THE SKILL OF MEDICAL SCIENCE and advances in medical technology have been responsible for saving countless lives and alleviating untold suffering. Yet at the same time they pose many ethical and moral dilemmas for the dying, their families, and their doctors, which are complex and sometimes anguishingly difficult to resolve. Should we, for example, allow our dying relative or friend to be connected to a life-support system, or removed from one? To avoid prolonging the agony of a dying person, should doctors have the power to terminate a life? And should those who feel they are condemned to a long and painful death be encouraged, or even assisted, in killing themselves? People often ask me questions such as these about death and dying, and I would like to review some of them here.
Even forty years ago most people died at home, but now the majority of us die in hospitals and nursing homes. The prospect of being kept alive by a machine is a real and frightening one. People are asking themselves more and more what they can do to ensure a humane and dignified death, without their lives being unnecessarily prolonged. This has become a very complicated issue. How do we decide whether to begin life-support for a person, for instance, after a serious accident? And what if the person is comatose, cannot speak, or has been rendered mentally incapable because of a degenerative illness? What if it is an infant who is severely deformed and brain-damaged?
There are no easy answers to questions such as these, but there are some basic principles that might guide us. According to the teaching of Buddha, all life is sacred; all beings have buddha nature, and life offers them, as we have seen, the possibility of enlightenment. To avoid destroying life is taken as one of the first principles of human conduct. Yet Buddha also advised very strongly against dogmatism, and I believe we cannot take a fixed view, or an “official” position, or make rules about issues such as these. We can only act with whatever wisdom we have, according to each situation. And, as always, everything depends on our motivation and on the compassion behind it.
Is there any point in keeping people alive artificially when they otherwise would die? The Dalai Lama has indicated one essential factor—the state of mind of the dying person: “From the Buddhist point of view if a dying person has any chance of having positive, virtuous thoughts, it is important—and there is a purpose—for them to live for even just a few minutes longer.” He highlights the stress on the family in such a situation: “If there is no such chance for positive thoughts, and in addition a lot of money is being spent by relatives simply in order to keep someone alive, then there seems to be no point. But each case must be dealt with individually; it is very difficult to generalize.”1
Life-support measures or resuscitation can be a cause of disturbance, annoyance, and distraction at the critical moment of death. We have seen from both the Buddhist teachings and the evidence of the near-death experience that even when people are in a coma they can have total awareness of everything that is going on around them. What happens just before death, at death, and until the final separation of body and consciousness are moments of immense importance for anyone, and especially for a spiritual practitioner seeking to practice or rest in the nature of the mind.
In general there is a danger that life-sustaining treatment that merely prolongs the dying process may only kindle unnecessary grasping, anger, and frustration in a dying person, especially if this was not his or her original wish. Relatives who are faced with difficult decisions, and overwhelmed with the responsibility of letting their loved one die, should reflect that if there is no real hope of recovery, the quality of the final days or hours of their loved one’s life may be more important than simply keeping the person alive. Besides, as we never really know whether the consciousness is still in the body, we may even be condemning them to imprisonment in a useless body.
Dilgo Khyentse Rinpoche said:
To use life-support mechanisms when a person has no chance of recovery is pointless. It is far better to let them die naturally in a peaceful atmosphere and perform positive actions on their behalf. When the life-support machinery is in place, but there is no hope, it is not a crime to stop it, since there is no way in which the person can survive, and you are only holding onto their life artificially.
Attempts at resuscitation can also sometimes be needless and an unnecessary disturbance to a dying person. One doctor writes:
The hospital erupts into a spasm of frenzied activity. Dozens of people rush to the bedside in a last-ditch effort to resuscitate the patient. The essentially dead patient is pumped full of drugs, stabbed with dozens of needles, and jolted with electric shocks. Our dying moments are closely documented by heart rate, levels of oxygen in the blood, brain wave readings, and so forth. Finally, when the last doctor has had enough, this technohysteria comes to an end.2
You may not wish to have life-support mechanisms or be resuscitated, and you may want to be left undisturbed for some time after clinical death. How can you ensure that your wishes for the kind of peaceful environment recommended by the masters for dying will be respected?
Even if you state your wishes about wanting or refusing certain kinds of treatment in the hospital, your requests may not be respected. If your next of kin does not agree with your wishes, he or she may ask for particular procedures to be started even while you are still conscious and able to talk. Unfortunately, it is not uncommon for doctors to comply with family’s wishes rather than those of the dying person. Of course the best way to have some control over your medical care when you are dying is to die at home.
