Euthanasia and First Buddhist Precept

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Dear all,

I just found a video about a dying man, depicting the final, agonising days of 56-year-old man who died of brain cancer in 2005. This video is the film released by a campaign group of right-to-die advocates pushing for euthanasia to be legalised in Victoria, Australia and the Victoria parliament voted in favour of the bill about assisted dying. Assisted dying will be legal in Victoria from 2019.

Here is the video: https://9gag.com/gag/aVMn0Ad?ref=fbp

Now, we know Buddhism disallow euthanasia for any reason because itā€™s against first precept of killing. If we have our parents or relative suffering of brain cancer like the old man in the video, should we allow him in agony? But in other hand, euthanasia whether active or passive breaks the Buddhist precept.

How is your opinion and solution about this?

Thank you
:anjal:

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The way I understand Euthanasia is not killing.

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Can you explain it?

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There is a discussion here.

Bhante Jag - Euranasia

https://dhammawheel.com/viewtopic.php?f=13&t=27879&hilit=euthanasia

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A difficult question: itā€™s neither simple nor easy.
But there is a basic answer: kammasaka.
The kammavipaka of any action depends on the intention behind it. So what is the motivation? Is it true compassion, or is it callousness or convenience?

The precepts are a practice not rigid commandments. Sometimes motivations are mixed and sometimes we break the precepts. Finding the middle way for ourselves between dogma and laxity is an art; unfortunately, there are no formulas.

And the precepts are personal.
If someone else (being of sound mind) wishes to end their suffering when it is clear that no recovery is possible, this is their wish, and their business. It is necessary to honor that, no matter how much we may disagree. This is a fundamentally different issue than suicide, which is a preventable tragedy, rather than a merciful response to extreme suffering at the end of a life.

I would never do this myself (or abortion, for that matter). But both are individual decisions, and itā€™s not my business to foist my values or beliefs on anyone else. I think thatā€™s fundamentalism, and always poison no matter what religion it springs from.

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Well, I like to encourage anyone who wants to euthanasia to be a Sotapanna at least.
I requested very close person of mine a doctor, never to participate in euthanasia.
It should be noted that it is a Parajika offence for a monk to help euthanasia.

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A good idea but at the end of a life the conditions make this extremely difficult. Which is strong incentive to practice now!

@SarathW1, yes - frankly and humbly sharing our views can be useful so long as it doesnā€™t come across as pressure. This is where vacikamma metta comes in.

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True loving-kindness includes kaya-kamma metta and two other forms of metta: vaci-kamma mettd, verbal acts of metta; and mano-kamma metta, friendly mental actions.

http://www.dharmanet.org/wisdomweek5.htm

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No we should not allow them to die in agony, but this is preventable with our current pain relief technology. At least this is the case in the UK. We can be really excellent at managing pain. The trouble is that often, for a whole number of reasons, the patients do not get the pain relief at the right time. Fix that and there is no need for euthanasia. The first step is that people educate themselves about what is achievable with modern pain relief and then to ask for it. If they canā€™t do that, then it is up to us as family, friends, carers, etc., to make sure we understand the options and ensure that pain relief is carried out in a timely fashion.

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Do not euthanize your parents, you will go to hell. It is ānantarika kamma.

Do not euthanize anyone else either, you will reap harmful results. It is against the first precept.

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Bhante Jag addresses this issue very well, I think. Thanks for the reminder of this video, Sarath.

Iā€™d rather talk about the arguments made by this monk, rather than the emotional fervor thatā€™s warming upā€¦ Iā€™ve recently been posting a bit about strict interpretations of the precepts, and so here we have yet another example.

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There are a lot of question involved in the matter of ā€œassisted dyingā€. What is active and what passive? Who is to be treated (what personal, cultural and religious background)? What does this particular patient want, and why? To date, there is a discussion on these issues in Germany.

What follows is not to be meant exhaustive and there are a lot more facets to these problems.

