End of Life Issues and Moral Certainty: A Discovery through Hinduism

- R. R. Kishore, MD, LLB

Chief Medical Officer, Ministry of Health, Government of India,

President, Indian Society for Health Laws & Ethics (Ishle)

D-II/145 Kidwai Nagar (West), New Delhi ‑ 110023, INDIA
Email: rrkishore@vsnl.com

Eubios Journal of Asian and International Bioethics 13 (2003), 210-3.

Introduction

Despite the basic human search being same i.e., the discovery of truth, science and religion view the life differently. While the former perceives it as a substance with definite biological activity, with possibilities of being completely decoded and synthesized, the latter sees it as an expression of God's will, an eternal bliss, crystallized in to different shapes and forms, a cosmic phenomenon beyond human perceptivity and determination. At the present stage of scientific development, every life has to come to an end and death is the natural consequence of life. This reality notwithstanding, preservation of life is considered to be a universal human value and death is always seen as a negative event. This is a basic human notion, regardless of religious affiliations, and reflects a continuous pursuit to win over death. In the context of end of life issues, moral discussion therefore revolves round the interpretation, causality and manner of death, raising many questions some of which are purely metaphysical, others are ethical, while some are biological. But, they are all fundamental and, at times, it may be difficult to separate intuition from science. Fast advancing biotechnology, growing institutionalization of health care and increasing material value of human body has imparted new dimensions to the end of life issues, contemplating a delicate balancing of individual and social perspectives. Decisions regarding prolongation and termination of life are now linked to the imperatives of necessity. At times, dictates of utility may reduce continuance to futility, while at times prolongation of life may be considered necessary in order to serve a social cause rather than an individual purpose. Advance directives, health care proxies, and the physician's or the family member's intervention in the matter of withdrawing life sustaining treatment are laden with serious complexities. Heterogeneous approaches with regard to patient's right of self‑determination coupled with legislative inadequacy have further compounded the problem. There have been cases of sentence against physicians by the courts of law in U.K. and Japan for assisting patients in the process of ending their lives. One of the biggest challenges continues to be the determination of presumed consent in case of incapacitated patients. In Asian societies where physician‑patient relationship is largely based on fiduciarism and family members play a bigger role in the decision making process end of life decisions, in the absence of distinct ethico‑legal paradigms, carry a risk of getting tainted with paternalism. But, in the face of science's failure to curb inevitability and certainty of death, religion continues to play vital role in determining moral content of life and death issues. Religious convictions and expressions make the decisions easier, comfortable and dignified by imparting them a higher moral certainty. In this essay I have endeavoured to study the religious sanctity and direction relating to end of life issues, as contained in Hinduism - a way of life reflecting a blend of culture, science and philosophy, not merely a religion, initiated nearly five thousand years ago.

The Moral Dilemma

The term 'life' signifies two different expressions, (1) the human body or human personhood (2) an eternal and perpetual cosmic phenomenon passing from one body to another, as believed by Hindus. Contemporary concerns about the 'end of life issues' relate to the former i.e., the loss of human body or personhood, which is known as death. With this connotation, "Sanctity of Life" means sanctity of human body or human person. This sanctity is a universal recognition and the whole controversy about the end of life emerges out of this sanctity. A physician is therefore, at times, confronted with profound ethical uncertainties. The physician has to decide which one is the better course of action? To leave a person to suffer incurable and unbearable pain, agony and indignity or to relieve him/her from this misery and allow him/her to pass away in peace and dignity by hastening the process of death. While taking such decisions the physician has to answer following questions:

i.  Is it professionally permissible to kill or to help in dying a terminally ill and incurable patient?

ii.  How does such a decision affect the person concerned and the society in general?

iii.  What are the values that are attracted in such situations?

iv.  How to assess that the individual's urge to die is based on cool and candid considerations and is not an impulsive act reflecting resources constraints, inadequate care or discrimination?

vi.  What are the practical risks involved in case a decision is taken to terminate the life of the patient?

vi.  Where should the physician look for guidance in situations of such moral dilemma?

vii.  Does the physician's or the patient's religion play any role in decision making process?

