The Better End? Euthanasia and Buddhist Values

A talk to the White Heron Sangha
February 3 2018

As a child, I grew up in a small family consisting of my mother, Lise, my father, Henry, and my grandmother, Elise, all refugees from Hitler’s Germany who arrived in New York in 1938. Elise and I adored one another all through my childhood and youth. Though she spoke little English, she was vibrant and irreverent and eloquent in expression and gesture.  She was also adored by the customers for whom she worked as a seamstress and to whose homes all over the City she travelled by subway until well into her eighties.

After my first year in graduate school in California, I returned to New York for the summer of 1964, spent nights in Greenwich Village with a friend and days in upper Manhattan studying for my Latin qualifying exams at Elise’s small apartment. She’d make me sumptuous hot lunches and watch admiringly as I practiced my conjugations.

A couple of months after I returned to California my parents wrote me that Elise had suffered a massive stroke that paralyzed her left side and left her unable to walk or speak. They had no choice but to place her in a nursing home and expected it would be over soon. But by the time I came back for a visit at Christmas, it wasn’t.

My mother pointed out the hunched figure in the wheelchair at the end of the corridor of the old mansion where she was cared for. I drew close, dropped onto a knee, placed my hand in her good right hand, and said ‘Oma.’ Her head lifted slowly, eyes vacant, skin drawn across the cheekbones. I felt my hand gripped tight, tighter. Her eyes focused and then her face collapsed into violent weeping. After a few moments she looked up at me and began to speak: ‘Nein, nein, nein,’ ‘no, no, no,’ she said, and stopped abruptly. That was her only word. She gave me a desperate, questioning look, and then uttered a high whine.

For three more years I visited her summer and winter, until I returned to work in New York with my new wife, Jan. Then the visits were weekly, but my efforts to bring her news and cheer always led to the same desperate weeping, and the intervals gradually increased. After another three years Jan and I headed back west to grow vegetables, animals and babies in the woods of British Columbia. There the news came that Elise had found her final rest after six years of despair.

Scroll forward to 1995. My father and mother have been living in San Luis Obispo for five good years since they relocated to be near us after Jan and I settled here thanks to long term career opportunities. Then, at age 89, my father suffered what appeared to be a mild stroke which turned out to be fatal brain cancer. While in the hospital for a biopsy, he climbed out of bed and fractured his pelvis. In a transitional care facility, partly delirious, he begged me to put him out of his misery. From the nursing home where he was transferred, he was taken to the emergency room and for hours suffered excruciating pain resulting from advanced constipation, a side-effect both of the cancer and the morphine in his palliative regime. The agony and indignity lasted another two months.

At Henry’s well-attended memorial, my mother gave a tribute to her husband of 65 years and then announced that her life was finished. She soon underwent a slow decline into dementia, at first living at home, where she sat reading one book over and over, and eventually, at her own request, moving to the same nursing home where he had died.  She remained there, impassive at our biweekly visits, until her death ten years later at age 95.

Those visits were interspersed with visits to other aged relatives whose lives had been productive, eventful, and admirable, but in their final stages seemed anguished, sordid and senseless. The inevitable decomposition of their bodies and minds created challenges that none of their loved ones could handle and were therefore delegated to officials and institutions.   So, during my fifties and sixties I re-experienced the emotions I’d felt in the face of Elise’s fate during my twenties: depression, anger and confusion.

Now that I’ve reached my mid-seventies, one thing I’m not confused about is the urgency of my desire to avert such a bitter end, to do what’s in my power to make for a better one.

Euthanasia is the word whose Greek roots signify “good death,” a much preferable alternative to the Latin based “suicide,” signifying “self-murder.” In the period between my grandmother’s ordeal and the present, the word and the idea have gone from taboo to timely. Passive euthanasia–the refusal or withdrawal of artificial life-support to hasten death if chosen by the patient or provided for by advance directives– is now a widely acceptable option for individuals and physicians.

