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.comEubios 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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