- Michael Cheng-tek Tai, Ph.D. Professor of Bioethics and Medical Humanities Chungshan Medical University, Taichung, Taiwan Adjunct professor of Religious Studies and Anthropology University of Saskatchewan, Saskatoon, Canada.
Death is a multi-faceted phenomenon. Not only does man's quest for the significance of his ultimate earthly experience vary in approach -- biological, philosophical, sociological or theological -- but also each person apprehends his own death in a unique way. The physician serves patients of varied beliefs whose diverse world-views result in divergent interpretations of the phenomenon of death. Yet in a society where filial piety is deemed a social norm, what should physician do when patient's family insists to prolong life through life-supporting system to a person in PVS stage without any hope of recovery? This medical technology enabling physicians to maintain life in an un-natural way deserves our deliberation so as to re-discover the real meaning and purpose of life.
This paper will consider what is natural and un-natural in terms of life and death phenomenon and ask the question -- is life relying on external means without any hope to recover worthwhile? The author will argue that such an effort is un-natural thus withholding or withdrawing treatments to terminally ill patients is ethically justifiable providing that patients are not let die in an assisted way.
In this sense, can't we say that all medical treatments are un-natural as they are the attempts to interrupt the flowing of natural development? No, if treatment can restore health, it is not un-natural but a halfway between the natural and the un-natural with the purpose to restore the natural. Every person deserves the right of this opportunity when sick. Yet when the treatments proven to be futile or when the un-natural attempts to restore health becomes ineffectively and inhumane, then, the un-natural way of maintaining life should be forgone. To put it simpler, when a patient in PVS on a life-supporting system can never be able to "live" on his/her own natural capacity, the withdrawing or withholding of treatments can be considered.
The rapid progress of medical sciences has enabled physicians to indefinitely prolong life on life-supporting machinery. This new technique has saved many lives but also complicated medical decision-making in a society where filial piety is regarded as a social norm. In order to appear to be filial, many people insisted that their elderly who actually were close to death or suffering from PVS, be kept alive. On the contrary, people realizing the impending death of their loved ones, requested that the life-support systems that kept them alive be shut off. In some countries the movement of right to die is gaining momentum, yet only a few countries passed the laws to allow euthanasia. According to the Taoist view, all these endeavors and attempts to prolong or shorten life are artificial, arbitrary and unnatural and should not have been contemplated. The key to equilibrium, prosperity, health…etc of a person is to allow the Tao to flow freely so that all things can operate according to their set places and rules. Any attempt to disrupt the flow of the Tao is against nature leading only to dissatisfaction and misery. The survival of humanity depends on the establishment of the harmony in the universe and the good health of a person, in other words, the harmony of microcosm within the body.
There are three key concepts in Chinese philosophy that we must first have a general understanding before discussing the Taoist view of what is natural and unnatural.
Heaven or Tien is a sacred power and the source of everything in the world. This Tien is impersonal, yet functions like a moral force that rewards good and punishes evil. The concept of Heaven sometimes is known as Tao.
The Tao is the ultimate principle of the universe. The Tao Te Ching, the seminal text of Taoism writes " Tao begot One, One begot Two, Two begot Three and Three begot ten thousands things ".  Tao is " Super One ",  the prime source. The One is the primordial being or Chaos, the Two indicates Yin and Yang, and the Three are Yin, Yang and their unity. Tao determines all things or everything depends on it. It is mysterious and omnipresent. When you "look, it cannot be seen -- it is beyond form". When you " listen, it cannot be heard -- it is beyond sound. " When you grasp, it cannot be held -- it is intangible. " " From above it is not bright. From below it is not dark." It is "the form of the formless, the image of the imageless…there is no beginning and there is no end… "  Tao is beyond the capacity of ordinary knowledge and the human intellect, yet " one may see Tao of heaven without looking through the window"  as it is in all things. The most primary meaning of Tao is a road, way or path. It can refer to the path of nature, the movement of stars according to natural law, the order of seasons, activities of living things according to their nature. Tao is intangible, invisible, absolute, eternal and unchanging yet there are forms which bear the substance of it. From the past to present, Tao has never ceased to be and has been the beginning of all things because it is the beginning of all things and it has been there before all things came into being. It is the absolute, yet formless, fathomless, always present, unchanging and everlasting. Tao is the mother of all things.
