Dying, death and ethical issues

Buddhist ethical conduct including the Five Precepts (Pañcasikkhāpada), and Eightfold Ethical Conduct (Aṭṭhasīla).
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Dying, death and ethical issues

Post by dagon » Thu Sep 05, 2013 5:04 am

Hi All

End of life situations are always difficult! They are difficult for the one who is dying, difficult for the family and difficult for the carers.

The complexity of the situation has only increased since the time of the Buddha due to medical treatments. No one wants to see those they care for suffer but at the same time they do not want to see the die. What we need to do is to find some middle way that respects the wishes of those involved, the dictates of the laws of nature and the Dhamma.
The parameters within which I am discussing are those situations where a person has a medical condition which without treatment will cause the death of that person. It specifically excludes those who wish to die as a result of a psychological condition such as those that have depression.

There is no doubt in my mind that killing (or encouraging another to kill themselves) is in breach of the teaching and has karmic consequences for those involved. Where things start to get complicated is when we start looking at terms such as the natural life span of a person. We are in the situation where we can extend the life of a person beyond that which would naturally occur without interventions. Where this is the wish of the individual concerned there is no ethical question in my mind that we should do this. From a legal standpoint (Buddha did say that we should obey the laws of the country) not to do so would be negligent.

Does this mean that we should extend life at all costs regardless of the wishes of the individual? I think that the Dhamma provides us with some guidance. According to the cannon Buddha said that he would have considered extending his life if he had been asked before the last stages but was no longer willing to do so. My take on this is where an individual chooses not to act to extend their life it should not be considered to be taking their own life.

Most, and probably all of those I look after are only here because of medical intervention (that is setting aside intervention early in their lives). Most are in a palliative care situation (my employer disagrees because we market the service as quality living). The definition of palliative care that I chose to accept is where someone has a medical condition that can no longer be treated and will (unless other condition take effect first) cause the death of that person. At that point treatment of the individual changes its focus from trying to cure the disease to treating the individual so that they can experience the best possible quality of life given the situation.

To illustrate this (and not to breach patient confidentiality) my first wife had breast cancer for over 10 years, the first period we tried to cure the disease. In this there is an ethical issue for Buddhist. The treatments that she was taking are poisonous derivatives of the nerve and mustard gasses developed in WWI. Trading in poisons is a breach of Dhamma – but the intention here was to preserve life. I believe that most here would consider that the intention redefine the poisons to medications. I raise this issue simply because later I need to consider other prohibited substances and we should be logical and consistent in our contemplation.

Five years before her death it was confirmed that it was incurable. At that point the intention of the treatment changed to quality of life (she had a prognosis of 3 to 6 months) a number of new medications came along at the right time which were unable to cure the disease but allowed her to maintain a quality of life (incidentally also extending it). What gave her quality of life was seeing the kids grow up and her work. She got to see the kids past their 16 birthday and even to see her first grandchild.

6 months before her death she was taken to hospital with bilateral kidney failure – a result of using NSAI pain management medications for 10 years. She was told that she had to crease that medication and use morphine. As we all know that is considered to be an intoxicant and if we applied this to the situation then she would have been in breach of the Dhamma. My argument here is that we need to apply the same considerations to intoxicants as medications as we do with poisons that are used as medication. I guess that there would be some that would not be as compassionate in this analysis.

She managed to return to work until 6 weeks before she died – it was on the day that she was told that she would never work again that the rapid decline started. What she had always told me was that she would live with her body failing but that she wanted to go when it affected her brain. The doctors did not tell her that her death was close and with her bones dissolving the calcium levels in her brain gave her dementia symptoms. I decided to respect her wishes and kept her at home giving her the best possible care that I could.

Letting go is hard – a few hours before she would have died I sent her to hospital. The hospital asked me what my wishes were and rather than let her die (which were her stated wishes) I put her on a medication that I knew would stabilize the calcium, clear her head but would probably cause her kidneys to totally fail – changing the cause of death. The intention and effect was that she got to spend 2 more days with the kids and grandchild and to say goodbye. She became unconscious reliving the visit from the grandchild.

She had been transfer from the hospital to a hospice run by catholic nuns – one of whom undertook the pastoral care. This nun pulled me to one side and told me that it was wrong that my wife was on the calcium treatment – it was a place to die not to have treatment. I explained to her that the treatment was for palliative reasons – she did not accept this but could not force change. As soon as my wife lost consciousness I had her transferred back to the hospital – the nun was still complaining about the treatment as I left the building. My response was “sister, I congratulate you on finding Catholicism, I hope that you find Christianity before you die”

When she returned to the hospital I crease all treatments apart from pain management - she passed away 3 days later. Interestingly the nurse who was looking after her as she went was a nurse who had previously intended to leave oncology. He had decided that he was unable to continue to inject people with poisons for ethical and personal reasons. The hospital management had asked my wife to speak to him about his decision (she used to help with induction programs in the unit). She explained to him that what was a poison to him was life to her. He stayed in oncology and stayed 3 hours after he had finished the shift because he wanted to return the kindness she had extended to him in his need. He is still there 8 years later!!!

After a beak I returned to a carer role working in a nursing home – careering is the most worthwhile thing I have done in my life – defiantly the best thing I have done for my practice.

I have no question in my mind that all of my actions were ethical, I post this for others to consider the complex issues that surround dying and death. If you have any questions you want to ask feel free to do so.


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Re: Dying, death and ethical issues

Post by Kim OHara » Thu Sep 05, 2013 5:23 am

Thank you, Paul.