Active euthanasia–formerly referred to as “physician assisted suicide” but now officially known as “patient directed dying” or “physician aid in dying,”–involves action: usually the administration of lethal drugs, to deliberately cause death.[1] Over the last ten years, active euthanasia has been recognized as a legal right by popular referendum in California, New York, Oregon, Washington, Vermont, Colorado and Montana and in several countries.  Legalization has come to pass largely as the result of the efforts of advocacy organizations like Death with Dignity, Compassion and Choices, Exit International and the Hemlock Society.

According to a Gallup poll (68% support in May 2015) and Harris poll (74% support in November 2014), the American public consistently supports medical aid in dying by large majorities.[2] As an example of high-profile changes of opinion, Episcopal Archbishop Tutu in South Africa and the Archbishop of Canterbury have recently endorsed the practice of active euthanasia.[3]

The reasons for this cultural transformation are evident at both societal and individual levels.

In recent decades, technology and medicine have developed the ability to extend life for the elderly, regardless of its quality, often prolonging pointless suffering for patients and their loved ones.Between 2010 and 2050, the United States population aged 80 and older will nearly triple, and the number of people in their 90s and 100s will quadruple, accounting for a vast disproportion of medical costs.[4]

For example, an average of $94,000 is spent on healthcare during the last year of life of a person with metastatic cancer.[5]

In addition to allowing for compassionate relief of suffering and for the reduction of economic costs, expanding end-of-life options to include euthanasia complies with principles of individual liberty and autonomy strongly held by present generations—changes also manifested in attitudes toward gender, sexual orientation, career choices and recreational drug use.

Atul Gawande argues that “…the freedom— to be the authors of our lives…. is the very marrow of being human,” citing philosopher and legal scholar Ronald Dworkin: “The value of autonomy … makes each of us responsible for shaping his own life according to some coherent and distinctive sense of character, conviction, and interest.”[6] Or in the blunter words of Phillip Nitschke, Director of Exit International, “Baby Boomers want to be in control of their own deaths. They don’t like the idea of someone patting them on the head and telling them what to do.”[7]

However, despite growing acceptance, the option of active euthanasia is limited by a range of restrictions.  In the Netherlands and Belgium, it must be administered directly to a requesting patient by a consenting physician who reports to a medical board to assure that the procedure followed legal requirements. In the U.S. a physician provides the patient with a prescription for a lethal drug after confirming 1) the patient’s ability to swallow it, 2) their legal competence, 3) the certainty of “natural” death within the next six months, and 4) the agreement of a second physician. Having secured the drug, the patient has the discretion to self-administer it at a time of their own choice.[8]

These restrictions on the right to die have generated serious objections.

1) Depriving patients whose natural life expectancy exceeds six months of that right imposes an arbitrary time limit and indefinitely extends the suffering and the cost of a life no longer desired, while depriving many of the assurance they want that if the circumstances arise, they have the ability to choose a peaceful end.

2) The requirement of self-administration by swallowing unfairly deprives sufferers without that ability, –not rare among the severely afflicted–of an option likely to be especially valuable to them.

3) The requirement of legal competency at the time of exercising the option of euthanasia is the most widely applicable and the most problematic restriction.

It denies the option for patients with advanced dementia, a condition regarded with as much antipathy as severe physical suffering by those concerned with “writing their own story” or maintaining responsibility for their own lives. This limitation “… will become an increasingly pressing issue as the world’s population ages. …Almost half of people over eighty-five have some form of dementia.  About 5.4 million Americans have Alzheimer’s disease, the most common form. These numbers will rise progressively over the next several decades.”[9]

One alternative to the prohibition of euthanasia for those rendered incompetent by dementia is the use of “Advance euthanasia directives” (or AEDs) like those presently in effect in the Netherlands and Belgium. They build on existing euthanasia legislation by extending the definition of competency of the agent at the time of its administration to a time preceding it, allowing someone in the early stages of dementia to determine what will happen to them after it progresses to a certain point.