Yin and Yang-- the interaction of Yin and Yang is the basis of changes. Yin originally means covered by clouds, the shade, dark, hidden, secret, cool… Yang means shining, bright, light, open and warm. . These two opposites were seen as the constituents of all things. The idea of sexuality is understood from the view point of Yin and Yang: male is open, active, aggressive. thus Yang. Female is hidden, passive, yielding...thus Yin. Some may regard Yin as bad and Yang good but essentially this is not the case. The entire system is good because it is the Way of Heaven and the proper ordering of the world. A healthy life is one in which the forces of Yin and Yang are balanced. An imbalance of these polar energies causes a shift in the organism's equilibrium, which in turn coalesces into patterns of disharmony and illness in the physical body.  Thus when one part becomes too dominant, it creates unbalance and harmony is broken. A balance between Yin and Yang and harmony among all the internal organs expressed through the interactions of the Five Elements  is important. Disease is the breakdown of this balance and harmony. To treat the diseases resulting from this unbalance is to recover the original balance so that Tao in the form if Ch'i (Qi) can smoothly flow within the microcosm of the body.
Chuang-tze, a sage in Taoism explains what is of nature is internal and what is of the unnatural is external. That oxen and horses should have four feet is what is of nature. That a halter should be put on a horse's head or a string through an ox's nose is what is of man. Following what is of nature is the source of all happiness and goodness, while following what is of man is the source of all pain and evil. All beings may have different nature and natural abilities but when they have a full and free exercise of their natural ability, they will be happy. Chuang-tze further explains that the duck's legs are short but if we try to lengthen them, the duck will feel pain. The crane's legs are long, but if we try to shorten them, the crane will feel grief. Therefore, we cannot amputate what is neither by nature long nor to lengthen what is by nature short.  If we should try to help wheat in the field grow by pulling it a little bid every day, the plant will wither and die eventually. The natural thus refers to flowing the way of Tao and the unnatural is the man's attempt to force his own will upon Tao. In this case, does Taoism teach that we could not and should not do anything at all? No, Taoism teaches actions without artificiality and arbitrariness.  If one overacts, it becomes harmful rather than good. We cannot force things to happen. If we try to make things happen it is not real. Real value must come naturally and spontaneously. Artificiality and arbitrariness are opposite to naturalness and spontaneity.
Artificiality is thus the source of evil. Even the best intention can lead only to suffering because it is not the simple reflection of Tao. We must adjust to the flow of Tao. The wise therefore has no personal interests and is impartial. He acts only according to Tao that is acting naturally and spontaneously.
Though Taoist sages Lao-tze and Chuang-tze lived around 300 -200.B.C., their view of what is natural and unnatural reflects the understanding of most people in Far East Asia until recent times. In the past, the world was indeed divided into things, which were natural that is given by nature and things artificial, that are made by human craft. But technology changes this understanding. We have technology and we can improve things. Yet this change comes with a price that challenges the traditional code of ethics. Technology is neutral in terms of value. It is up to the hands of man who created it to decide which way technology should turn. Professor Oliver O'Donovan of Oxford University expressed it: "When every activity is understood as making, then every situation is seen as a raw material, waiting to have something made out of it " . John Wyatt, a British scholar called this a "Lego Kit ". In a Lego Kit, there is nothing natural or unnatural, no right or wrong way to put the pieces together. In other words, there is no ethical basis of Lego construction. You can do whatever you like . In fact, as it says in its advertisements, " the only limitation is in your own imagination".
