- Pitak Chaicharoen, M.D. & Pinit Ratanakul, Ph.D.*
Faculty of Medicine, Ramathibodi Hospital, Mahidol University
*Center for Human Resources Development, Mahidol University,
45/3 Ladphrao 92 Bangkapi, Bangkok 10310, THAILAND

Eubios Journal of Asian and International Bioethics 8 (1998), 37-40.

Is Mercy-Killing really Merciful?

It is clear that active euthanasia including assisted suicide is against the Buddhist teaching. This is because in Buddhist psychology, "mercy killing" cannot be carried out without the ill-will or feeling of repugnance (dosa) of the perpetrator toward the fact of the patient's suffering. Even though the motivation behind this action may have been good, i.e. to prevent further suffering of the patient, but as soon as such thought becomes action to terminate life it becomes an act of aversion. So when a doctor performs what, he believes is "mercy-killing", actually it is due to his repugnance of the patient's pain and suffering which disturb his mind. Subsequently the doctor experiences negative emotions toward this disturbance and projects it on the suffering of the patient. But he disguises his real feeling (i.e. repugnance) as a morally praiseworthy deed to justify to himself "mercy-killing". If he understands this psychological process he would recognize the hidden hatred that arises in his mind at the time of performing the lethal deed, and would not deceive himself with the belief that this deed was motivated by benevolence alone. Therefore from the view of Buddhist psychology "mercy-killing" is not really a benevolent act. It is done from ill-will and thus has bad kammic effects both for the doctor and the patient. However, the Buddhist teaching of compassion complicates the issue, for to end the suffering of others is the goal of this Buddhist ethical value. In health care, compassion implies two obligations doctors have towards their patien,t i.e. to do all they can in their power to enhance the well-being and health of their patients, and to do no further harm to the patients by preventing and alleviating their harm and suffering. Accordingly doctors and nurses are obligated not to expose their patients to further harm and suffering because of their lack of knowledge, inadequate skills or negligence. In case of terminal patients, compassion is limited to giving drugs in sufficient quantities to relieve intense pain, as that experienced by cancer patients, as a last resort when no hope of recovery is possible and the patient is dying. This is the farthest that compassion can go. Beyond this point the precept against taking of life is violated.

Is Letting-go of-life a form of Killing?

The position of "passive euthanasia" is more difficult to resolve in Buddhist terms. In this case the ethical waters become more muddy. Because of its complexity involving scarce medical resources, the high costs of treatment, and medical uncertainty the majority of lay Thai Buddhists are more cautious in their approach to "passive euthanasia". Despite their belief in the law of kamma for some of them withdrawing life support systems can be justified in a case when, by the best medical wisdom and through rigid testing, there has occurred in the patient total brain death which means irreversible coma and no hope for recovery. Some Thai Buddhists recognize that there is a real moral distinction between "letting die" or allowing a patient to die and directly and intentionally taking life. For them, allowing a patient to die does not violate the precept and is considered an altruistic action for those involved.

In Buddhist ethics intention is crucial in determining actions as right or wrong, but with regard to euthanasia other factors are also important. There can be mixed motivations behind the intention to act in seemingly good ways. The intent of family members and the doctor to let the patient die, may be motivated by selfish as well as altruistic desires. For example, for family members there may be the desire to relieve the suffering of a patient and the desire to inherit his fortune. In the case of the doctor he may have the desire to end the pain and suffering of one patient and the desire to have a viable organ for transplantation in another patient. A hospital can have a policy accepting passive euthanasia with both a desire to relieve the suffering of patients and families and to contain medical costs. For these reasons lay Thai Buddhists are cautious about extending the grounds for "letting-go-of-life" by the withdrawal of medical technologies beyond the strict and narrow grounds in the case just mentioned above. And because of many factors entering into decisions about withdrawing life-support treatments such decisions have to be made on a case to case base. They also recognize that sometimes in real life human choices are only between two evils. Yet even in this tragic life situation one still has responsibility to choose the lesser evil. But for such agonizing decisions there has been little guidance culled so far from Buddhist sources to help Buddhists and to ease their conscience. As generally known, Buddhism encourages each person to face the troubles by relying on oneself alone, without expecting any divine power to intercede and help. Choosing among evils requires wisdom (panna) or insight arising from the regulated mind (samadhi), right understanding (sammadhithi) of the real nature of existence characterized by conditionality (paticcasamuppda), impermanence (anicca), suffering (dukkha) and unsubstantiality (anatta), and from continuing learning (sikkha). With samadhi and sammadithi one is able to make a realistic evaluation of a given situation and to act unselfishly. Sikka enriches panna diminishing the number of mistakes made. Since there have been cases especially with younger people where remarkable recoveries have occurred even after doctors pronounced them terminally ill or as being in irreversible coma, Thai lay Buddhists also are unwilling to see general policies adopted accepting passive euthanasia. As there are always risks and uncertainties, they would favor risking in favor of life and not against it.

