Are contemporary mindfulness-based interventions unethical?

Mindfulness involves regulating ruminative thought processes by focusing awareness on the present moment.¹ The technique derives from Buddhist practice and has received substantial interest and uptake among the scientific and medical community, as well as the public more generally. Based on emerging empirical evidence, the UK’s Mental Health Foundation recently called for mindfulness to be made more readily available on the NHS.²

Although there is considerable interest in mindfulness, the rapidity at which it has been extracted from its traditional Buddhist setting has given rise to what has been termed the ‘mindfulness backlash’.³ This has emerged from a wider movement that views many mindfulness-based interventions (MBIs) as highly superficial representations of traditional Buddhist mindfulness teachings, and asserts that MBIs are teaching ‘McMindfulness’.²,³ Included within the criticisms levied at MBIs are claims that patients are being treated unethically due to being provided with misleading information regarding the possible religious intentions of certain MBIs.²,³

Within healthcare settings, MBIs are generally delivered in a secular format, with limited use of Buddhist terminology. Consequently it might appear as though potential issues regarding religiosity have been circumvented, and there are no grounds for claiming ethical impropriety. However, a closer inspection of the rhetoric employed in the promotional literature of certain MBIs, and also by some of the founders and leading-advocates of these interventions, suggests otherwise. A notable example are the assertions made by Kabat-Zinn, founder of Mindfulness-Based Stress Reduction (MBSR) and the University of Massachusetts Medical School Centre for Mindfulness (CFM). On the one hand, Kabat-Zinn asserts that MBSR is neither spiritual in nature nor is it about Buddhism per se.⁴ However, Kabat-Zinn also asserts that MBSR is about ‘... the movement of the Dharma into the mainstream of society’.⁴ ‘Dharma’ is a Buddhist word meaning the ‘Buddhist teachings’.

Similar claims have recently been made by Santorelli (executive director of CFM) who attempted to explicitly associate MBSR with Buddhism by asserting that: ‘MBSR is simply a contemporary expression of a twenty-six hundred year old meditation tradition …’ ⁵ Likewise, such rhetoric also appears to be present in some of the MBI promotional literature in which a qualified teacher is deemed by the CFM to be ‘... a committed student of the dharma, as it is expressed both within the Buddhist meditation traditions and in more mainstream and universal contexts exemplified by MBSR ’. ⁶

There are two principal reasons why such widely-propagated assertions give rise to serious ethical implications. The first is that it is questionable whether contemporary MBIs actually embody and teach mindfulness in a manner bearing resemblance to the traditional Buddhist meaning of this term.¹–³ It is misleading to claim that MBIs teach the Dharma if this is not the case. The second reason relates to the fact that, within healthcare settings, most participants of MBIs think that they are receiving a non-religious and non-spiritual intervention designed to enhance their levels of psychosomatic wellbeing.¹ Therefore, it is misleading and ethically inappropriate to assert that an MBI is non-spiritual and not Buddhist-related if, consistent with the assertions of some leading MBI proponents, an underlying intention is to use MBIs as vehicles for introducing individuals to the Buddhist teachings.

According to Purser, contemporary mindfulness providers are ‘engaging in self-censorship’ and ‘camouflage’ when they say that their treatments have nothing to do with Buddhism.³ Given that there are both historic (Malnak versus Yogil, 1979) and recent (Sedlock versus Baird et al, 2013) lawsuits relating to wilful or inadvertent exposure of ‘unsuspecting’ individuals to religiously and/or spiritually-orientated techniques (that is, Transcendental Meditation and yoga), it appears that healthcare providers choosing to offer MBIs are taking on a significant legal and commercial risk.

Moving forward, we recommend that individuals involved in developing, administering, and/or advocating MBIs decide whether their primary intention is to provide either: an intervention for transmitting Buddhism to clinical and non-clinical populations; or an attention-based behavioural intervention based upon mindfulness but fundamentally different from the Buddhist interpretation of this term. If the intention is to realise the first scenario, then it should be made abundantly clear to patients that a primary purpose of the intervention they are about to receive is to learn about Buddhism (with mindfulness taught in the traditional Buddhist way). However, if the intention is to realise the second scenario and provide a non-religious behavioural intervention, claims that MBIs embody and teach the Dharma should be abandoned.

• © British Journal of General Practice 2016