Buddhism and Euthanasia

Recently there has been widespread discussion in Singapore about the pros and cons of euthanasia. The government originally broached the subject, probably in response to rising health costs, and various medical and religious bodies have given their opinions on the matter. On Nov. 4th the Straits Times reported that Christian, Muslim and Buddhist religious authorities were opposed to any form of euthanasia and that Hindus were (on going to press) unable to give an opinion one way or the other. I suspect this means that they were simply unable to find anyone who could speak authoritatively on the matter, a sad reflection on the state of Hinduism in Singapore. Venerable Kwang Phing of the Singapore Buddhist Federation was asked for the Buddhist position and said that Buddhism would consider euthanasia to be unacceptable. I do not know exactly what Ven. Kwang Phing said but I would like to give some of my own thoughts on the issue.

I will use the word euthanasia here to mean intentionally killing a terminally ill patient by performing or withholding medical procedures. Euthanasia can be either active, e.g. administering a lethal injection, or passive, e.g. no longer feeding an unconscious patient. It can also be either voluntary, e.g. requested by the patient, or non-voluntary, e.g. where the patient is unconscious and a legally competent person makes the decision. Thus there are four types of euthanasia – active voluntary (AVE), passive voluntary (PVE), active non-voluntary (ANE) and passive non-voluntary (PNE). There is also what is now called voluntary suicide (VS), where the care-giver provides the patient with the means of killing himself or herself but has no involvement beyond that.

There are three main arguments in favour of euthanasia –

The Compassion Argument. If someone is in extreme pain and going to die soon anyway, or if they are brain dead, it is compassionate to both them and their family to end their life.

The Choice Argument. Our life is our own and no one has the right to tell us what to do with it if we are not interfering with the welfare of others. If I choose to end my life I should have the right to do so.

The Economic Argument. The cost of keeping terminally ill patients or brain dead patients alive for as long as possible is driving up the health care costs for those who are only curably ill.

To my mind the first of these arguments is the strongest and the last one the weakest.

There are five main arguments against euthanasia –

The Moral Argument. Killing for any reasons is wrong. It is just another type of murder.

The Unprofessional Argument. The whole rationale of the medical profession for centuries has been and is to enhance and preserve life. In asking or allowing doctors or nurses to kill patients we are compromising the most fundamental ideal of the medical profession.

The ‘How Can We Know?’ Argument. We cannot know for sure that a terminal patient is going to die as quickly as the doctors predict. Doctors are sometimes wrong. We cannot know for sure that a brain dead or long-term unconscious patient is going to remain in that state. They sometimes suddenly wake up. When a terminal patient asked to have their life ended we cannot know for sure that they are making a truly free choice. Perhaps they feel guilty that their medical expenses are becoming a burden for their family.

The Slippery Slope Argument. If we allow euthanasia, where will it stop? Then there might be calls to kill the elderly or physically and mentally disabled people.

The Theistic Argument. Life was created by God and is therefore sacred and no one has the right to take it except God.

I have arranges these arguments from most to least valid. The last two are equally unconvincing in my mind.

Is there anything in the Buddha’s Dhamma that could help come to some conclusion on the admittedly very complex issue of euthanasia? The usual Buddhist argument used in the euthanasia debate is that it is always negative to take a life – full stop. One text that is often used in such discussions is this one from the Vinaya which seems to directly address the question of euthanasia. “If any monk (or nun) intentionally deprive a human being of life, or search for a killer for them, or praise the advantages of death, or incites them to die saying, ‘What use is this wretched and miserable life to you? Death would be better for you than life’, or with a similar idea, a similar purpose in mind, should in various ways praise the advantages of death or incite them to die, he is excommunicated and no longer within the monastic community.” (Vin.III,71-2). However, seen within its context, I feel that this text does not really contribute much to the euthanasia debate. Firstly, the origin story of this rule tells us that some monks encouraged a sick man to kill himself so that they could get up to mischief with his wife (Good God! That’s what some of the recruits to the Sangha were like then). Secondly, there is no suggestion that the man was terminally ill, that he had expressed the desire to end his life and the monks intentions in getting him to do so were clearly negative and without concern for the sick man. Thirdly, there are several passages in the Vinaya that stipulate clearly what a monastic’s role is and making it clear that monks and nuns should stick to that role and not stray into other roles. So the question of counselling a patient on the pros and cons of euthanasia or any medical questions is not a monastic’s job and he or she should have nothing to do with it. But what about doctors, care-givers, terminally ill patients and their loved ones who are not monks or nuns?