A physicians perspective:
The possibilities of palliation are vast, always keeping in mind that the relief of distressing symptoms while keeping side effects as low as possible is the goal of the intervention here. The spectrum of ranges from minimizing pain or dyspnoea up to palliative sedation in the case that symptoms are not to handle otherwise. Other things may be the discontinuation of tube feeding or life support to not prolong a dying process that is imminent or in progress. These are things to consider and to discuss with the patient and/or family and beloved ones ideally before it comes to this situation. Under these circumstances, especially when death is imminent, it is allowed to apply medications in doses high enough to achieve symptom relief and accepting a shortening of life due to the side effects of these medicaments (for example administering morphine to a dying patient with dyspnoea which causes a depression of the respiratory drive - this is well known side effect of the drug which you use here to gain relief, but which also may speed up the dying process).

Assisted suicide is legal in Germany since suicide itself is not a crimeā€“as long as there are no other criminal actions involved. A physician could assist suicide under special circumstances but could be expelled from being allowed to practise from the medical council (there is a lot of debate on these issues).

Clearly forbidden is to actively provide the means for suicide and make money with that. It is also forbidden to administer a medication in order to end someoneā€™s life.

My personal view:
I have been asked several times to end someoneā€™s life or provide the means for doing so and always refused. What I think is most important (and I practise that), is to discuss all the possibilities with the patients and their families. They should be allowed to ask any question and express their fears and worries. To face a patient with sympathy, compassion and respect is the least we (medical professionals) can do.
With regard to the intention involved (I assume the best) offering palliation, best supportive care, discontinuation of life support as mentioned above is not breaking the first precept.

To sum up:
with optimal care, the wish to end oneā€™s life will appear less often. But even in Germany with a well-developed network of hospices and palliative care, there are regions with suboptimal access leaving people to suffer.

P.S.: I am not a native speaker, so please accept my apologies for any confusions I may have caused.

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Not long ago I was listening to a radio program where one of the subjects was euthanasia and palliative care. The interview was with Kathy Eagar, she is director of the Australian Health Services Research Institute at the University of Wollongong, and also executive director of Palliative Care Outcomes Collaboration.
Here is one part of the interview:

Kathy Eagar: I think the biggest myth is that the reason that people elect euthanasia is because they have unbearable pain that palliative care canā€™t control, and that they are left with no choice but to elect voluntary euthanasia, and thatā€™s just not what the evidence says at all.

Norman Swan: What does the evidence say?

Kathy Eagar: The evidence from international says that pain is not in the top five reasons that people elect, that internationally people are electing euthanasia or voluntary assisted dying because of a lack of independence and autonomy, because they canā€™t enjoy the things in life that they used to, a loss of dignity, and also that they are concerned about being a burden on their family and friends.

Our evidence in Australia is that our palliative care is second to none in the world internationally, and only about 2% of people are in severe pain in the period immediately up until their death, if they are receiving specialist palliative care.

Norman Swan: So those reasons you just gave donā€™t seem tractable to palliative care, they seem to be outside the palliative care remit, if you like.

Kathy Eagar: Oh yes, thereā€™s a whole lot of good reasons we should be having a community debate about euthanasia, and itā€™s really about euthanasia as a social issue rather than as the last choice after medical failure.

Here is the link if somebody is interested to listen or read the rest of this short but very interesting interview: Palliative care and euthanasia - ABC listen

Also, Ajahn Brahm talked about euthanasia and abortion yesterday https://www.youtube.com/watch?v=2QqevcL9VDI

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Thank you, thank you, thank you.
This is the point I always tried to convey to people.
Euthanasia is the sign of a morally bankrupt society.
The society has lost its value.
This is a sign that the government and the healthcare workers and the society, in general, have failed to deliver.

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May I ask , if a person is announced brain death by doctor and life is only supported by respiratory equipment , if take away the oxygen supporting unit , would this considered Euthanasia ? And against first precept ?

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Good question! Does discontinuing life-supporting measures such as a ventilator or parenteral nutrition constitute bad kamma, good kamma, or mixed kamma for a patient who will proceed to death without them and had they not been initiated, would have died without them? Who performs the most forceful kamma and how forceful is it? The doctor that gives the order? The nurse that implements it, ā€œpulling the plugā€ themselves? The family requesting the doctor give the order? Do they all share a portion of blame or is there no blame at all? How about if the patient is found brain dead vs. not brain dead? How about if the patient has a DNR: is there any blame to the medical providers or first responders who follow this order to withhold lifesaving inverventions?

