MEDICALLY ASSISTED SUICIDE FOR THE TERMINALLY ILL
A Loss of Moral, Spiritual & Religious Context

Geoffrey Hunt BSc(Hons) MLitt PhD
Professor of Ethics, and Buddhist Associate Chaplain, University of Surrey.
Co-Chair, Clinical Ethics Group, Princess Alice Hospice, Esher.

Presented at a conference on the 'Assisted Dying for the Terminally Ill Bill' at
Princess Alice Hospice, Esher on 6th June 2006

The occasion for this lecture was the 2005-06 debate on the 'Assisted Dying for the Terminally Ill Bill'. Lord Joel Joffe introduced a private member's bill to allow doctors to give terminally ill patients a painless lethal injection if they request it. The Assisted Dying Bill was blocked in early 2006 by the House of Lords, but it has reopened the euthanasia debate again, and may be introduced into the legislative process in a different form some time in the future. The idea is to have a law providing for a competent adult suffering from a terminal disease or a serious, incurable physical illness to request 'medical assistance' to die. They would have to have two doctors - one a consultant - to confirm their diagnosis. All the alternatives to assisted suicide would have to be considered including hospice and palliative care. And a patient would have to make a written statement declaring their wish to die. That statement would have to be witnessed by a solicitor who was satisfied of the patient's mental competence to understand their decision. In the Bill there is provision to allow doctors opposed to the notion of assisted suicide to opt-out on grounds of conscience. Another clause provides for a "cooling-off" period in the wake of the request to die so a patient can further consider their decision. A record of every instance of assisted dying would be kept by a monitoring commission. The Bill had the backing of the Voluntary Euthanasia Society.

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If we are faced with the suffering of a dying loved one, then we too become distressed. If that loved one asks us to help him or her to die, then it would be a tragic moment in which what happens next is between those who intimately and genuinely care for this dying person. But we are here today to talk about shifting such inevitably tragic moments of life into the medical and legal decision-making process. That is where I stop short. Could there be at work here an illusion that there is no limit to what medicine and law can do to make our lives free of suffering?

The point I wish to make is a very simple one: We would not even be discussing so-called medically assisted suicide for the terminally ill (ASTI) but for the fact that our society is suffering a widespread loss of moral, religious and spiritual context. While we may believe that our consumer society is the most advanced there has been in history, it is in reality the most self-destructive and is in rapid and possibly terminal decline. In my view the loss of spiritual context is a symptom of that self-destructive decline.

Religious and non-religious
Considering this question of suffering in the process of dying: is there a spiritual attitude to this question, as opposed to a secular one? (I realise that neither 'spiritual' nor 'secular' are entirely appropriate terms here, but they will have to do within the narrow remit I have been given. I use them in a very broad fashion.) In general, I think there is an enormous difference in attitude. I say 'in general' because it has to be admitted that if we look at the institutional forms of the spiritual, i.e. religion, there is quite a lot of room for disagreement, and also that in the current debate about assisted suicide in the West some religious people favour it and that some secularists are against it. Even within one religion there may be disagreements. All the same, if one reads through various debates, especially perhaps the more 'popular' ones, there is definitely a tendency for the spiritual position (institutional or not) to be against or very reluctant to accept ASTI, while many of the (at least more vocal) supporters of ASTI are secular. What is the meaning of this polarising tendency?

All spiritual outlooks put dying in the context of a much wider and richer whole, and it is that context which provides a strong presumption against ASTI for the terminally ill. Since the secular outlook does not have such a wide context, when its adherents listen to spiritual people appealing to the terms of that context it appears as though they are referring to an insubstantial 'something extra' that those people have a peculiar, irrational attachment to. Those who hold a secular position, either through default or through reflection, cannot see what could possibly be unacceptable about, as they see it, helping someone put an end to pain and distress by suicide.

These differences in outlook are so radical that particular facts or arguments cannot be persuasive for one side or the other. Thus it is usually, or often, hard to explain to the secular person what grounds there could be for such unacceptability. Secular people will say, which is understandable from their standpoint, that the spiritual person has a dogmatic attachment to something wispy, 'metaphysical' or 'mystical', and unnecessary. Locked onto their own fundamental assumptions about the nature of reality and life, the secularist fails to see that the spiritual person may perceive them as having a dogmatic attachment to a narrow worldview based on such unexamined notions as 'evidence', 'facts', 'choice', 'science', 'reason', 'explanation' and so on. If they were to spend some sincere time in examining these notions they would find them as wispy and metaphysical as anything they choose to call by those names. Of course, it is perfectly acceptable, and even unavoidable, to speak of 'evidence', 'science', 'reason', 'explanation' and so on in various specific contexts for specific purposes, but one does not have to make a world outlook or ideology out of them: materialism, scientism, rationalism, consumerism, call it what you will.
Secularists themselves have made a 'choice' about how they see the world - it is a choice which springs from the industrial, technological, socially atomised age we live in, and it is a choice which leads to all sorts of fragmentary, postmodern positions (some of which I have discussed elsewhere). The idea that it is not only alright to kill a suffering person who wants it but is actually compassionate to do so, is just one of these fragments of post-modern loss of context. The notion of 'compassion' has been narrowed down to vanishing point, because a wider spiritual context has been completely lost.