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Re: Dying, death and ethical issues

Post by SarathW » Thu Sep 05, 2013 5:30 am

Hi Paul
I deeply moved reading your story. I feel for you and I know exactly what you been through with my own experience.
I t is great to see you that you are working as a carer for sick.
I know it is not the easiest job but hope that will help you to contemplate on Dhamma.
Thanks for sharing it with us.
“As the lamp consumes oil, the path realises Nibbana”

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Re: Dying, death and ethical issues

Post by dagon » Thu Sep 05, 2013 9:29 am

continuing :soap:

There is no deigning that sickness, old age and death are suffering, but if anyone is indifferent to the suffering of others they can hardly claim to be practicing loving kindness or compassion to others. It is loving kindness and compassion that drives people to the point where they make requests or act to end that suffering. It is also the unbearably suffering that drives people to take their own lives in such situations.
Thus, the patient requested the doctor to help him die. Out of pity, the doctor did so. The patient did die. In this case, both the patient and the doctor violated the first precept. Both of them committed the offence of killing a living being.
Some children may request a doctor to practise euthanasia for their mother or father. If the doctor does as requested, the children are guilty of one of the five heinous crimes (ānantariya kamma). How dreadful this is! Everyone should be extremely careful to avoid such heinous crimes.
http://www.aimwell.org/problems.html#Th ... Euthanasia

I know that such requests are often made – I have been asked by dozens of patients (never family members) to help them depart. I have never personally known any doctor that has complied with such as request. However I can tell you that such requests do leave a negative imprint.

The ethical and compassionate way of dealing with such requests is to clearly say no, but to offer the patient hope with an alternative course of action. Of course this requires that the patient had trust in their carers (family, doctors or other staff). Dying and death are still very much of a taboo subject in the developed world and as such are avoided in conversation especially where someone is very sick / probably dying. The 4 precept is all too often abandoned in the guise of “little white lies” to protect the patient. For most this is a lie in its self as the lie is formulated out of aversion – we don’t find death to be a comfortable subject. I question if it is ethical to try and hid the truth from the person most concerned. The outcomes of such lies include things being unsaid by patients and families to each other adding to the suffering before and after bereavement. The other major victim of the lies is the breaking of the bonds of trust at the time when the patient most needs to trust those around them. When we tell them that their pain and distress will be managed after lying to them are they going to believe us.

The Buddha taught the middle way. In this subject we have on one side suffering (in this life) and on the other side euthanasia with the resulting karma and suffering that it brings. Palliative care is the middle way in my view – the principles are outlined below.

Palliative care:
 affirms life and treats dying as a normal process;
 neither hastens nor postpones death;
 provides relief from pain and other distressing symptoms;
 integrates the physical, psychological, social, emotional and spiritual aspects of care, with coordinated assessment and management of each person’s needs;
 offers a support system to help people live as actively as possible until death; and
 offers a support system to help the family cope during the person’s illness and in their own bereavement.

As individuals we need to be informed about palliative care and make our wishes know to others should we reach that situation arise. Ideally we should have live wills or written end wish plans – but to achieve this we need to face the realities of the first Noble truth and have honest conversations flavoured by loving kindness, compassion and equanimity.


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Re: Dying, death and ethical issues

Post by tiltbillings » Thu Sep 05, 2013 9:39 am

dagon wrote:
The Buddha taught the middle way. In this subject we have on one side suffering (in this life) and on the other side euthanasia with the resulting karma and suffering that it brings.
it is never so black and white.
>> Do you see a man wise [enlightened/ariya] in his own eyes? There is more hope for a fool than for him.<< -- Proverbs 26:12

This being is bound to samsara, kamma is his means for going beyond. -- SN I, 38.

“Of course it is happening inside your head, Harry, but why on earth should that mean that it is not real?” HPatDH p.723

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Re: Dying, death and ethical issues

Post by Ben » Thu Sep 05, 2013 9:42 am

Hi Paul

Thank you for sharing your incredible story.
Like you, I witnessed the death of loved ones. In one instance my sister-in-law and I had the conversation with the consultant doctor in ICU about withdrawing life support for by brother who was brain dead following a car accident.
I think what you did well was to outline some of the nuances of the many ethical issues that surround death and dying.
What I also want to say is that I think we need more care givers such as yourself.
with metta,

“No lists of things to be done. The day providential to itself. The hour. There is no later. This is later. All things of grace and beauty such that one holds them to one's heart have a common provenance in pain. Their birth in grief and ashes.”
- Cormac McCarthy, The Road

Learn this from the waters:
in mountain clefts and chasms,
loud gush the streamlets,
but great rivers flow silently.
- Sutta Nipata 3.725

Compassionate Hands Foundation (Buddhist aid in Myanmar) • Buddhist Global ReliefUNHCR

e: ben.dhammawheel@gmail.com..

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Re: Dying, death and ethical issues

Post by dagon » Thu Sep 05, 2013 11:17 am

Thank All for the pain of reading and the responses;

@Ben – You have to understand that I am the lucky one to have the privilege of being with those I look after and their families. I receive more loving kindness, compassion and joy than I give. Going home after work knowing that you have 20 peoples lives (sometimes deaths) better than they would have otherwise been is a fantastic reward. As I know you understand the giver receives far more than the receiver of the gift – a point that I sometimes think we overlook. I get to study the realities that The Buddha tries to teach but which I have too much dust in my eyes to see in texts .

I make no apologies that one of my agendas is to try and get others to consider working/volunteering in nursing homes.


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