- R. R. Kishore, MD, LLBChief 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
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.
1. DharmaThe 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‑attachmentIn 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. ContinuityAccording 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 22Death 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. LiberationIn 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.
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.