Although the theistic argument is to me the weakest argument against euthanasia it always seems to be the one that gets the most attention. Therefore I will examine it in detail rather than the other arguments against euthanasia. Archbishop Chia, who represents Singapore’s 320,000 Catholics (although probably not all of them would agree with him), got more coverage for his views on euthanasia in the Straits Times than any other religious leader (3 Nov. 2008). His opinion fairly well represents the general theistic (in this case Christian) position. “One must not yield to on another person’s request for euthanasia. To yield to such a request is false compassion.” “This is not a matter of life and death. It is not up to you or me to decide.” The former Anglican Bishop Moses Tay pointed out that the whole argument turns on the understanding of who has the right to take away life. “The moral, and I believe biblical, answer to who has the right to take away life is the one who created it; God Himself. Human beings may be the procreators of life, but they do not actually have the right to take away life.”

As a Buddhist, I have a few problems with this perspective. All monotheistic religions, the Catholic Church and most Protestant churches, have long upheld capital punishment, which seems to contradict the idea that only the deity has the right to take a life. A friend who knows the Bible much better than I informs me that there are 87 offences mentioned in the Bible which God says a person can and should be executed for, some of them extraordinarily minor. One could also ask this question: “If it is acceptable to prevent life coming into being (using birth control), to artificially prolong life (using life-support machines), to require people to endanger their lives and take the lives of others (sending soldiers into battle), then why is it wrong to shorten life?” It seems that the reproach: “You’re playing God!” is only used when the question of euthanasia comes up. I find this contradictory.

There is another aspect to the theistic argument that could be examined. According to Christian theology Jesus gave his life for others. He could have avoided this fate but instead willingly chose to be tortured and killed so that his death would allow other to be saved. Many early Christians likewise chose to be killed when it could easily been avoided by simply bowing to an image of the emperor or a pagan god. Such people were lauded as martyrs and held up as examples. Now there is a difference between courting death or willingly allowing oneself to be killed when there is an alternative, and killing someone else. But there is a similarity between courting death or willingly allowing oneself to be killed and asking to be killed, as in the case of a terminally ill patient. For reasons that are not clear to me the self-killing of martyrs and of Jesus are acceptable but euthanasia and assisted suicide are not.

And of course the other problem with the theistic argument is that not everyone believes in a god and even some who do, consider euthanasia to be justifiable. Biblical teachings can and are interpreted in many very different ways. The monotheistic faiths should of course have the right to instruct their followers in what they believe to be moral and immoral, and the followers should have the right to decide for themselves or for their loved ones concerning the issue of euthanasia. But should the monotheistic faiths impose their views on everyone else and should their point of view be the main one taken into account? I do not think they should.
In an article in the Straits Times (24,12, 2008), Jennifer Yeo and Madan Mohan highlight the possible dangers of euthanasia and argue against changing the law in Singapore. This article is thoughtfully written and carefully argued – until the last few lines. After mentioning that the late Pope John Paul II followed the example of Jesus by dying in pain and without trying to avoid it, the authors conclude by saying: “It is at this point, as we enter the spiritual and metaphysical realm, that all debate on euthanasia must stop.” This statement highlights better than I ever could another problem with the god-centred perspective. For the believer, once God has spoken he or she must suspend all debate, inquiry and judgment. It should be of concern that people who think like this have such influence in deciding issues of importance to the general community and in a secular society like Singapore.

But to return to the question above – What can the Buddha’s Dhamma bring to the euthanasia debate? That Buddhism is strongly against killing and emphasizes gentleness and kindness is well-known. But why? Why did the Buddha consider killing to be so wrong? There seem to be two main reasons for this. (1) Because beings treasure their life above all things and thus to threaten it or to take it is to inflict great suffering upon them and suffering is intrinsically evil. “All fear death…therefore one should not kill another” (Dhp.129). (2) Knowing that deliberately killing someone is the worst thing one can do to them, it requires intensely negative intentions to do it which in turn reinforces such intentions making it more likely that the evil of suffering will be perpetuated. In other words, killing is not wrong in itself, it wrong because of its results – because it imposes on the victim something they do not want and it requires strongly negative intentions on the part of the killer.

All this would normally be the case. But we know that there are situations where someone can choose death because circumstances have made it a worse option that remaining alive. For example, a soldier captured by a barbaric enemy. Having vital information which, if it falls into the hands of the enemy, may lead to the deaths of many others, knowing that he is going to be tortured to get this information, certain that he will not be able to endure the torture and be killed afterwards anyway, he may decide to kill himself. People sometimes give their lives out of what is usually called altruism; the fireman who enters the burning house to try to save the children trapped inside even when he knows he has only the slimmest chance of finding them alive and getting out safely; the two elderly gentlemen in the overcrowded lifeboat who ease themselves overboard so that the boat will sit higher in the water and increase the chances that the 36 other people in the boat will survive. Now in these cases (and they have all actually happened) it cannot reasonably be said that the persons concerned had negative intentions in killing themselves. In fact, their intentions were clearly to save lives. So I maintain that while killing oneself or another is almost always motivated by negative intentions, that this is not always the case. Interestingly enough, this is a point confirmed by Buddhism. In the Mahayana tradition, it is said that the bodhisattva may even give his or her life for the sake of others. The most famous example of this is the story in which the Bodhisattva cut his throat so that a starving tigress could feed herself and her cubs. The very purpose of this allegory is to suggest that compassion and courage can cancel out self-concern, the craving to live and identification with the body.