Contemporary world order is founded on reason, equity and dignity. Reason envisages definition and distinctness. What is the distinction between 'killing' and 'letting die'? Or, in other words, what is the difference between 'causing death' and 'denial to prevent death'? Also, can the prolongation of life be ever 'unnecessary'? And, if yes, what are the criteria to determine the life's worth? Equity mandates equality of opportunity, balancing of interests and optimization of resources. This means addressing questions such as; for how long one should live? Who should die first? What should be the ideal method of terminating one's life? Dignity imposes obligation to preserve life at all costs and in the event of an individual's conscious expression to end his life, contemplates a valid purpose and truly informed consent.

Deontologically, in the context of sanctity of life, there is not much of conflict between secular and religious concepts as both consider life as sacred and worthy of protection. But, the differences appear in the face of application of advanced technology which has the potential of keeping alive the terminally ill and incurable persons who would have otherwise died. Since the technological resources are not unlimited prioritization becomes a functional imperative, bringing in the concepts of worth and utility. In other words, the questions like whose life is more precious and worthy of protection have to be answered. This is a formidable task, attracting multiple and diverse perspectives, moral as well as strategic, leading to heterogeneous approaches and despite agreement on fundamental issue of value of life the decisions may seem to be at variance. A fair and objective decision in such circumstances may be a difficult exercise and any liberalization is fraught with following apprehensions: Danger of abuse; Enhanced vulnerability to the poor; Slippery slope outcome; Weakening of protection of life notions.

Any ethical model governing end of life decisions should therefore be impervious to all extraneous forces such as, the utilitarian bias, poverty, and subjectivity i.e, inadequate appreciation of socio‑economic, family, cultural and religious perspectives of the individual. The poor and resourceless are likely to face deeper and more severe pain and agony before dying and as such may request their physicians to terminate their lives much earlier than those who have better access to resources. This poverty‑death nexus makes an objective decision difficult, constituting a formidable challenge to committed physicians and others involved with the end of life issues. Taking a decision on case to case basis, depending on individual's material constraints and inadequacies, enhances the problem rather than solving it, as it reduces the life from an eternal bliss to a worldly award, subjecting its preservation to socio‑economic exigencies. For these reasons many feel that the safer and more respectable course to improve death is to  provide good palliative care and emotional support rather than assisting the end of life. The moral ambiguities notwithstanding, decision to assist or not to assist the act of dying by correctly interpreting the patient's wish and the accompanying circumstances, including the moral dictates, constitutes a practical problem. Let us see how Hinduism addresses these issues.

Hindu Approach

Hinduism perceives facts at a level much deeper than the molecular plane, identifying the cosmos by its unique characteristics of holism, universality and complementarity and thus offers great insight in to the philosophies of mind, religion, science, and ethics. In the context of end of life decisions following Hinduistic perceptions are specifically relevant ‑

1.  Dharma

The entire Hindu religious thought, concerning human conduct and the way of life, is founded on the theory of Dharma and Karma. According to Hinduism humanity is the manifestation of human content of Homo sapiens. Human content means human properties i.e., intrinsic human traits or attributes, known as Dharma (in ancient Indian language Sanskrit), the nearest synonym to which in English is virtue. There are ten human virtues namely, love, trust, compassion, truthfulness, righteousness, tolerance, beneficence, sacrifice, forgiveness and rationality. These virtues constitute human dignity, a characteristics distinct to human beings. Recognition of these virtues is known as respect. Thus, respect means recognition of dignity.

2. Karma and Non‑attachment

In Hinduism the ultimate goal of all life‑forms is Moksha (emancipation) i.e., merger with the Absolute, or freedom from the eternal wheel of birth and death. This can be achieved through karma i.e., acts consistent with dharma. Karma plays a vital role in the journey of life in as much as it determines the life‑form a soul is lo acquire. Life embodies in to physical form in order to perform karma and as such karma is the essence of human existence. But, it must be understood that karma is not a consequentialist phenomenon. It is an integration of cause and effect, both occurring simultaneously. It is the means and end merged in to one. Karma is based on the doctrine that the desire to enjoy fruits robs an act of its intrinsic worth and meaning. Air act performed with good intention, without any reward or return, is an expression of divine activity.

