Courtney S. Campbell, professor of Philosophy, Oregon State University, USA
Staving
off death may sometimes compromise a fundamental value, the quality of human life.
Hindus and Buddhists believe that it may be permissible to shorten life
when physical suffering impedes a patient’s self-control and lucidity.
Judaism, Christianity
and Islam basically address ethical issues concerning the end of life from a common
value perspective
To die well, say the teachers of eastern religions, one must live well
The advance
of technologies to prolong life and control dying can raise agonizing moral dilemmas.
What guidance is offered by the great world religions?
In “The
Parable of the Mustard Seed”, the Buddha teaches a lesson that is valid for all cultures:
human beings receive no exemption from mortality. Deep in the throes of grief after
the death of her son, a woman seeks wisdom from the Buddha, who says that he does
indeed have an answer to her queries. Before giving it, however, he insists that
she must first collect a grain of mustard seed from every house that has not been
touched by death. She canvasses her entire community, but fails to collect a single
seed. Returning to the Buddha, she understands that, like all other living beings,
we are destined to die.
Death is a defining characteristic of human experience. Yet, while the event of death
remains elusively beyond human control, the process of dying has increasingly been
brought into the domain of medicine and life-extending technologies. Some technologies,
including organ transplantation, respirators, antibiotics like penicillin, and feeding
tubes, enable life to be prolonged. Other technologies may hasten death.
The decision to use these technologies is a moral choice, because it involves a decision
about a fundamental human good, the preservation of life. Yet, in some situations,
a resort to technology to stave off death comes at a price of compromising another
fundamental human value, the quality of that life. Decisions about continuing treatment
for the dying or of allowing death to take place by foregoing or terminating such
treatment, or even by physician-assisted suicide or euthanasia are thus both existentially
and ethically agonizing. As individuals and their families face these controversial
questions and as many countries consider revising their laws on end-of-life choices,
religious traditions and values can offer guidance and insight, if not solutions.
Historically, religious communities have sought to appropriate death within the life
cycle through rituals of remembrance, and religious teachings have emphasized that
death brings meaning to mortality. The process of dying is often portrayed as an
invitation to spiritual insight and a key moment in the cultivation of spiritual
identity.
The world’s great traditions of moral wisdom all begin with a strong predisposition
to favour the preservation of life, although the specific reasons for this conviction
vary from tradition to tradition. Turning first to three monotheistic religious traditions
which have had global influence, Judaism, Christianity and Islam, for all their differences,
basically address ethical issues concerning the end of life from a common value perspective.
In particular, discussions centre on the values of sovereignty, stewardship, and
the self.
Sovereignty denotes that the lives and bodies of persons are created by, and ultimately
return to, God. We owe our existence to a loving Being who has graciously brought
us into being. Thus, the fundamental passages in human life, including birth and
death, are of divine concern. This understanding of sovereignty has significant implications
for decision-making at the end of life. It bestows sacredness upon human life, which
supports the impulse towards preserving life by available medical technologies. Yet
sovereignty also entails that the ultimate authority for deciding our mortal passages
belongs to God. Human beings must not overstep these boundaries, or so to speak “play
God” with life and death.
‘Agents
of God’
Through the value of
stewardship, we are considered “agents of God”, called to carry out the work of divine
intent on earth. This task entails decision-making responsibilities for which we
are accountable: our actions either further or violate divine intent. In addition,
as emphasized in Islamic teaching, we are the trustees or stewards of our bodies.
We are therefore entrusted with the capacities and responsibility to make appropriate
decisions when confronting a treatment choice at the end of our own life or that
of a loved one.
Indeed, with very few exceptions, the major faith traditions of the West have rejected
a view known as “vitalism”, which holds that biological life is to be preserved at
all costs and with all available technologies. Vitalism is considered theologically
mistaken because it appears to make divine will and intent contingent upon the state
of medical technology. In other words, it puts technology in the role of God.
The dignity of persons, linked to the notion of “self”, is another core value of
these monotheistic faith traditions. In Jewish and Christian thought, this is expressed
in the idea that humans are distinctively in the “image of God”. Islamic theology
does not use such language, but no less affirms the significant value of persons.
The “religious self” is constituted in part by the person’s rationality, freedom,
and decision-making capacity, but also by relationships (with loved ones, for example)
and bodily integrity. These characteristics support human responsibility in addressing
end of life decisions, including refusals of medical procedures that invade the body
with no real benefit, in the context of a caring community. Put another way, preserving
life is not an absolute good in and of itself. Life is a good that opens the way
to achieving higher goods that constitute the religious self.
So by looking within the moral parameters set by these three values of sovereignty,
stewardship, and the self, we find that a patient can decide to forego life support.
A doctor can also allow a patient to die if the continuation of life (by technological
means) assaults the dignity of the person—if it attacks their rationality, freedom,
relationships with others or their bodily integrity. Certainly, differences can be
discerned between these traditions precisely over the priority of these goods. For
example, Orthodox Jewish thought emphasizes the sanctity of life (as displayed in
bodily integrity) which translates into a stronger commitment to life-extending technologies
than in Roman Catholicism, which stresses the capacity for human relationships as
a threshold for determining the permissibility of stopping life support.
The monotheistic faiths have also focused a great deal on the legalization of physician
assistance in hastening death by providing a terminally ill patient with a lethal
prescription of medication. In each instance, arguments supporting physician-assisted
suicide have to overcome a long-standing prohibition of suicide. For a variety of
reasons, suicide is sinful according to the three traditions. Suicide constitutes
a wrong against one’s nature and personal dignity (“religious self”). It also harms
the community and violates the sovereignty of God. As a result, a physician assisting
in suicide may be seen as a moral accomplice in evil, undermining the sacred covenant
of the healer.