Objections to the use of AED’s raise philosophical and theological problems about the nature of the self. If the self is constantly changing and has little coherence over time, does the rational self that makes such a directive commit murder against the demented self that no longer understands it and in its demented state may have different interests and priorities? Or is there a single self, identified with the body over time.

In confronting this question, thinkers like Dworkin maintain that the radical change in some of a person’s interests in dementia does not undercut the moral authority of advance directives. The choice that the competent “then-self ” expressed in a directive manifests real autonomy and also defines the person’s continuing “critical interests,” which prevail over mere “experiential interests.”[10]

I believe that the power of a present self to determine the fate of a future self is already enshrined in the general power of wills and trusts whereby people make binding contracts expressing their direction about what is to happen to their property and their bodies. It is also assumed in conventional living wills and advance directives. Such directives presently include passive euthanasia in the form of Do Not Resuscitate orders. We create advance directives privileging the moment of commitment over future contingent preferences whenever we make contracts, for instance in marriage.

As a thought experiment I formulated my own AED. It asks that euthanasia be administered by a doctor or a willing executor as soon as I have been determined to no longer be legally competent to make my own healthcare and financial decisions. In the process of doing that experiment, I concluded that mental competence is required to make my life worth living.

That conclusion led me to imagine other conditions of life to which I find its cessation preferable:
1. Being subject to enough ongoing pain to require continual analgesics
2. Being unable to locomote, eat, or toilet by myself
3. Being fully and permanently limited to the role of patient rather than agent

For the sake of my own dignity and autonomy and for what I believe to be the sake of my family, friends and society, I would attempt to arrange a deliberate and peaceful farewell. I imagine it as a positive occasion, possibly in the presence of loved ones—a “celebration of life” and a welcome to its closing chapter.[11] *

A further extension of these lines of thought has led to a political initiative in the Netherlands whose outcome is soon to be decided. The proposed “Completed Life Bill,” drafted in consultation with doctors, ethicists and other experts, would allow any person age 75 or over who decides their life is “complete” to receive euthanasia regardless of their physical and mental health. The Bill assumes that the judgement of the elderly person that they consider their life completed is the prerogative of the person in question only.[12]

A psychologist serving as counselor for people requesting euthanasia for this reason reports “During this consultation my client (90 years old… one of his children was present) … [when] I asked him: could he in a few words indicate what this meant to him, his life being ‘completed’? He came up…  [with] five characteristics which I jotted down thus: 1) done everything 2) seen everything 3) no need to do or see more 4) have had great times 5) have been very happy.’”[13]

A widely reported example of this approach to the option of a good death was supplied in 2003 by Carolyn Heilbrun, an eminent professor of Comparative Literature at Columbia University and author of academic mystery novels, who took her own life at age 77, surprising her beloved colleagues, family members and friends. “To watch parents go on and on and on, and well beyond where they would have liked to have gone, makes one feel strongly that you want to end it while you still are capable of doing so,” [said] Joan Ferrante, a [fellow] Columbia University professor and friend. “We had agreed for a long time that [ending one’s own life] was the sensible way to face things.”[14]

Ending one’s life while it retains reasonably high quality doesn’t seem at all sensible to me.  But these stories highlight the radical implications of claiming the individual’s right to do that.  And even the less extreme position of affirming the right to avoid a bitter end and assure a better one leaves me uncertain about whether or not, if the time comes, I would remain as decisive as I feel now, or instead would let things just “take their course.”

That uncertainty prompted me to search for guidance from Buddhist authorities. It was my expectation that the Buddhist ideas of mutability (anitya), the contingent and illusory nature of the self (annata), the causal interconnection of all phenomena (pratityasamutpada), the primacy of compassion (metta), and the release from suffering through the abandonment of craving would be conducive to the idea of a self-chosen, peaceful death.