3. Continuity

According to Hinduism life never comes to an end. It is a part of cosmic consciousness. Death means a process through which life passes from one body to another. In other words, death means end of form, not the end of 'being'. Life is continuous and perpetual. It is not merely a biological identity. It is a part of the Whole, separated through a barrier known as body, and possesses strong cosmic dimensions. This idea is very deep‑rooted in every Hindu. This is a part of his convictions and the foundation of all religious expressions. In holy Gita (which, to Hindus, is like Holy Bible or Quran) the process has been described thus:

"Just like the body passes through childhood, youth, and old‑age, it attains another body. Death therefore does not affect the wise ones" Holy Gita Chapter 2, Shloka 13

"Just like a person discards old clothes and puts on new ones

the Soul leaves the old body and enters in to a new one"

Holy Gita Chapter 2, Shloka 22

Death is thus not the end of life. It is simply a transformation of body. Body is like clothes which need to be regularly changed. The destruction or annihilation of physical structure or cessation of its vital functions does not mean end of life. One continues to live after death, in a different abode. As such, loss of the body does not constitute an irreversible loss and death does not mean the denial of life.. Rather, it is an enabling event as it provides one a chance to exchange his old body with a new one. Death therefore is not something to be grieved over.

4. Liberation

In Hinduism, the human existence possesses three dimensions namely, individual, social and cosmic. The ultimate goal of all life forms is to attain cosmic character i.e., merger with the Absolute, known as Moksha. But, as long as the life is embodied, individual and social obligations in accordance with dharma, are a part of person's duty. This creates a necessity for righteous conduct. As a general rule, every life form, particularly that of human, is sacred and it has to be protected at all cost. No person is bestowed with the right to end his or her life. But, an individual's act of discarding his/her body may be permissible under certain circumstances and, at times, it may be his moral duty to sacrifice his life. Some of the situations under which a person's act of terminating his life enjoys religious sanctity are as below-

i).  A Yogi (a person who has mastered the art of regulating his involuntary physical and mental functions, at will) can discard his/her mortal coil (body) through the process of higher spiritual practices called yoga. This state is known as Samadhi (a state where soul leaves the body) The purpose of discarding the body is emancipation i.e., merger with the Absolute or freedom from death and birth cycle.

ii) An individual who, by enhancing his spiritual power, has mastered the art of leaving his body at his will can discard it when he finds at a ripe old age that he cannot do any good to the society owing to deterioration of his/her physique, due to old age or disease.

iii) A person can end his life willfully if he considers such an act to be conducive to the protection of the weak, helpless or needy, or it is necessary to protect his dharma.

The above acts of embracing death do not constitute suicide, as it is understood in its usual connotation. They reflect a positive activity i.e., a candid desire to discard the mortal form for the sake of liberation.

5.  Beneficence and Compassion:

Dharma contemplates beneficence and compassion in human actions which means it is the duty of every person to be sympathetic and helpful to those who are in need. Such action may include the physician's act of assisting a person in dying if it is aimed at relieving the person from unbearable and incurable pain, agony and misery.

Discussion

Thus, we find that in Hinduism the concept of end of life is founded on intrinsic voluntariness and a person's act of accepting death may be morally permissible under certain circumstances. The Western notion of assisting end of life in order to provide "good death" i.e., free from unbearable and incurable pain and misery is distinct from the Hindluistic thought of embracing death, without assistance of any other person, in order to attain individual salvation or to discharge a community obligation. In Hinduism, a person carries the right to end his/her life under prescribed conditions but no right is vested on any other person, including the physician, to kill an individual. In other words in Hinduism the decision regarding self‑inflicted death vests wholly in the person concerned. Hinduism therefore confers the right to end their lives only on those who are mature enough to take a conscious and independent decision and are capable to embrace death without any external support or assistance. Decision to end life reflects a spiritual direction that appropriate time has come to leave the existing structure. Thus, it is an expression of a pure and candid desire to merge with the Absolute or to enter in to a fresh body. In Hinduism, the desire to die is not to be aided or abetted by any external agency and killing is thus not permissible under any circumstances The act of dying has to be achieved by spontaneous effort by the individual i.e., by developing his spiritual faculties to die at will. It does not necessarily reflect paucity of resources or presence of suffering.

