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Taking the Precepts as Your Guide: How to Approach Difficult Decisions, Accept the Consequences, and Not Keep Yourself Up All Night
CRAIG D. BLINDERMAN
An Ethical Dilemma: Request to Hasten Death
The Problem
Mr. Lewis, a lively and relatively high-functioning eighty-seven-year-old, requested that his pacemaker be inactivated. He explained to his primary care physician that he’d noticed a change in his cognitive functioning: forgetfulness and scattered thinking. His wife had died of vascular dementia approximately five years ago, and noticing some of her symptoms within himself was deeply troubling. Extensive neurologic evaluation determined that his objective neurologic functioning was not significantly impaired and that there was no other reversible medical explanation for his symptoms. There was concern, however, that this presentation may be a sign of underlying depression, an early onset of dementia, or a delirium that emerged following the placement of his pacemaker.
Mr. Lewis, his two adult sons, and their spouses felt strongly that his quality of life had declined so much, that his current state of health was so unacceptable to him, that he sought to end his life by deactivating his pacemaker and dying of subsequent congestive heart failure.
The Precepts
The Ten Grave Precepts
1. Not Killing
2. Not Stealing
3. Not Misusing Sex
4. Not Lying
5. Not Giving or Taking Intoxicants
6. Not Discussing Faults of Others
7. Not Praising Yourself While Abusing Others
8. Not Sparing the Dharma Assets
9. Not Indulging in Anger
10. Not Defaming the Three Treasures (Buddha, Dharma, Sangha)
The Ten Grave Precepts are what Zen students of the path vow to uphold when committing to practice together. These precepts provide an ethical structure for people living together in community and are also thought to be essential guidelines for one’s own spiritual development.
While there are many ways to reflect on the precepts, I will focus primarily on the relational perspective: an inquiry into whether our thoughts and actions are useful, skillful, and in a compassionate spirit.
Unlike Aristotelian virtues, the precepts are not for the sake of building character or improving one’s virtuous qualities. Rather, they allow us to move toward a life of right action. The precepts can be used to reflect on various aspects of our lives to see what motivates our behavior — are we speaking and acting from a place of compassion, or is our mind clouded by delusion or other beliefs?
This way of approaching the precepts, I believe, can offer us as healthcare practitioners an opportunity to reflect on whether our actions are in accord with the professional goals of medicine, nursing, chaplaincy, and other allied health professions. That is, are we acting out of compassion? Do we act to alleviate suffering? Are we focused on the healing of our patients? Can the precepts be used not as a means of “solving” a medical ethics dilemma, but as a way to better understand our intentions and attitudes in the process?
Not Killing
The literal perspective would simply not permit us from assisting in ending Mr. Lewis’s life through the deactivation of his pacemaker. Though he has a right to discontinue life-sustaining treatment under US law, this ethical precept would nonetheless ask that we explore this request more deeply.
Thich Nhat Hanh interprets the precept in the following way: “Aware of the suffering caused by the destruction of life, I vow to cultivate compassion and learn ways to protect the lives of people, animals, and plants. I am determined not to kill, not to let others kill, and not to condone any act of killing in the world, in my thinking, and in my way of life.”
Would agreeing to deactivate the pacemaker be an act of compassion, releasing the patient from what he believes to be an unacceptable quality of life? Are there other ways to reduce the patient’s existential suffering than letting him die from heart failure? Surely this is the first “gut” reaction many have when they are asked to contemplate following through with this request. But does that mean that we can never discontinue a life-sustaining therapy when the discontinuation will lead to the patient’s death? Of course, there are examples when the suffering and burdens of treatment outweigh any possibility for healing or for the patient’s well-being. In such circumstances, the killing is not in the discontinuation but perhaps in the continuation of treatment. That is to say, we may be “killing” the memory or even the dignity of the patient through continued life-sustaining therapy. Or perhaps by maintaining the patient on life support we are “killing” potential moments of peace and healing for the patient and his family even as his body is dying. The contextual factors of time, degree, condition, and place obviously affect how we interpret this precept, moving from a literal interpretation of killing to an inquiry into “What is killing?”
According to the Zen Peacemakers, an organization of socially engaged Buddhists, “Recognizing that I am not separate from all that is. This is the precept of Non-Killing.”
Not Stealing
This precept moves the angle of inquiry further from what we have explored above. That is to say, what might we be “stealing” if we were to honor the patient’s request? Would we be robbing the patient and his family of potential moments of healing, love, and understanding? Would we be “stealing” opportunities for transcendence or awakening?