Modern medical technology explains this "unlimited venture "well. The reproductive technology is a good example to describe all this. Technology is changing the very nature of parenthood, so that what is natural and what is unnatural is becoming ambiguous. John Wyatt, a pediatrician at University College London posed some thought-provoking questions: Is a frozen embryo in a tank of liquid nitrogen a being of nature or is it a product of human planning, an artifact of human creation? Does reproductive technology mean that the process of making babies has changed from being a natural activity to being an artificial activity or is the distinction no longer meaningful? When we change the nature of parenthood, we change our relation and our attitude toward children. Perhaps when a child is created by the wonderful technology of embryo donation and in vitro fertilization, the child may be seen no longer as a mysterious and wonderful gift but more as a product of human ingenuity and meticulous planning. There is a phrase in Chinese to denote the naturally conceived child as Ch'in-sheng meaning that " I gave birth to this baby myself and this baby bears my gene ". It is only natural for the mother to say this but the surrogate mothers' program developed by the modern reproductive technology changes all this. The Ch'in-sheng no longer stands that this baby is my own and my flesh. The baby may have no genetic tie to the bearing or the rearing mother at all.
In addition to reproductive technology challenging the traditional understanding of what is natural and unnatural, prolonged by life-sustaining machinery also pose a question to the Taoists. Does a respirator natural or unnatural aid breathing? If unnatural, is the person who depends on it still a person? Does the person breath, or the air through the machine breaths the person? Is this still meaningful? Or when we intentionally terminate a life in the name of euthanasia, would it be natural or arbitrarily? Does death occur spontaneously or artificially? If artificially, would it be a murder?
One question people will undoubtedly ask, if this is a Taoist belief, then there is no medical treatment possible. The answer is no and it could be explained through a story Chuangtzu told:
" Yen Ho was about to become tutor of the Crown prince, the son of Duke Ling of the state of Wei. He went to consult Chu Po Yu, saying, ' here is someone who is naturally violent, if I let him remain undisciplined, the state will be in danger. If I try to correct him, I shall endanger myself. He knows enough to see the faults of others but not to see his own. Under these circumstances, what shall I do? '
Chu Po Yu replied: That is a good question! Be on guard, be careful and be sure that you yourself are acting appropriately. Appear to be flexible but maintain harmony within.
However there is danger in doing these two things. While being flexible, be sure to remain centered. While maintaining harmony within, do not display it openly. If you are too flexible and lose your center, then you will be overcome and destroyed and you will collapse. If you try to demonstrate your composure, you will be criticized and slandered, called a devil and a son of a bitch. If he wants to be a child, be a child with him, if he wants to act strangely act strangely with him, if he wants to be reckless, be reckless with him. Then you can reach him and bring him to his senses." 
Obviously, the Crown Prince in this story is not right with the Tao for being violent. The master taught that he be brought to his senses. In other words, when one departs from the way of Tao one will need help to correct the imbalance suffered within the person. This implies that who goes astray from the way of Tao should be given a chance to flow back to the original natural way. Chinese culture views the individual as a microcosm, a reflection of the surrounding universal macrocosm. The principles of universal energy flow are embodied in the inner working of human beings. Thus, a healthy life is one in which the forces of yin and yang are evenly balanced. An imbalance of these polar energies causes a problem. The Crown Prince in the story apparently suffered from it. His imbalance causes the violent behavior, thus, he is sick and needs help.
From this understanding, we discover that Chinese medicine basically is an attempt to restore the balance of yin and yang flowing with the human body through Ch'i. Ch'i is the foundation of body and life. In the Taoist view, everything is composed of Ch'i. It is somehow mysterious in terms of science but it is an important and useful concept in Chinese culture, including traditional medicine, the practice of acupuncture and Chi-kung exercise.
