to the students who will benefit from the knowledge their body will generate. It also grows in students a new form of accountable relationship, what the director called a ‘hidden curriculum’. In their analysis of 89 student letters written to the Silent Mentors, Chen and colleagues (2011, 449) found repeated mentions made by students of the future, of not wanting to disappoint, and of promises to visit: ‘We promise that we’ll often come back to see you’. They observed that students also spoke of this connection to their Silent Mentors in terms of ‘yuan’, or ‘yuan feng’, a term for serendipitous, fated, or predestined relationship (Chang and Holt 1991, see also Yang and Ho 1988), or the placement of a person in one’s life. This is perhaps not surprising, given the term is developed from Buddhist thought, but as one student wrote, ‘Before, I even thought that someday somewhere I might have yuan to see this silent teacher, which might only be like a dot in one’s life, but now, this dot has extended and expanded into a line and weaved into a medical map deeply rooted in every person’s heart’ (Chen et al. 2011, 447). Returning then to the link between training and the imagined obsolescence of the ethics review committee illustrates a different place of hope for the future of ethical research, which falls not in audit-like ethics but another kind of watching, the companionship of the Silent Mentor. In this sense, the new immortality being generated is not merely that willed by the intentions of the deceased but the animation of the dead for the ends of the living. By transferring the ethics associated with that of an ethics committee to the researchers, my interviewees on the committee hoped these new doctors would make the committee unnecessary. In this way, the committee is replaced with a person, through a process that renders the external cadaver into an internal ‘guide’ to students, intended to govern, improve, and even censure. Both donors and students openly anticipate a future to their relationship, which involves eventual patients who receive the trainee doctor’s care. In using the Silent Mentor programme’s refusal of anonymity, and its incorporation of new forms of teacher-student accountability, there is the hope that ‘the souls of the silent mentors live on in the hearts of their students’ (Her 2013, 66). Building on the depositing of cremated remains in the urns of the Hall of Still Thoughts, we must also regard the Silent Mentor programme as a practice of memorialisation through which new immortalities are being forged.
The Silent Mentor programme, with its break from anonymity and ‘scientific detachment’, belongs to a set of contemporary challenges to longstanding modes of medical pedagogy. It inserts into student experiences the lives of donors and their families and, on the other side, offers donors a reconfigured domain of theological promise and scope for personhood through giving within Tzu Chi Buddhism. In this article, I have drawn on my own experiences with the Silent Mentor programme in Hualien and a range of accounts in diverse literatures to show the intersection of anonymity and detachment, and to explore the significance of non-anonymous donation for Buddhist medical training and for questions of medical pedagogy more broadly. In my discussion above, I queried the designation of a ‘Benthamite’ framing of ‘use’ referenced by the philosopher Her (2011, 55) in the context of Tzu Chi’s donation and charity work, and I here want to return to my unease with this association, as a way of drawing together the complex ways in which gifting, use, and ethical self-formation are bound together in the act of donation for medical education.
When Her (2011) references the English philosopher Jeremy Bentham in his discussion of Tzu Chi’s Silent Mentors, it is with a nod towards shifts in Japan, not Taiwan, through the White Chrysanthemum Society. This society, mentioned above, coordinated willed Japanese body donation as a way of ensuring respect for the deceased in student training. Their aim, writes Her (2011, 55), was neither to aid in the sublimation of grief nor to guide people in overcoming fears of death, but rather ‘to maximise the effective use of bodies … based purely on practicality’. This reflection is followed by the emphasis placed on use by Tzu Chi’s Master Cheng Yen, whom Her (2011, 55) quotes as saying, ‘This body is not mine, but I will leave my love to this world’. This, Her continues, is a way of considering ‘the belief that the spirit needs to stay in the body for a certain time before going to the Pure Land [as] groundless. After death, the body is just a shell. It is a wise choice in life to put useless matter to good use’ (Her 2011, 55). In anthropological literature, the ‘usevalue’ of bodies, as the anthropologist Jacob Copeman (2009, 9) has pointed out, has tended to raise a division between panicked analyses of the ‘biologically intrusive ideology of late capitalism’ and what he calls the ‘biospiritual’, or the scope of donors to figure their donations as part of their own ethical or spiritual formation. In his work on the donation of blood in India, Copeman (2006) argued for a novel form of ‘donation theology’ that recognises the synthesis of piety and utility, a space of ethical self-formation on the part of donors alongside – often constitutive of – the new economies or markets of which anthropologists have been critical (Scheper-Hughes 1996; Lock 2000). Following Copeman, I suggest that a similar move of developing a ‘donation theology’ analysis of Tzu Chi is worthwhile here, particularly for the way it explicitly centres utility within, and not in ethically divided contrast to, donation. By siting utility from other parts of Tzu Chi’s work (environmental collection and disaster relief in particular) inside a reworking of Buddhist theology at the moment of death, the Silent Mentor programme elevates utility to ‘a state of virtuousness’, displacing the centrality of self-erasing detachment in the Buddhist death (Cook 2013) and reinstating a self whose new immortality comes into being as they become a Silent Mentor bodhisattva. For all the attention the Silent Mentor programme has received internationally, for all its success in attracting thousands of pledges to donate, attending to the accounts both of those who donate and those who steer the pedagogical intentions of the Silent Mentor programme makes it clear that ‘biomedical utility is not just biomedical utility’ (Copeman 2009, 181). When students and trainee surgeons benefit from the donated bodies upon which they can learn anatomy, make their first incisions, and conduct their first surgeries, they benefit from the ‘the sum of [that utility’s] interaction with other phenomena’ (Copeman 2009, 181); in this case, that includes its relationship to filial piety, the family of Tzu Chi, the place of death and its rituals within contemporary Chinese Buddhist Taiwan, and the charismatic leadership of Master Cheng Yen herself (Huang 2009). A Benthamite reading, focused on ‘the greatest happiness for the greatest number’ or the way donation makes bodies ‘become useful objects to society’ (Her 2013, 55) would miss or perhaps reduce to ‘mere’ instrumentality the ethical and virtuous dimensions of this remade utility. The doctors the Silent Mentor programme intends to create are made through this utility-as-virtue, ideally made accountable and accompanied on their professional paths as physicians. In this sense, the new immortalities of the programme involve not merely the donors themselves, but, extended through memorialisation and the pedagogical desire for ongoing presence, constitute an intergenerational animation of the dead for the medical and ethical ends of the living.
About the author
Rachel Douglas-Jones is Associate Professor at the IT University of Copenhagen, where she codirects the ETHOSLab. Her research interests lie at the intersection of ethics, computation, and biomedicine, and are informed both by anthropology and science and technology studies. Her work has focused on ethics as a form of governance over science, examining specifically the form of the ethics review committee and research ethics capacity-building initiatives in the Asia Pacific region. New research projects concern the implementation of research integrity frameworks in Denmark, comparative research ethics capacity-building in Asia and Africa, the practicalities and politics of biomedical ‘big data’, and the ethics and technicalities of global clinical trial infrastructures.
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