Another way in which we can be guided by this precept is when we consider our interactions with the patient and family. Are we fully present and attentive with the patient and family? Not listening and not being present may be thought of as “stealing” a potential moment of understanding and healing in our shared encounter.
We may also use this precept by asking ourselves, “How can I be satisfied with what exists? Can we help the patient and family be satisfied with the current conditions, or must we change something radically?” Dogen Zenji states, “The self and things of the world are just as they are. The gate of emancipation is open.” Can we assist this patient and his family to accept what is, to be free from ideas about life, health, and death? Can we, ourselves, be free of such ideas?
Not Misusing Sex
The Zen Peacemakers offer a broader interpretation of this precept: “Meeting the diversity of life with respect and dignity. This is the precept of Chaste Conduct.” Therefore, it is not sex itself, but its misuse — treating the other without respect and dignity — that is the true cause of harm.
How then can we respect Mr. Lewis? How can we approach him with dignity? He presents his providers with a serious request to help end his life. He finds his current state of life unacceptable. Can we help bring dignity to his state of memory loss? Are there ways that he could be helped physically or socially to render the conditions of his current mental health less intolerable? Addressing his decline in functioning with respect and compassion may give him a sense that he is being listened to, that his suffering is real, and that it is our concern, as well as his.
Not Lying
One of the primary challenges in addressing any medical ethics case is assessing the medical “facts” — the likely prognosis, available treatment options, risks and benefits of the various treatment options, etc. Speaking honestly can be challenging when there is so much uncertainty. Without speaking falsely, how can we make recommendations to a patient when there is so much unknown? Much of medical knowledge is based on statistics, but statistical information can never be applied directly to the patient we are encountering. For that patient, the chances are either 0 or 1 that an event will happen, regardless of the chances of an outcome occurring in similar patients. Therefore, how can I know what I am stating is not false, or at least misleading?
The precept reminds us that we need to listen attentively and respond with a compassionate heart, transparent about the limits of medical knowledge. In doing so, we will be able not only to contribute our medical opinion, but also to respond from a place of understanding and intention to alleviate the patient’s suffering, not from a false view that we actually know the outcome or the best course of action.
Not Giving or Taking Intoxicants
In the context of Mr. Lewis’s case, this precept can be interpreted as avoiding anything that may delude the mind. Bodhidharma, the founder of Zen Buddhism, interprets the precept in the following way: “Self-nature is subtle and mysterious. In the realm of the intrinsically pure Dharma, not giving rise to delusions is called the Precept of Not Giving or Taking Drugs.”
We should avoid needing to be “right.” This is a mistaken way of thinking that likely arises out of our notions of power, position, reputation, responsibility, etc. In any case, thinking that “we know what is best” for Mr. Lewis and his family is a kind of delusion — it means that our minds are not clear to other options, other possibilities, nor are we able to be fully empathic to the patient’s existential suffering. Indeed, our desire to change the circumstances to “help” Mr. Lewis may itself be a deluded way of thinking, regardless of how laudable it may seem.
Can we see the situation clearly, in all its implications — for the patient, for his family, for his cardiologist, for his PCP, for the hospital, for the healthcare system? What sort of precedent would be set if we were to grant Mr. Lewis’s request? What would it mean to deny his request? How can we see things more clearly in order that we might provide guidance to this suffering man and his desperate family?
Not Discussing the Faults of Others
Many of the healthcare providers involved in this case reflected on how difficult it was not to judge the patient’s family for agreeing and even trying to facilitate the deactivation of the patient’s pacemaker. Many felt that this was unduly influencing the patient’s decision-making and autonomy.
The healthcare team could not truly know the family’s motivations and intentions for their loved one. Nonetheless, several healthcare providers found fault with the family’s decision to help Mr. Lewis end his life rather than finding other means of reducing his suffering. This natural inclination to find fault in others and, moreover, to discuss it in a healthcare team will likely create more distrust and separation between the treating team and the patient and family.
This precept challenges us to unconditionally accept whatever is given in each situation. In the case of Mr. Lewis, we should attempt to fully accept his family’s position and their motivation to help him alleviate his suffering. Of course we need to remain open to all other possible motivations, but this will become clearer over time through direct clinical involvement, not through judging immediately upon hearing about the case.
This precept is of particular importance when there is significant conflict between the healthcare team and the family, or between family members and the patient, or any permutation of conflict that may arise in healthcare. Remaining open to — and not judging — the perspectives of all who are involved in the conflict is the first step toward finding a negotiated solution and respecting everyone who has a stake in the conflict’s outcome.