The bioethics of Taoism is based on its concepts of what is natural, the harmony of Yin and Yang, and the interaction of the Five Elements. Whatever follows the flow of Tao is regarded as natural and thus ethical, contrariness would be arbitrary and against the movement of nature. Applying these principles to bioethics, we can see the Taoist is uncomfortable with extra-ordinary treatments. But if this treatment could enable the body to restore its ability to function according to the original goodness of Tien, then the unnatural measures become ways to help return the way of Tao. This treatment thus can be accepted. But if the treatment is a violation of natural process and unable to restore the natural ability of the body to function on its own, this kind of medical treatment would be rejected as an arbitrariness against natural spontaneity. For instance, during an open-heart surgery, the function of the heart is temporarily replaced by a machine so that surgeon can repair an ailing heart. This attempt may appear to be unnatural, but if the heart would eventually resume functioning after the repairing operation, this treatment can be accepted. If a person has to depend on life-sustaining machinery indefinitely, such a measure will be unnatural. The removal of the life supporting system from the person would be ethical. The unnatural measures that lead to the restoration of natural ability can be acceptable. But if the unnatural measures would fail to restore the body's natural ability to function, then these medical treatments should not be recommended.
From this Taoist understanding we can easily find that cloning or using a surrogate mother, and using donated eggs and sperm to help any pregnancy are not accepted. However, the treatment that enables a woman's own ability to bear a baby will be all right. All illness including infertility is due to the disharmony of Yin and Yang and the mix-up of the interaction of the Five Elements. Medical treatments to restore the natural flow of Tao are always good.
In the case of PVS patient, if the patient can breath on his own, he is still alive, but if this person has to depend on a life-supporting system for his life, the life is no longer natural. The removal of the system is to let Tao be Tao. Taoism however would oppose active euthanasia, as it is an artificial way of ending life. Palliative care will be Taoists' option to let nature take its course. Thus a Taoist will be in support of Hospice movement and in opposition to the Right to Die movement.
Death must not be fought against but to accept it is a natural development of life. When Lao-tze died, his friend Chin Shih criticized the violent lamentations of the other mourners saying: " this is to violate the principle of nature and to increase the emotion of man, forgetting what have received from nature. When the master came, it was because he had the occasion to be born. When he went, he simply followed the natural course."  Experiencing the death of his wife, Chuang-tze said; " when she just died, I couldn't help being affected. Soon, however, I examined the matter from the very beginning. At the very beginning, she was not living, having no form, nor even substance. But somehow or other, there was then her substance, then her form, then her life. Now by a further change, she has died. The whole process is like the sequence of the four seasons, while she is thus lying in the great mansion of the universe, for me to go about weeping and wailing would be proclaim myself ignorant of the natural laws. Therefore I stop mourning. " 
What will the Taoist bioethicists say to the dilemma such as what Karen Quinlan's father faced? Here is a brief re-visit to the episode: in 1974, after drinking a potent mix of hallucination drugs and alcohol at a party in New Jersey, twenty one year old Karen lapsed into a coma. After being rushed to hospital she was placed on a respirator, Karen, however, never regained her consciousness. Seven months later, her father requested to have Karen's life-supporting system removed so that she could die in dignity, but his plea was rejected. Two years later, the New Jersey Supreme Court issued a landmark decision declaring that Karen had a constitutional right to die. Karen, however, lived on for another nine years after the respirator was removed. When Karen's respirator was removed, her father was asked if he wanted Karen's feeding tube to be removed as well. He said, Karen had the right to nutrition and wanted her feeding tube remain connected. The decisions made by Karen's father evoked many heated debates regarding the right to die, the right to food and water, what is ordinary and extraordinary treatments…and so on. A Taoist would applause the decisions Karen's father had made. After all, breathing through a respirator is unnatural. Since Karen was able to breath naturally on her own, her life should not be artificially terminated either despite the fact she remained in a deep coma.
Francis Schaeffer's death offered another example. Dr. Schaeffer was a Christian apologist and a close friend to Dr. C. Everett Koop, the Surgeon General under Carter's administration. He had been dying from cancer for several years. The extensive treatments allowed him to write and lecture to very near the end. But when final treatment decision had to be made, Schaeffer was no longer able to make them himself. A team of his doctors asked his wife should he be placed in intensive care on machines. She, reflecting on the distinction that her husband had drawn between preserving life at all cost and prolonging death, replied: " you have already done great things during these last years and these last few weeks. You fought for life and gave Fran time to complete an amazing amount of work. The time had come for him to go home. "  Ten days later, Schaeffer, being surrounded by the familiar things in a bedroom at home with a large window overlooking colorful flowers, died without the treatment that could have prolonged his death.
