Physician Assisted Suicide - Some Questions for Buddhists

Let us suppose, dear reader, that you or I are terminally ill. Let us suppose that we have considerable spiritual maturity and have meditated for many years on the Great Question of life-and-death.
 
However, in our final months we begin to experience very severe pain. There is a dilemma here for those Buddhists who believe that our state of consciousness at the time of death is a major determinant of the next rebirth. In fact, a survey by Karlis Osis of over 35,000 observations by medical staff concluded that only 10% of patients were even fully conscious in the hour of death. And of these only one in twenty (0.5% of the total) showed any sign of elation – doubtless glad just to be released at last. Most of these patients will have been subject to pain-killing medication. Should this be withheld ? Dr Steve Heilig, a director of the San Francisco Medical Society, writes out of wide experience:
 
Pain itself can cloud the mind or even obliterate it in ways that no amount of diligent practice and forbearance can withstand. Serious, lasting pain can be dehumanising. Using drugs to alleviate suffering, even if it renders us seemingly unaware of what is happening, may be a blessing greater than the unknown merits of staying awake, aware and in agony to the end.
 
Even when the best palliative care is available pain specialists variously concede that they can "control" pain in around only 85% of cases. However, let us suppose either that our terminal condition falls within the other 15%. Note, by the way, that physician assisted suicide is increasingly seen not as an alternative to palliative care but simply as a very last resort when the patient is convinced that all else has failed.
 
In our case we are next faced with a terrible quandary. If we were to wait until our helplessness were more advanced we would need an accomplice, either to assist our suicide or, if needs be, to be solely responsible for our deliverance. But our accomplice would be liable to prosecution and probable imprisonment in most countries. There is thus for some the cruel pressure of the law to take their life prematurely, rather than later to be faced with the possible need to depend on another for assistance.
 
But surely the greatest obstacle of all to suicide, physician assisted or not, is that the First Precept of Buddhism clearly condemns the taking of one’s own life or, presumably, helping someone else to do so. This brings us to a much larger question which has received remarkably little public discussion among Buddhists. I refer to the ethical divide between "literalists" and "situationists".
 
The literalist treats Buddhism as if it were a "religion of the book" where the precepts must be applied literally no matter what the circumstances. Yet surely a great many situations arise in public and private life which are sufficiently complex as to put us in some moral perplexity. Courage is required when whatever decision we do make may turn out to be harmful and it is difficult to know what to do for the best. We can only act out of our compassion for all involved (including ourselves) and do our honest best. Of the five distinguished Buddhist teachers who contributed to a symposium on euthanasia in the UK Buddhist Hospice Trust journal four assumed the situationist position. One of these, Ajahn Sumedho, wrote as follows:
 
We seem to want to take absolute, moral and fixed positions on such questions as "How do you feel about euthanasia?" Our minds tend to be conditioned to take a fixed view on [such] issues, and we interpret life morally. But the Buddha-mind is not fixed on a position and is able to take into account all the things that are affecting a given situation. This means that sometimes it seems a bit wishy-washy and we would like Buddhism to come through with a strong moral position; and yet what Buddhism has to offer is not moral positioning but real morality; the opportunity to take responsibility for your own decisions.
 
This is not some quandary of contemporary Western Buddhism. In all the Buddhist traditions there is warranty for a situational morality.  Moreover, the present world offers many examples. Anarchic states are increasingly common, with much random butchery of the helpless by drug crazed soldiery or ideologically crazed fundamentalists. Such situations require multi-skilled peace making teams of mediators, aid workers and others. These must of necessity include specially trained soldiers able to make a judicious use of force where it is clearly essential to protect the innocent and enable more peaceful remedies to be applied.
 
Note, however, that the situationist is concerned with ethically extreme, complex and problematic situations. The literal precepts certainly do not cease to be invaluable base lines, from which we should depart only with great reluctance and circumspection. So it is with physician assisted suicide which I define – please note! -  as the medically assisted suicide requested by a terminally ill person who is mentally competent but experiencing unbearable distress for which all forms of relief have failed.
 
For my part I respect the personal views of my literalist co-religionists hold about such euthanasia, but surely they should not uphold the coercive power of the State to deny the dignity and autonomy of fellow human beings to make their own decisions about life-and-death when they find themselves in a condition of great anguish ? I know of Buddhist hospice and palliative care workers who have confessed how their exposure over the years to the reality of the messiness and distress of dying pulled them up short. Their black-and-white view of things changed because so many anguished patients begged that their lives be ended. Incidentally, it is where euthanasia is illegal and takes place by subterfuge that abuse is most likely, rather than where there are strong and well-considered safeguards built into the legislation.
 
Finally, there is the belief that if we “murder” ourselves, or have others do it for us, this violent act will have an adverse karmic effect on rebirth (not, of course, our rebirth, which would suppose a self to be reborn). Would the literalists have us believe that, as punishment for having compassionately released ourselves from irremediable suffering or having helped another to do so, we shall be reborn into some Buddhist hell, or condemned to some lower form of life ?  However, it appears that many Western Buddhists either simply do not believe in rebirth — and the doctrine has proved thorny and problematic throughout the history of Buddhism –- or they are agnostic about it.
 
Whatever position we may take, it is worth recalling that karma, as a volitional mental phenomenon, is only one of the five Abhidhamma modes of causality. Several of these niyamas may be involved at death, and certainly the physical-organic one (uti-niyama). I refer the reader here to a valuable recent book by Nagapriya, Exploring Karma and Rebirth, (Windhorse Publications (Birmingham), 2004):
 
In reality, there are not five distinct orders of conditionality. Every experience comprises a vast network of conditions; our previous moral conduct will often have a bearing on our present experience, but in many situations non-moral factors will exert a more decisive influence. The teaching of the five niyamas thus presents a more complex and subtle account of why things happen as they do than the crude view of karma criticised above (p.39).
 
"The crude view" here is the traditional folk belief (without canonical warranty) that everything that happens to a person is karmically determined and a consequence of volitional intent. Nagapriya is the latest of a long line of Dharma scholars who have tried to kill off this "simplistic model that was both able to account for suffering and to spur people into living a good life through fear of a nasty rebirth and the promise of a pleasant one" (p.131).  He concludes that “it does not seem appropriate to assume that people are suffering as a result of their previous karma. This is [only] one possibility.” The causal stream is commonly so subtle, complex and problematic for the karmic thread (if there is one) to be readily distinguished at all. This must be especially so in the manner of our dying, over which we appear to have less control than idealisations of “the Good Death” would lead us to suppose.
 
Religious attitudes to any kind of suicide, as to much else, have for too long been bedevilled by a clinging to righteousness and scriptural fundamentalism.  Our insecure self craves above all else for moral certainty and all too easily slides into punitive morality.
 
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The Steve Heilig quotation is reproduced from Turning Wheel, magazine of the Buddhist Peace Fellowship, Spring 2002, with grateful acknowledgement to the author and editor. Karlis Osis  At the Hour of Death, New York, Avon Books, 1979.
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