Not Praising Self While Abusing Others
According to Buddhist teaching, there is no difference between self and other. This precept asks us to investigate how we separate ourselves from others — from our patients, from our colleagues, from our healthcare system.
This precept has particular resonance when it comes to medical error. In contemporary thinking about medical error, it is not one person’s fault when something goes wrong, but rather the responsibility of everyone in the healthcare system that was part of the process (the physician prescriber, the pharmacist, the nurse, etc.). The precept supports this notion of collective or shared responsibility. We do not say, “I am blameless in this incident, it is he that is responsible.” Instead, we each recognize that we are collectively responsible for the well-being of our patients.
Not Sparing the Dharma Aspects
This precept asks that we consider our generosity in all things. According to the Zen Peacemakers, the precept can be stated in the following way: “Using all of the ingredients of my life. This is the precept of Not Being Stingy.” We should inquire into whether we are withholding anything in our interactions and actions.
How can we live up to this demanding requirement? Are we holding back in our care for others? Are we too tired to listen attentively? Are we distracted in the moment when our patient most needs our attention and empathy? Being generous with our time and attention may give the patient a feeling of comfort and prevent feelings of abandonment or not being listened to.
How can we give generously to Mr. Lewis and his family? Perhaps we can start by fully appreciating his unique circumstances, listening attentively, offering words of comfort and reassurance, reframing misconceptions, giving our advice and counsel, offering to work together to find a solution that everyone can be comfortable with.
Not Indulging in Anger
It’s easy to want to change reality, whether for the purpose of serving our patients or for our own lives. In letting things be as they are, we are less likely to engage in anger. Bodhidarma states this precept in the following way: “Self-nature is subtle and mysterious. In the realm of the selfless Dharma, not contriving reality for the self is called the Precept of Not Indulging in Anger.”
When we seek to change reality we may become angry when it does not change according to our wishes. This is true whether the object we seek to change is a situation or a person’s attitudes and actions. This precept asks us to look at how we may become angry. In the above case, we can easily find ourselves being angry with the patient’s family. How could they support (and encourage) Mr. Lewis in hastening his death? We may believe that children and their spouses should behave or believe otherwise. Perhaps they should be trying to persuade Mr. Lewis against the desire to deactivate his pacemaker. Perhaps they should be asking themselves whether they are really acting in the patient’s best interests.
Thoughts like these may anger us, but this is where the precept can guide us toward accepting a larger view of reality. By seeking to understand, through curiosity and compassion, we may be better able to empathize with their concerns and worries. Possible underlying issues may become manifest — a respect for Mr. Lewis’s autonomy and dissatisfaction with his current quality of life, his underlying fear of disability and dependency, or his deep wish to avoid further suffering, etc. For Mr. Lewis, there may be the desire not to be a burden to others, to die on his own terms, to face the reality of cognitive disability with dignity, not dependency. All of these underlying interests may become clear if we can avoid anger and approach the reality of the situation as it is, with all the complex beliefs, desires, and fears that inform our decisions.
Not Defaming the Three Treasures
This last precept is perhaps the most abstract for a healthcare provider. What do we mean by defaming the Three Treasures or the Three Jewels of Buddha, Dharma, and Sangha? Sangharakshita, the founder of the Triratna Buddhist Community, interprets this precept in the following way: “I undertake the item of training which consists in abstention from false views.” He also says, “Transforming ignorance into wisdom, I purify my mind.”
Again, we are reminded of how precious this human life is — that we are a vehicle for perfecting wisdom and clarity of mind. In remembering this aspiration, we may be better able to approach this challenging ethical dilemma. In Mr. Lewis’s case, members of our interdisciplinary team — physician, fellow, chaplain, and social worker, as well as the hospital’s clinical ethicist — collectively spent many hours listening attentively and mindfully to both the patient’s and his family’s concerns and worries. Each member of the team approached the patient’s distress and suffering in its totality, not as some problem to fix but as a shared responsibility. We attempted to abstain from false views through nonjudgmental listening, which proved to be the most effective way to connect with the patient and his family. We tried to see the family and patient, as well as ourselves, enmeshed in a web of suffering and responsibility.
In the end, our team managed to forgo previously held beliefs or biases in favor of a new understanding. We resisted proposing a solution, but instead attempted to understand and alleviate the underlying suffering of the patient and family. Integrating a deep belief in the inherent wisdom within each of us, we hoped to create a space of healing for all those involved in caring for this patient. By simply remembering why we do the work that we do, we can return to each case with a fresh perspective, free of delusion and judgment.