In some parts of the world, documents known as Living Wills exist, through which you can state your desires for treatment in case the time comes when you can no longer make decisions for your own future. These are a sensible precaution, and help doctors if they are faced with a dilemma. However, they are not legally binding, and cannot anticipate the complexities of your illness. In the United States you can draw up what is called a “Durable Power of Attorney for Health Care” with a lawyer. This is the most effective way to state your choices and ensures, as far as possible, that they will be respected. In it you name an agent, a legal spokesperson who understands your attitudes and wishes, who can respond to the special circumstances of your illness, and who can make crucial decisions on your behalf.
My advice (as I indicated in Chapter 11, “Heart Advice on Helping the Dying”) is to find out whether or not your doctor is comfortable honoring your wishes, especially if you want to have life-support measures withdrawn when you are dying, and you do not wish to be resuscitated if your heart stops. Make sure that your doctor informs the hospital staff and has your wishes written onto your chart. Discuss the issue of your dying with your relatives. Ask your family or friends to request the staff to disconnect any monitors and IV lines once the process of dying has begun, and to move you from an intensive care unit into a private room if feasible. Explore ways in which the atmosphere around you can be made as quiet, peaceful, and as free from panic as possible.
In 1986 the American Medical Association ruled it was ethical for doctors to remove life-support, including food and water, from terminally ill patients about to die and from those who could linger in a coma. Four years later a Gallup poll showed that 84 percent of Americans would prefer to have treatment withheld if they were on life-support and had no hope of recovering.3
The decision to limit or withhold life-sustaining treatments is often called “passive euthanasia.” Death is allowed to happen naturally, by refraining from medical intervention or heroic measures that can only lengthen a person’s life by days or hours, and where their condition is not amenable to treatment. It would include terminating aggressive treatments or therapies aimed at curing the dying person, refusing or discontinuing life-support machinery and intravenous feeding, and dispensing with cardiac resuscitation. This passive form of euthanasia also takes place when the family and doctor choose not to treat a secondary condition that will result in death. For example, a person dying in the final stages of bone cancer may develop pneumonia, which if not treated may lead to a death that is more peaceful, and less painful and prolonged.
What about people who are terminally ill and decide to take themselves off life-support? By ending their lives, are they committing a negative action? Kalu Rinpoche has answered this question very precisely:
The person who decides that they have had enough suffering and wish to be allowed to die is in a situation that we cannot call virtuous or non-virtuous. We certainly cannot blame someone for making that decision. It is not a karmically negative act. It is simply the wish to avoid suffering, which is the fundamental wish of all living beings. On the other hand, it is not a particularly virtuous act, either. . . . Rather than being a wish to end one’s life, it’s a wish to end suffering. Therefore it is a karmically neutral act.
What if we are caring for a dying person who asks us to remove life-support? Kalu Rinpoche said:
We may not be able to save the patient’s life. We may not be able to relieve the person’s suffering. But we are trying our best, motivated in the purest way possible. Whatever we do, even if it is not ultimately successful, can never be thought of as karmically damaging or karmically negative.
When a healer is instructed by a patient to remove life-support systems, that puts the healer in a difficult position, because the instincts of the healer may be telling them, “If this person stayed on the life-support system they would remain alive. If I take them off, they will die.” The karmic consequences depend upon the healer’s intent because the healer will be depriving someone of the means to stay alive, regardless of the fact that it was that person that told us to do it. If the basic motivation of the healer has always been to help and benefit that person and relieve their suffering, then from that state of mind it seems as though nothing karmically negative can develop.4
The same 1990 Gallup poll cited earlier showed that 66 percent of people in the United States believed that a person in great pain, with “no hope of improvement,” had a moral right to take his or her own life. In a country like Holland, ten thousand people are said to choose euthanasia each year. The doctors who help them to die must prove that the patient consents, that he or she discussed the alternatives with them fully, and that the doctor consulted a colleague for a second opinion. In the United States matters have come to such a head that a book clearly describing methods of suicide for people faced with a terminal illness has become a runaway best-seller, and movements have been begun to legalize “active euthanasia” or “aid in dying.”
But what would happen if euthanasia were legal? Many people are afraid that patients labeled as terminal, especially those in great pain, might choose to die even though their pain might be manageable, and their lives might be longer. Others fear that the elderly might simply feel it is their duty to die, or choose suicide simply to spare their families’ lives and money.