What Criteria Should Influence Euthanasia Decisions?

The problems surrounding the euthanasia issue are complex. It involves the expanded use of hi-tech medicine, doctor's traditional values, patient's autonomy, medical costs, family's desires and religious teachings. There are also many cases of moral conflicts between doctors and families over the continued life or death of patients and between nurses and doctors. The fact of medical costs for serious illnesses weighs differently on the rich and the poor. Distribution of scarce and expensive high-tech medical treatments follows no rule of justice. Lay Thai Buddhists in general are opposed to euthanasia considering it to be against the Buddhist precept of taking life. At the same time they have become aware of the many aspects of the issue which make it not that clear cut. For example, through the newspapers they have become aware of cases such as that of a 94 year old woman, kept alive by artificial means for over a year at the cost of bankruptcy of her family. Another case was that of an 11 year old girl in irreversible coma for years, again at high cost to the family. To these lay Buddhists, questions are raised if when asked whether economic factor, the age of the patient and the quality of life would make any important difference in their decisions regarding the use of life-support systems, none could give a definite Buddhist answer. Some say yes and some no, but they could not find grounds in Buddhism to support their answers.

The reality is that some forms of euthanasia are currently being practiced in some hospitals by doctors who make life and death and decisions alone without any directives whether these be ethical, religious, moral or legal. If such practice it is allowed to continue unchecked, public suspicions and therefore mistrust of medical professionals will increase to the detriment of all, patient, families and doctors. Central Buddhist teachings must be reinterpreted to deal with the issue of euthanasia which is a new challenge arisen as a result of the discovery and expanded use of modern technological medicine.

Is there a Buddhist Principle for Euthanasia Decisions?

Perhaps the Buddhist concept of mutual dependency and interrelatedness (paticcasamuppada) should be applied to the field of medicine. This concept affirms the interdependence of all beings. When all beings depend on other beings, none of them is primary, and concern for other, co-operation and harmony are crucial human values in social relationship. Suicide or assisted suicide as a "right to die" cannot be absolute because people do not live lone but are members of communities who might be injured by their death or by a social policy that encourages such death. With regard to life and death decisions doctors and other medical personnel should not decide and act by themselves but in partnership with patients, their families and/or surrogates when making decisions on treatment, including the use of life-sustaining technologies. Accordingly doctors ought to include in their professional ethics the need to have the consent of their patients or surrogates for any treatment. When conflicts between doctors and patients or surrogates arise, some form or structure of mediation is needed. Lacking such mediational means, resolution of conflicts depended upon the good will of the two sides to find a compromise. Such good will or possible compromise may not always be present and a law might be enacted to regulate decision-making in cases of conflict. But the law tends to be a blunt instrument, unable to deal with the individual differences and nuances that mark human interactions especially in matters of life and death. Rather, the public must be more educated about what is involved in such decisions. Similarly doctors and nurses must be educated to change their roles to be more of a partner and facilitator in helping patients and surrogates make decisions. Apart from this, while keeping their primary image as healers, dedicated to preserving and prolonging the life of all patients under their care, they have to develop a new approach to death and dying, so that when death becomes imminent they would become graceful acceptors of the inevitable, without considering the hopeless condition of the dying patient as representing the failure of their skills and knowledge. They should instead turn their full attention now to the compassionate care of the dying. Their main concern of course is to relieve the suffering of patients and families and ensure a "good death". To make these changes a long process is required but it is a needed one to minimize conflicts, and pitfalls.