Working with the Precepts; Not “Solving” the Case
The precepts encourage self-reflection and help us see reality as it is, not as we would want it to be. Through carefully investigating how we relate to the ethical issue (or issues) at hand, we become more present and connected, allowing the unique circumstances to be seen for what they are. The use of biomedical principles and casuistry-based analyses are useful tools, but they do not necessarily resolve the inner struggle that we may feel when faced with an ethical dilemma, nor do they require that we see the interconnectedness of our lives and actions.
The struggle for me in this case was that I could intellectually rationalize the patient’s right to discontinue a medical therapy regardless of whether it would hasten his death, but I felt that this was not something that I could suggest or perform in this circumstance. I attempted to connect more fully to the suffering than the stated request. The precepts help remind me to reflect on my attitudes and actions. Was I being open? Was I being intimate? Was I able to connect? Were notions of “right” and “wrong” preventing me from truly listening and being present? Could I exercise patience and skillful deliberation? Could I allow for a nonjudgmental, open space to offer what was needed?
After much deliberation and reflection, we explained to Mr. Lewis that we would not be able to discontinue his pacemaker at this time. Most of us felt that there were still other options to consider before determining that Mr. Lewis’s suffering could not be alleviated, at which time the most compassionate thing to do would be to deactivate the pacemaker and allow him to die.
The social worker and I offered options to Mr. Lewis and his family — increased social support, change in living environment, psychotherapy, pharmacotherapy, and other ideas. Our suggestions were met with hostility and frustration. “He has a right to have his pacemaker turned off!” his daughter exclaimed.
Bodhidharma teaches that we should “not contrive reality for the self.” Was that what I was doing? Was I contriving this patient’s reality for what I believed was right? I noticed that I wanted things to be a certain way, and how painful and disappointing it was to be rejected. How does one transform this anger into acceptance? It doesn’t happen quickly.
Through speaking with spiritual friends I started to loosen my grip on how I thought things should be. As an ethical consultant in my hospital as well as a palliative care physician, I often rely on my moral and professional judgments to suggest what ought to be, whether they are recommendations for symptom management or to resolve an ethical dilemma. This is what we typically do. However, the outcome we wished for — alleviation of this man’s suffering and his family’s distress through some transformative process — was not likely to happen. What occurred to me, both in the ethics committee discussion of this case and through the palliative care team’s assessment, was that there was a deliberative, reflective, and committed process. I could appreciate the process and the intimacy that was created in our time together with the patient, his family, and one another, regardless of the outcome.
In the end, Mr. Lewis and his family decided not to pursue any of the options that we suggested, and they transferred to another hospital where the decision was made to discontinue the pacemaker. The patient survived for several hours after the pacemaker was turned off and received adequate medications to relieve his symptoms until he passed away.
I was deeply saddened when I learned of this outcome. I was also surprised to learn that the other hospital’s ethics committee had reached a different conclusion. Once again I found myself feeling separate, distraught, and guilty of not doing more. It was natural to want to place blame on the other hospital’s clinicians and their ethics committee. But I found that blaming was not a skillful means, especially if I wanted to truly not be kept up at night second-guessing our understanding, worrying that we had failed in some way, and finding fault with other colleagues who approached this patient’s care differently. Thinking about these things results in no shift toward equanimity. If anything, I learned that it even manifested physically as a tightening of my face and neck, which may have reflected my tightened grip on my own understanding of how things should be. I felt that we approached this case openly and spoke the truth, as we experienced and perceived it. So does it matter that the outcome was not what many of us would have wanted?
The Zen Peacemakers interpret the Seventh Grave Precept as “Speaking what I perceive to be the truth without guilt or blame. This is the precept of Not Elevating Oneself and Blaming Others.” I came to rely on this wisdom in the ensuing days, weeks, and months. When asked about this case, I would reply that we had dutifully and compassionately assessed the distress of this patient and his family and offered our services and our whole selves in the process. We cultivated a place of intimacy through the exploration of the request, understanding that the outcome would ultimately be largely out of our control.
I may often find myself disagreeing with others’ assessments, wanting to change the patient or family situation, often discouraged by narrow views and conceptions about how to care for seriously ill and suffering patients. But therein lies the trap. When I become attached to my perspectives, I become more separate and stuck. The precepts can then serve as a reparative to this small-minded habit, like the cool water in a deep well — refreshing, nourishing, and sustaining.