Was this decision nonfilial in Confucian tradition? Perhaps in some peoples' minds yes. But to a Taoist it is absolutely no. When treatment no longer bears any purpose, a Taoist will happily let nature take its course. This is the Way of Tao.
In a society where filial piety is regarded as a social norm, should a son consent to withdraw treatments to his terminally ill father or should he request that his father's life be maintained as long as possible? Leaving a father unattended is deemed as unfilial in a Confucian society, let alone untreated while being ill. But the Taoist asserts that artificiality is unnatural, uselessly prolonging a life through life-supporting devices or futilely treating an incurable terminal patient is against the flow of Tao.
Artificial life relying on external means is not harmonious with nature. Keeping a life of a PVS person on respirator going is unnatural. If medical procedures fail to revert the deteriorating health of a person and the treatments received proven to be futile , foregoing treatments should be the way of Tao and is thus ethically justifiable.
Lao-tzu : Tao Te Ching, A New Translation by Gia Fu Feng and Jane English. Vintage Book, New York, 1972 : 42
Fung YL: A Short History of Chinese Philosophy, The Free Press, New York, 1948:97
Lao-tzu: Tao Te Ching, ibid : 14
Lao-tzu: Tao te Ching, ibid: 47
Zhao RJ: An Ideal Medical Model -- Integrating Chinese Medical Philosophy and ethics into the Current Healthcare System, paper presented at International Conference on the Unity of the Sciences, Washington DC,1997:3
The Five Elements refers to five dynamic and interactive forces. They are water, Fire, Wood, Metal and Soil. Water is to moisten and descend, Fire to flame and ascend, Wood to be crooked and strengthen, Metal to yield and to be modified and Soil to provide for sowing and reaping. These five are mutually begetting and yet also mutually conquering. In human body these Elements each also represents certain organ, such as water representing kidney (lower orifices), wood, liver (eyes), earth, spleen(mouth),fire, heart (ear), metal, lung (nose). All these need to be kept in balance lest disease be caused. All dietary regiments are intended to nourish the respective organs in right proportions with foods and medical herbs containing energy corresponding in quality to their respective elements. The seasons and even the hours of the day were classified with respect to the elements and various internal organs. Spring belongs to the liver, summer belongs to the heart, late summer belongs to spleen, autumn belongs to the lung and winter belongs to kidney. Different disease attack people in different seasons. Human body is an integral whole in which all organs and tissues have correspondences with one another. Chinese medical philosophy aims to restore balance and harmonization by treating the diseases holistically. Neglecting this principle when treating patients invites disaster.
Giles HA: Chuang-tzu, Mystic, Moralist and Social Reformer, Kelly and Walsh, revised edition, Shanghai,, 1926
Also see, Fung YL:ibid ;105
Fung YL, ibid:100
O'Donovan O : Begetten r Made, Oxford University Press, Oxford. 1984:3
Wyatt JW: Matters of Life and Death, Intervarsity Press, Leicester, England,200 : 31
Wyatt JW, ibid
Chuang-tzu, A New Translation by Gia Fu Feng and Jane English. Vintage Book, New York, 1974:77
Fung YL, ibid:108
Lin XG: Taoism in Sharma A ed, Our Religions, Harper, San Francisco, 1973:247 Also see Fung YL: 108
15. Larson EJ and Amundsen DW, A Different Death, Intervarsity Press, Downers Grove,Ill, 1998:175
16. Dr.Norton Spritz, chief of Medical Service at Veteran Affairs Medical Center and professor of medicine, New York University discussed about this issue in his article " Medical Futility: a useful concept ? " collected in " Medical Futility " and suggested that some guiding principles are needed when withholding and withdrawing treatments to PVS patient. The Taoist view would be a good guide when facing such dilemma. See Zucker M and Zucker H, Medical Futility, Cambridge University Press, Cambridge,1997: 36-47.