Many of those who work with the dying feel that higher standards of terminal care are the answer to requests for euthanasia. When she was asked about the pending legislation on euthanasia, Elisabeth Kübler-Ross replied: “I find it sad that we have to have laws about matters like this. I think that we should use our human judgment, and come to grips with our own fear of death. Then we could respect patients’ needs and listen to them, and would not have a problem such as this.”5
People are afraid that dying will be unbearable, that they will be overtaken by immobilizing, even dementing illness, and intolerable and meaningless pain. The Buddhist teachings offer us a different attitude toward suffering, one that gives it a purpose. The Dalai Lama points out that
Your suffering is due to your own karma, and you have to bear the fruit of that karma anyway in this life or another, unless you can find some way of purifying it. In that case, it is considered to be better to experience the karma in this life of a human where you have more abilities to bear it in a better way, than, for example, an animal who is helpless and can suffer even more because of that.
According to the Buddhist teachings we should do everything we can to help the dying cope with their deterioration, pain, and fear, and offer them the loving support that will give the end of their lives meaning. Dame Cicely Saunders, founder of St. Christopher’s Hospice in London, said: “If one of our patients requests euthanasia, it means we are not doing our job.” She argues against the legalization of euthanasia, and says:
We are not so poor a society that we cannot afford time and trouble and money to help people live until they die. We owe it to all those for whom we can kill the pain which traps them in fear and bitterness. To do this we do not have to kill them. . . . To make voluntary [active] euthanasia lawful would be an irresponsible act, hindering help, pressuring the vulnerable, abrogating our true respect and responsibility to the frail and the old, the disabled and dying.6
What happens to the consciousness of a baby that is aborted, or dies very young? What can the parents do to help the baby?
Dilgo Khyentse Rinpoche explained:
The consciousness of those who die before birth, at birth, or in infancy will travel once again through the bardo states, and take on another existence. The same meritorious practices and actions can be done for them as are usually performed for the dead: the purification practice and mantra recitation of Vajrasattva, offering of lights, purification of the ashes, and so on.
In the case of an abortion, in addition to these usual practices, if the parents feel remorse they can help by acknowledging it, asking for forgiveness, and performing ardently the purification practice of Vajrasattva. They can also offer lights, and save lives, or help others, or sponsor some humanitarian or spiritual project, dedicating it to the well-being and future enlightenment of the baby’s consciousness.
What happens to the consciousness of a person who commits suicide?
Dilgo Khyentse Rinpoche said:
When a person commits suicide, the consciousness has no choice but to follow its negative karma, and it may well happen that a harmful spirit will seize and possess its life force. In the case of suicide, a powerful master must perform special kinds of practices, such as fire ceremonies and other rituals, in order to free the dead person’s consciousness.
Should we donate our organs when we die? What if they have to be removed while the blood is still circulating or before the process of dying is complete? Doesn’t this disturb or harm the consciousness at the moment before death?
Masters whom I have asked this question agree that organ donation is an extremely positive action, since it stems from a genuinely compassionate wish to benefit others. So, as long as it is truly the wish of the dying person, it will not harm in any way the consciousness that is leaving the body. On the contrary, this final act of generosity accumulates good karma. Another master said that any suffering and pain that a person goes through in the process of giving his or her organs, and every moment of distraction, turns into a good karma.
Dilgo Khyentse Rinpoche explained: “If the person is definitely going to die within a few moments, and has expressed the wish to give his organs, and his mind is filled with compassion, it is all right for them to be removed even before the heart stops beating.”
What about cryonics, where a person’s body, or just the head, is frozen to await the time when medical science has advanced to the point where they can be resuscitated?
Dilgo Khyentse Rinpoche called this utterly meaningless. One’s consciousness cannot enter one’s body again after one is actually dead. The belief that one’s corpse is being kept for future revival can obviously trap the person’s consciousness in a tragically increased attachment to the body, and so aggravate its suffering immensely and block the process of rebirth. One master compares cryonics to going directly to a cold hell, without even passing through the bardo state.
What can we do for an aging parent, a father, for example, who has become senile or demented?
At that point it may be of no use to try to explain the teachings, but practicing quietly or saying mantras or the names of the buddhas in his presence will definitely help. Kalu Rinpoche explains:
You will be planting seeds. Your own aspirations and altruistic concern for him in this situation are very important. In offering this service to your father in his unhappy circumstances, you must go about it with the best of intentions, out of a true concern for his welfare and happiness. That is a very important factor in your relationship to him in these times . . . The karmic connection between parents and children is very strong. Much benefit can be worked on subtle levels because of that bond, if our approach to our parents is marked by compassion and concern and our involvement in spiritual practice is not only for our sake, but for the benefit of other beings as well, particularly, in this case, our parents.7