However, some faith communities in Protestant Christianity and in Reformed Judaism
have argued otherwise. When faced with terminal illness, one may well be disposed
to ending life, and one’s immediate community (or family) may support this method
of death. These kinds of arguments stress the dignity of the individual as a free
decision-maker (which also applies to persons entrusted with the decision-making
responsibilities of others). This dignity provides the basis for a political and
philosophical claim to self-determination and opens the possibility for choosing
the timing, circumstances and method of one’s death. So physicians may be permitted
to hasten death by prescribed medications, or even by administering lethal medication.
Yet they would never be obligated to do so.
Many religious communities have denounced the question of legalizing physician euthanasia,
or administrating death. The most vigorous opposition has come from the Roman Catholic
tradition, with Pope John Paul II describing euthanasia as an example of the “culture
of death” in Western societies. The Pope believes euthanasia is a manifestation of
social views that have abandoned the protection of life and lent support to liberalized
abortion, capital punishment, and incessant warfare. In general, much religious opposition
is based on concern for patients who may be in vulnerable positions because of their
illness or their lack of social and economic resources. There is fear that patients
who cannot afford expensive treatment, for example, will be pressured to accept euthanasia.
There is also great concern about the moral nature of the doctor’s professional self.
Islamic teaching, for example, stresses the physician’s commitment or covenant to
healing. Euthanasia would violate this sacred role.
Although few in number, there are individual theologians within both the Jewish and
Christian traditions for whom euthanasia is not a contradiction but a culmination
of religious values such as compassion, mercy, and love. By joining these values
to respect for self-determination, some theologians can find a way of tolerating
euthanasia as a final resort.
Eastern
faith traditions
To die well, say the
teachers of eastern religions, one must live well. The views of eastern religious
traditions and philosophies have been very influential in global understanding about
providing appropriate care to the dying. For example, the pioneering work of the
Swiss-born psychiatrist Dr. Elisabeth Kubler-Ross in understanding the experiences
of dying patients in Western medical institutions drew directly on understandings
of the meaning of “good death” and “stages” in life in Hindu tradition. Buddhist
values of compassion, non-violence, and suffering have also influenced the discourse
of Western medical ethics. The ethical tension in these two traditions about end-of-life
choices is rooted in two main values, liberation and ahimsa (non-violence).
In Hinduism and Buddhism, human beings are captured in endless cycles of rebirth
and reincarnation (karma-samsara). The goal of mortal life is detachment from the
material world, culminating in the liberation of the true self from the body-mind
complex. To experience the good life and the good death, we must be constantly aware
of the ultimate trajectory towards liberation.
In both traditions, all living creatures (humans, animals, plants, etc.) represent
manifestations of the laws of karmic rebirth. To honour these laws, one must show
great respect for the preservation of life and non-injury of sentient beings. Acts
destructive of life are morally condemned by the principle of ahimsa, which is the
conceptual equivalent of the Western principle of the sanctity of life. In most circumstances
ahimsa bears a moral bias towards life-preservation. Yet there is some ethical flexibility
which opens the possibility of foregoing treatment or seeking assistance to hasten
death.
As a general rule, both Hinduism and Buddhism oppose suicide as an act of destroying
life. However, a distinction is made in both traditions between self-regarding (or
self-destructive) reasons and other-regarding (or compassionate) motives for seeking
death. To commit suicide over the loss of a child or because of economic hardship
(self-regarding reasons) is to commit a morally reprehensible act which reflects
the individual’s ignorance about the nature of life and human destiny. Instead of
achieving the ultimate spiritual goal of liberation, a person who acts in this way
will remain trapped in the ongoing karmic cycle of life-death-rebirth. Those who
assist in this suicide may also be subject to karmic punishment, for they have violated
the principle of ahimsa.
However, a very different perspective emerges when individuals seek death for spiritual
motives, of which there are basically two kinds. The first revolves around compassion;
concern for the welfare of others as one is dying can be seen as a sign of spiritual
enlightenment. So a person can decide to forego treatment to avoid imposing a heavy
burden of caregiving on family or friends. He or she may also stop treatment to relieve
loved ones of the emotional or economic distress of prolonged dying.
The spiritual goal of liberation can also be seen as an ethical reason for seeking
or hastening death. When physical suffering impedes self-control and lucidity, it
is permissible to shorten life. Pain or lethargy might cloud the awareness and consciousness
at death that both Hindus and Buddhists believe is necessary to ensure a favourable
rebirth. Extreme suffering might also cause someone to be so attached to their material
life (bodily condition) that they cannot pursue the ultimate spiritual goal of liberation
from the material world.
This pattern of reasoning—the primacy of spiritual goals of liberation or compassion
relative to the preservation of life—also applies to euthanasia through physician
injection or administration of a lethal drug. Hindu and Buddhist scholars have found
support for this so-called “active” euthanasia in their traditions by reflecting
on the meaning of death as a door to liberation, the culmination of life in detachment
from the material world. They then go a step further by linking compassion to the
norm of self-similitude: “one should act towards others as one would have them act
toward oneself”. So euthanasia can be seen as a compassionate act or a “mercy killing”
for a dying person striving to the highest purpose of human destiny, liberation.
A moral problem arises with euthanasia, however, if the administered medication renders
the patient unconscious or unable to comprehend their descent toward death. The patient
is unaware precisely at the moment when he or she should be most sensitive and receptive
to spiritual teaching and meaning. For these reasons, other modes of bringing about
death are preferable morally and religiously.