What I discovered was not the assurance I was looking for. There’s little contemporary discussion of the topic, but among the published sources, the single most cited is an article in The Journal of Law and Religion, entitled “Suicide, Assisted Suicide and Euthanasia: A Buddhist Perspective,” by Damien Keown.[15]

Keown argues emphatically that “suicide, assisted suicide and euthanasia are all contrary to Buddhist ethics.” He supports this claim with reference to 1) the Eightfold way: “Someone who respects the First Precept ‘does not kill a living being, does not cause a living being to be killed, does not approve of the killing of a living being,’” 2) to the first Noble Truth– “a person who opts for death believing it to be a solution to suffering has fundamentally misunderstood the First Noble Truth which teaches that death is not the solution, but the problem,” 3) to the Third Noble Truth stating that the primary purpose of life is to reach enlightenment, a goal which euthanasia forecloses prematurely, and 4) to the doctrine of reincarnation according to which suicide will lead to rebirth in a lower realm.

However, a reply article in the same journal by another Buddhist scholar, R.E.Florida, takes issue, noting that there are many different Buddhisms and often contradictory Buddhist positions, none of which are finally authoritative, and that Keown’s support comes exclusively from Pali texts rather than taking into account Theravaden and Mahayana sources.[16]

Florida maintains that the intention of the act is what counts, and if it is motivated by compassion rather than craving, suicide can be acceptable for Buddhists. For contemporary support, he cites Thich Nhat Han’s approval of the political gesture of self-immolation by Buddhist monks during the Vietnam war.

Indeed, the Dalai Lama has declared: “In the event a person is definitely going to die and he is either in great pain or has virtually become a vegetable, and prolonging his existence is only going to cause difficulties and suffering for others, the termination of his life may be permitted according to Mahayana Buddhist ethics.”[17] These are the conditions stipulated by California and Oregon law allowing patient directed and physician assisted dying.

For me then, Buddhist authority today is a matter of situationist ethics rather than absolute principle. It supports leaving the question of the good death open to personal choice. That choice comes down to particular circumstances and to the individual’s unique identity—the cumulative outcome of a life of choices and circumstances. That’s why I think it should be as autonomous, as free, as unconstrained as possible. No one else should make it for me.

With that in mind, I recalled a dharma talk five years ago entitled “Three Teachers,” by a revered individual member of this sangha, Bonnie Wolfe, delivered a few months before her death from cancer. There she shared what she was learning as her life neared its end.  In doing so she demonstrated how that condition could uncover meaning for herself and render service to others.[18]

One such service was to model through her grace and eloquence what she referred to as “staring down your death fears through making the contemplation of death a part of your daily life,” thereby reinforcing the counsel of the Buddha to reflect on these facts:

I am of the nature to grow old.  There is no way to escape growing old.
I am of the nature to have ill-health.  There is no way to escape having ill-health.
I am of the nature to die.  There is no way to escape death.
All that is dear to me, and everyone I love, are of the nature to change.
There is no way to escape being separated from them.
My actions are my only true belongings.  I cannot escape the consequences of my actions.  My actions are the ground on which I stand.[19]

Then she enumerated some of the teachings provided by her situation that strengthened her Buddhist values: 1) gratitude–toward medical providers, friends, and family members (even obnoxious ones) from whom she was receiving support, 2) compassion–for fellow cancer patients with whom she came in contact 3) generosity–in volunteering her own efforts when possible to assist them 4) illumination—citing Steven Armstrong, she said, ‘Now, when I look at other people, I can see “bright souls walking.”’

To be able to transform the negatives of age, illness and death into such positives is indeed, in Hamlet’s words, “a consummation devoutly to be wished,” moreso than the oblivion for which he yearns when uttering them. That ability may be karmically earned by a lifetime of skillful effort.

But in her talk Bonnie acknowledged, “…I remember the days, when I felt, ‘That’s enough. Can we just fast-forward to the end?’  Those times may come again.  Thoughts and feelings come and go. The desire to go on living, and the desire to be done with living, come and go.”