These are complicated questions that we must, at best, infer the answer to if weā€™re to use the EBTs as a guideline. These life-extending techniques and technologies were not existence then. Weā€™ll find not direct answer or prescription and must ultimately come to our own judgement.

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There is no single definition of ā€œbrain deathā€ in the world and even with the help of certain guidelines, there is significant variability in the determination of this condition. A widely accepted mechanism of death is the irreversible cessation of function of the entire brain.

In general, the following criteria have to be met (local guidelines may differ) (only an excerpt, not meant to be complete):

  • an acute catastrophe of the central nervous system (the cause should be known)
  • exclusion of confounders like severe electrolyte or circulatory or other disturbances
  • exclusion of drug intoxication or poisoning
  • (near) normal core temperature
  • normal blood pressure

A neurologic examination should demonstrate:

  • coma
  • the absence of several brain-originating responses and reflexes
  • apnoea

With a valid diagnosis of ā€œbrain deathā€, somatic death will follow usually within a few days even with life support.
Brain death is not equal to a biological death, where whole organ-systems lose their functions permanently and finally, the body disintegrates.
Brain death is a legally accepted definition of a personā€™s death in many countries and discontinuation of life support or taking organs for transplantation is legally warranted in this situation.

Is this definition of brain death compatible with a Buddhist perspective of death? The definition I found is from MN 9, MN 141, SN 12.2 (all nearly the same):

The passing of beings out of the various orders of beings, their passing away, dissolution, disappearance, dying, completion of time, dissolution of the aggregates, laying down of the bodyā€”this is called death. - MN 9, BB

Not all items mentioned above seem to be met with the definition of brain death, but one interesting point might be the dissolution of the aggregates. With the permanent cessation of the (entire) brain function, it seems that feeling, perception, sankhārā, and consciousness are unable to arise again in this remaining rupa. With this I think, we see here the final stage of dying where the ā€œpersonā€ is gone and the breaking up of the body is imminent.

In conclusion, I think, with a proper diagnosis of brain death, discontinuation of life support is neither euthanasia common sense nor a breaking of the first precept.

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I wonder if you could ask you to comment on this article: Morphine Kills Pain -- Not Patients, New Research Shows | ScienceDaily

ā€œUnlike many other drugs, morphine has a very wide safety margin,ā€ wrote Dr Rob George, Consultant in Palliative Medicine, from the University College London, in his commentary about the research. ā€œEvidence over the last 20 years has repeatedly shown that, used correctly, morphine is well tolerated, does not cloud the mind, does not shorten life, and its sedating effects wear off quickly. This is obviously good for patients in pain.ā€

I do not have access to the two articles that are referenced, but maybe you do?

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I tried to access the article and the comment. With the article, I have no luck with my institutional PubMed-account, but the comment I could read in full.

What it does say, in short, that morphine and opioids are safe to use for control of cancer pain if done properly, even in patients with respiratory deficiency.
I agree with the comment, morphine and other opioids are safe to use. Care should be taken in the opioid naive patient.

From my own experience, I have only rarely seen overdosing in cancer patients. In these few cases, the patients had comorbidities, leading to an accumulation of the drug and finally to a sedation and respiratory depression - none of these patients died because of this.
In an end-of-life situation, the application and doses of these medicaments may change, for example, applying morphine etc intravenously as a continuous infusion, adjusting the dose rate to the symptoms until controlled.

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In my experience (P.A./pathology in the USA), there seems to be a lot of overlap between ā€œcomfort careā€ and backdoor euthanasia. We recently had a law passed in my state which physician assisted suicide is permitted (physician giving drugs to patients wishing to die). From a medical perspective, I certainly understand it. From a Buddhist perspective, I do worry about some of these medications being given at the time of death and wonder if it effects the mind state for rebirth.

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