As already stated, dharma and karma are the core concepts of Hinduism. Life and death issues are also governed by these core concepts. Physician's act of serving the patient is a karma which has to be consistent with dharma. There are no specific religious guidelines concerning the end of life issues and Hinduism does not expressly sanction "assisted suicide" or "mercy‑killing" But, the theory of karma grants sanctity to all acts consistent with dharma. The conduct of physician and patient and the entire course of action has to be consistent with dharma. Let us take an example: A person has been lying in persistent vegetative state with the help of life sustaining treatment and a decision has to be taken about the future course of action. Since the patient cannot take the decision, somebody else has to decide on his behalf. It may be a family member, friend or the physician. The physician in such situations is confronted with two moral injunctions; 1) every life is sacred and worthy of protection, ii) every patient should be treated with love, trust, compassion and beneficence. How a physician translates these perspectives in to action depends on several factors, the primary one being the physician's own convictions and value concepts. But, I feel the whole process is made simpler by the Hinduistic belief that death does not mean one's end. One continues to live after death, but in a different abode. Concepts of liberation as enshrined in Hinduism, defining death as the process of changing old clothes with the now ones and sanctioning the act of discarding the worn out mortal coil (human body) in order to enter a new form which, in tact, may be a better one depending on the karma performed by the person, offer clarity and strength to the decision making process. Additional strength is provided by the doctrines of non‑attachment i.e futility of attachment to worldly objects, and emancipation i.e., freedom from the eternal wheel of birth and death and merger with the Absolute, as the ultimate goal of life. As such the physician and family members grown in Hinduism may find it easier and morally more certain to take decisions under such difficult situations. Similarly, in a situation where a person wishes to leave his body owing to unbearable and incurable pain, agony or misery and the physician is convinced that the individual's desire is conscious and well‑founded, the dictates of beneficence and compassion which are integral component of dharma, contemplate that the physician should assist in the fulfillment of patient's task of liberation from that unending trauma.

Likewise, while making an advance directive or living will pertaining to end of his/her life a person is guided by many perspectives such as, emotional, moral, material and religious. Hinduism in such situations ‑‑ through convictions emerging out of dharma, karma, nonattachment, rebirth and continuity ‑‑ reduces fear of the unknown, dilutes lure of worldly attachments and minimizes inner conflicts thereby providing peace and tranquility, imparting an element of divine sanction to human decisions and providing the individual a feeling of proximity with God.

Religious notions are not absolute commands. But they do offer enlightenment and guidance in the moments of darkness and ambiguity. The purpose of this article is to familiarize the players involved in the end of life decision making about different dimensions of life and death as viewed through Hinduism. It is not possible, nor desirable, to draw a code of conduct based on religious perspectives  alone  because every religion has a  different approach and even in the same religion different persons draw different interpretations. Furthermore, religion constitutes just one out of several imperatives in policy formulation or decision making. Nevertheless, Hindu religious doctrines as enshrined in this article are helpful in providing a moral certainty to the end of life decisions by enhancing the perspectives and insight of the persons concerned.