It should be noted that in only one of the 548 Pali Jatakas does the Bodhisattva give his life for someone else. However, the Buddha does say (approvingly) that a friend may be devoted to another enough to give his or her life for them (D.II,187) more evidence that killing, in this case killing oneself, need not always be negative. Incidentally, this same point is made in the Bible: “No greater love has he than that he give his life for his friend.”

Now, to return to the question of euthanasia – could someone kill themselves or asked to be killed and do so without negative intentions? Let’s say that a woman has terminal liver cancer, she has been in terrible pain for the last month and it gets worst every day, the stench coming from her body is sickening, her veins have collapsed so that the nurses have to stab her six or seven times with the needle before they can administer morphine and the doctor has said that she has a week, perhaps two or three left. Let’s say she decides she has endured enough and asks the doctor to (1) give her a lethal dose of morphine, or (2) give her an injection containing a lethal done of morphine so she can administer it herself. What would be going through her mind at this time? The dominant ones would probably be (a) resentment and fear of the present pain, and others would be (b) desire to avoid the future pain, (c) revolution with the body. Now I maintain that a and b would have to be classed as kammicly negative but also that they will both continue and almost certainly increase if this patient decides not to end her life. As for c, it is exactly this outlook that the Buddha hoped to evoke when he encouraged his disciples to do the meditation on the unpleasant aspects of the body. So while a terminal patient who desires to end their life may have some negative intentions (and thus some negative vipaka) they are likely to have them anyway. Perhaps a highly developed meditator may be able to free themselves from such thoughts and intentions, but not the average person. And if the care-giver decided to leave a lethal injection besides her bed so that she can administer it to herself, what could their intentions be? Respect for the patients wishes, sympathy and compassion, desire to see them free from pain? Quite possibly.

If we accept that the intentions of a terminal patient in great pain who wants to deliberately shorten their life would not be much different from a patient in a similar position who does not think of or is not in a position to kill themselves (and this is what I posited as a possibility above), what about the care-giver who decides to end the life of such a patient? What would their intentions and thus their vipaka, be? Now the kin of a terminal patient could have plainly negative reasons in wanting such a patient euthanatized – to limit the hospital bills, to end their own grief and distress or perhaps just “to get it over and done with.” But let’s say the care-giver has had a long, close and loving relationship with the patient and they have bee been asked by their loved one to end their life. I honestly cannot see how they would have anything but compassion and fellow-feelings for their loved one in agreeing to and carrying out their request. Surely, in acquiescing to their loved one’s request they would be doing what the Buddha said we should try to do, putting themselves in the place of the other (attanam upamam katva, Dhp.129), feeling for them, feeling with them, and acting out of compassion. I cannot see in what way this would be, as Archishop Chia called it, “false compassion” other than that it contradicted some dogma. In the past, before the rise of our litigatious society, this is exactly what doctors did. Their years of experience told them when the kindest thing to do was to withhold treatment or even administer a lethal does of medicine. It was not taught, it was never talked about, but it was widely done and it no doubt prevented untold pointless suffering. A doctor’s reason for not doing this now is the fear of being sued, hardly a positive or noble reason in allowing a patient to end their days in unendurable pain.
Just to sum up the main points I made or tried to make –
From the perspective of Buddhism, what gives any behaviour its ethical quality is primarily the intention (cetana) behind it and also the effect it will have on oneself and the other.

Under most circumstances, killing is morally wrong because it requires strongly negative intentions on the part of the killer and it goes so much against the victim most cherished desires, thus causing great terror, distress, etc. and such suffering is intrinsically evil. Killing oneself or allowing oneself to be killed in order to save the lives of others could be motivated by compassion and thus not have negative vipaka.
If killing oneself could be done out of positive intentions it is conceivable that killing another (at their request and to save them from great pain) could be done with the same or similar intentions.This last point is reinforced by the universalizability principle – applying to others one’s own wishes. I would not like to spend my last days suffering great pain so I will (when requested to do so) relieve the pain of someone in that position.

The theistic faiths’ objection to any type of euthanasia is based on the belief in a life-giving, life-taking deity. Speaking with Buddhists on this issue, it seems that their objections to it (when they do object to it and by no means all do) are derived from the idea that killing is wrong because it is wrong in itself, it is intrinsically wrong. But my understanding is that this is not what the Buddha taught. For example to unintentionally and unknowingly kill something has no kammic consequences (vipaka) because it is not intentional. It is intention that makes an act moral or immoral. It is this point that needs to be kept in mind when thinking about euthanasia. I am undecided on the pros and cons of euthanasia but I do think the issue is much more complex and nuanced that the usual ‘it’s wrong’ stance. What do you think?