Is Hospice Care a Buddhist Alternative?

Specially in regard to euthanasia, there are grounds in Buddhism for hospice care. This is because in Buddhist tradition death is accepted as the natural end of life and one is not encouraged to either hasten it or to save it all costs. Buddhism is also known for its holistic approach to health care focusing on the entire person, and for its emphasis on the last stage of life as being of great importance and, on the practice of compassion on the part of doctors and nurses to provide a special care for the dying. The ideal is to help them to die in a calm, conscious state, so that possible good rebirth is obtained. Hospice care provides humane treatment, comfort, consolation and companionship to the dying either in their own homes or in special units at hospitals staffed by specialists specially trained to deal with all kinds of suffering that people and families endure at the end of life, in volving physical, mental, emotional, moral and spiritual. These hospice specialists have successfully demonstrated not only that no one needs to suffer from unbearable pain toward the end of life, but that most people can be maintained at a level of pain-relief which does not impair their faculties or cloud consciousness, but permits them to have meaningful lives at the end. Such care obviates much of the concern for euthanasia and is in conformity with the Buddhist teaching about life and death and the practice of compassion. The success in pain-relief and the atmosphere and policies of hospice movement indicate that no one needs die neglected, alone, shunted aside by doctors and nurses, busy with the living yet unconscious and hooked to machines, kept from their families and that death with dignity and humane treatment is still possible in our time. The question of the use of artificial means to keep a alive does not arise in hospice care, for the acceptance of death is one of the main tenets of the hospice movement when dying is the only option open.

Conclusion

Euthanasia is an agonizing problem of Thai society as more and more high-tech treatments are being used by doctors. It has raised many unresolved ethical problems as the issue is further complicated because of the increased of the practice of organ transplantation. The question being raised now is whether the Buddhist compassion as practiced by doctors should go beyond their concern for their own immediate patients to those patients whose lives could be saved by their own dying patients' organs, as Buddhist compassion is impartial and is directed to all involved in a given situation. There should be extensive dialogue between members of the public and medical profession about this issue. Doctors, patients and the public alike will be benefited by this discussion of the reality and possibility of organ transplantation.

While active euthanasia violates the Buddhist first precept against killing passive euthanasia presents a complex ethical challenge to Buddhist morality. Doctors cannot prolong the use of life-support systems indefinitely because of complicated factors involved such as medical cost for family members, scarce medical resources, medical uncertainty, and the resulting quality of patients' lives saved or sustained. Contemporary emphasis upon patients' autonomy, that patient should have the right to choose and refuse treatment and the possibility of conflicts between patients and doctors, doctors and family members are the other factors that complicated the issue. But the situation is even more aggravated when cases involved incompetent patients such as seriously defective infant (e.g. spina bifida babies, and anencephalics) who may be spared the agony of short but futile life by stopping life-sustaining treatments. In this case it is not the length of life that is really significant in making life and death decision it is the infants' own agony and the futility of treatment that matter.

Suggestions are given by some Thai Buddhists that one can draw a distinction between "killing" and "letting-go-of-life" is worthy of serious consideration because in Buddhist ethics the motivation and intention behind actions are morally significant factors not simply the end result. If there really is such distinction Thai Buddhists may feel that letting-go-of-life does not constitute a breach of the Buddhist first precept, and Buddhism can offer a "middle way" between the two extremes i.e. active euthanasia including assisted suicide and the position of sustaining life at all costs and under all circumstances. However for general public there is still uncertainty about distintinguishing between "killing" and "letting-go-of-life", and passive euthanasia remains problematic for them. It is even more problematic for the doctors who strongly believe that sustaining the lives of their patients is their primary duty and obligation. Therefore the question of to save or let-go-of-life is a continuing ethical issue as Thai Buddhists grapple with the reality of existence in the modern world and the need to be faithful to Buddhist teachings. More and more elderly Buddhists, monks and lay people alike, express their wishes to be allowed to die in the last stage of their lives accepting death as a natural end simply because, they believe, this is the Buddhist way of facing the inevitable death.