Conclusions

Ethical crisis emerging out of biotechnological revolution cannot be addressed merely by a paradigm shift, It calls for a much deeper change in our notions towards life, death and norms of human conduct. Religion is no substitute for thought and philosophy but religious dictates and sanctions act as a source of enlightenment and certainty in morally conflicting situations. At present, there are no definite ethical guidelines or moral directions for a person who intends to take decision about the end of his/her life or for a physician who is confronted with a situation where he/she has to decide to let a patient die by not providing, or withdrawing, the life sustaining treatment or by adopting some more active methods. Hindusim, bestowed with unique cosmic consistency, provides ground for determining moral content of human actions, thereby imparting choice, dignity and independence to the end of life decisions. The doctrines of dharma, karma, non‑attachment, continuity, liberation and rebirth provide spiritual support, and freedom from inner conflicts, in the face of worldly concerns and inducements, thereby reflecting positively on the end of life issues. Dharma, the core Hindu concept, has enough scope to address all the issues relating to life and death, with certainty. Its components of love, tolerance and sacrifice lay the foundations of an egalitarian social order by protecting the interests of the poor and resourceless. Its other components of truthfulness and righteousness ensure against the danger of abuse and exclude possibilities of enhanced vulnerability of the terminally ill. Since Hinduism prohibits killing for reasons such as material gain, optimization of resources, or any other man‑made exigency, the only permissible ground for withdrawing life support is the desire to relieve the patient from incurable suffering and indignity. This is an expression of beneficence and compassion which are integral components of dharma. These concepts provide moral support to physician while taking end of life decisions. Hinduism grants sanction to an individual to discard his body which is in advanced stage of degeneration, provided he is able to achieve this goal by activating his spiritual faculties. This, by implication, offers scope to a physician for assisting a person in the act of dying in order to get rid of incurable and unbearable pain and agony. In this increasingly shrinking world, ruled by technology, curiosity and materialism, bioethics calls for integration of cross‑cultural perspectives in order to evolve holistic ethical paradigms and determinants on vital issues such as end of life decisions and Hinduism, in my view, offers a genuine hope of evolving a sound and stable ethical order in this context.

Religious notions are not absolute commands. It is not possible, nor desirable, to draw a code of conduct based on religious perspectives alone because every religion has a different approach and even in the same religion different persons draw different interpretations. But, there are occasions when reason and knowledge fail to address issues and religion provides complementary support in the decision making process. 

The question is, do the Hindu religious doctrines offer any insight or conceptual clarity in the decisions pertaining to end of life issues and, if yes, what are the doctrines relevant in this context and how do they help in decision making? The answer is that Hinduism offers clarity of vision and reduces moral dilemma in such situations by providing following perspectives to the physician.

Human body is sacred and its protection is a pious human duty. But, death does not mean annihilation of life. It simply means change of abode or physical structure and the soul will immediately enter in to another body or structure and the person will continue to live albeit in another life form. As such the physician is simply helping the person to transform his/her structure.

Prophecy, not the advocacy; wisdom, not the knowledge are the hallmarks of Hinduism. It thus bestows higher degree of representative power and parental jurisdiction on certain characters such as parents, Guru (initiater/preacher) and the physician thereby offering him/her greater freedom in decision making process.

Pleasure and pain, joy and suffering are the effects of our acts i.e., Karma. A person's miserable condition leading to a situation where death is the only answer is the outcome of his/her Karma and as such compatible with the laws of universe.

Non-attachment to worldly objects and charms is a means of salvation. Clinging to a dilapidated and exhausted structure is incompatible with this notion. Parting with the body in such a situation is the wiser course.

The acts of all, including the physician, are guided by Dharma which includes love, trust, beneficence and compassion as its essential ingredients. These attributes contemplate helping a person to come out of the misery.

Hinduistic doctrines of Dharma, Karma, non-attachment, liberation and rebirth offer great insight and provide moral force to human acts. These concepts are unique to Hinduism and are not found in any other religion. The physician must draw strength from these doctrines at the time of difficult decisions

Hinduism allows exit from mortal coil or physical structure by an individual when his/her body is completely worn out and depleted, as a self-accomplished process by awakening spiritual faculties. As such, a physician's act of helping a patient die is simply a substitute for the patient's spiritual inability to depart from his/her body and does not constitute any moral infringement

The physician need not worry or be afraid of superficial reactions as long as his/her conduct is consistent with Dharma as all moral laws are subordinate to human virtues. This imposes obligation on the physician to ensure that the individual's urge to die is based on cool and candid considerations and is not an extraneous or impulsive act reflecting frustration, inadequate care or discrimination. In the latter case, physician's Dharma contemplates genuine efforts to eliminate such factors.


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