Another of the values that her illness summoned was patience or equanimity.  She ended her talk with a quote of the Buddha’s dying words, which she characterized as “the essence of the dharma”: All compounded things decay.  Strive on diligently. Those words, she said, describe her own “balancing act” at the edge of life and death.

To me that balancing act is between acceptance on the one hand and resolute effort on the other. In fleeing the Nazi Holocaust, my mother, father and grandmother chose decisive action to escape the cruel and random fate suffered by other family members.

Alas, that choice was not available to them at the end of their lives.

 

 

 

 

[1] https://depts.washington.edu/bioethx/topics/pad.html

[2] https://www.compassionandchoices.org/wp-content/uploads/2016/02/FS-California%E2%80%99s-End-of-Life-Option-Act-FAQs-FINAL-3.15.16-Approved-for-Public-Distribution.pdf

[3] http://www.telegraph.co.uk/news/2016/10/07/archbishop-desmond-tutu-asks-for-the-right-to-an-assisted-death/

[4] https://www.kff.org/medicare/report/the-rising-cost-of-living-longer-analysis-of-medicare-spending-by-age-for-beneficiaries-in-traditional-medicare/

[5] https://www.onfaith.co/onfaith/2014/10/31/the-economics-of-modern-death-how-money-shapes-the-end-of-life/34854

[6] Being Mortal: Medicine and What Matters in the End (NewYork: Henry Holt 2014) p.148

[7] http://www.newsweek.com/elon-musk-assisted-suicide-machine-727874

[8] http://californiadeathwithdignity.org/end-of-life-option-act/

[9] Paul T. Menzel and Bonnie Steinbock, “Advance Directives, Dementia, and Eligibility for Physician-Assisted Death,” New York Law School Law Review, Volume 58 | 2013/14 http://www.nylslawreview.com/wp-content/uploads/sites/16/2014/01/NYLS_Law_Review.Volume-58_Issue-2_Menzel-article.pdf, pp. 485

[10] Ronald Dworkin, Life’s Dominion: An Argument About Abortion, Euthanasia and Individual Freedom (New York: Alfred A. Knopf, 1993), p.184, cited by Menzel and Steinbock, p.489

[11] In the course of a brief exchange about this talk with the Susan Quinones, chair of our Sangha’s program committee on the day I completed writing this, she pointed me to a several tools that address these concerns that I had missed: https://www.compassionandchoices.org/eolc-tools/, http://coalitionccc.org/tools-resources/advance-care-planning-resources/ https://theconversationproject.org/ Susan’s profession is hospice nurse. A week later I found an article in the NY Times reporting on a newly developed advanced care for directives that provides much more specific guidance for proxies and care providers: https://www.nytimes.com/2018/01/19/health/dementia-advance-directive.html.

[12] http://www.worldrtd.net/sites/default/files/newsfiles/UVW%20engels%20definitief%201.1_0.pdf

[13] https://ethicsofcare.org/wp-content/uploads/2017/05/Artikel-Ton-Vink-Completed-Life.pdf

[14] http://nymag.com/nymetro/news/people/n_9589/

[15]  Vol. 13, No. 2 (1998 – 1999), pp. 385-405 Published by: Cambridge University Press

[16] “A Response to Damien Keown’s ‘Suicide, Assisted Suicide and Euthanasia: A Buddhist Perspective’” Journal of Law and Religion, Vol. 13, No. 2 (1998 – 1999), pp. 413-416 Cambridge University Press
Stable URL: http://www.jstor.org/stable/1051474

[17] https://euthanasia.procon.org/view.source.php?sourceID=000676

[18] http://www.whiteheronsangha.org/Three-Teachers

[19] “Upajjhattana Sutta: Subjects for Contemplation” (AN 5.57), translated by Thich Nhat Hanh, in The Heart of the Buddha’s Teaching (New York: Broadway Books, 1999),124.[Cited by Bonnie Wolfe]

Leave a Reply