Continuing to speak very generally, if we look at the institutionalised forms of the spiritual outlook we see that the overwhelming view is either a great reluctance to allow voluntary active euthanasia (another name for ASTI) or an absolute prohibition against it. The secularist may be inclined to believe that this is because they are dogmatic, ignorant, superstitious etc., etc. But then, have those who say this really engaged with any of these religions or the spiritual outlook underlying them? Is it just possible that it is the secularist who is dogmatic, ignorant and superstitious?

What all institutionalised spirituality does, with all its flaws and setbacks and misunderstandings, is provide an organised setting for a coherent spiritual context, in which human life has its place. Living as we do in comfortable and largely secular England it is easy to lose touch with the millions of our fellow humans who have their lives cut short by mere lack of clean water. It is also easy to forget that most people on the planet do live with some spiritual sense of things, however tenuous. So it is perhaps worthwhile to remind ourselves of the view of most people on the planet about the suffering of dying, though I do not wish to deny the diversity and uncertainties underlying that view.

Western religions
The three major Western religions are very reluctant to accept assisted suicide in any shape or form. I draw on a survey of ethical views in six religions in a book by Morgan and Lawton (1996). In Judaism, "Nothing should be done to shorten a person's life, but nor should anything be done to prolong agony", but drugs that ease suffering may be given, even if they accelerate death (p153). Of Islam, the academic Mashuq ibn Ally writes:

The hardships and sufferings of this life are a test of a person's iman (faith) and taqwa (God-consciousness), therefore a Muslim is required to approach life optimistically, and not to give up or run away from the difficulties of life. That is why the Qu'ran implores people 'not to kill yourselves; indeed, God is merciful to you' (4:29). (Morgan and Lawton, p247).

Suicide and assisting suicide are prohibited in Islam, and such a death would also be seen as a failure of the community to recognise the needs of and give support to the distressed and dying person. Death is regarded as a time assigned by God, and while suffering is not to be endured for its own sake, it is also an opportunity for spiritual growth for patient, attendants and community.
Christians are of course divided, with the Catholic Church taking the most single-minded position. Still, the general drift would appear to be against ASTI or very reluctant to allow it (perhaps allowing only few exceptional circumstances). Life is seen as a gift from God, and therefore only God has the right to take it away. Humans cannot rightfully substitute themselves for God. Suicide, then, is generally seen as wrong, although the potentially suicidal should be counselled and cared for. Similarly, for many Christians the terminally ill patient who asks to killed ought to be especially counselled and cared for, because they are distressed, but that does not make killing them on request the right thing to do. The hospice movement, as we all know, has a strong basis in Christian thought, and many of the Christians involved maintain that hospice care shows that euthanasia is unnecessary (p199).

Eastern religions
According to an authority on Sikhism, there is no place in this religion for euthanasia and all humans should have an accepting attitude to the trials of life and dying (Morgan and Lawton, p116).
Then there is the Taoism of China. According to a Taoist commentator (Cheng-Tek Tai, 2004) all extraordinary medical interventions, including assisted suicide, go beyond acceptable natural limits. It is far better for a healthy and wholesome life to try as far as possible to go with the 'Tao', with the unconstrained and natural course of things. Every thing and every event has a place in the universal order of things which was not chosen by man and not should be upset willy nilly without consequences, sometimes dire consequences. Intervention is acceptable, in so far as it is a gentle way of teasing things back to their natural course, so a limited kind of medicine is good. This commentator says,

Taoism however would oppose active euthanasia as it is an artificial way of ending life. Palliative care will be [the] Taoists' option to let nature take its course. Thus a Taoist will be in support of the Hospice movement and in opposition to the Right to Die movement.

In Buddhism to die well is to have lived well and attained as high a level of enlightenment (non-attached, compassionate wisdom) as one can, by living harmlessly, helpfully, honestly, mindfully and striving for insight into the (non-dual) Dhamma, up until the point of death itself. Buddhism is a way of life: striving to subdue one's anxiety and dissatisfaction by subduing craving (Hunt, 2000).

For the Buddhist, dying may provide an opportunity for reflection on life, on being, on attachment and suffering. The Buddhist teacher Peter Harvey writes, "Dying presents the reality of the components of body and mind as impermanent, dukkha and not-Self in stark form; it is thus an opportunity for gaining insight into these. An enforced death cuts short this opportunity" (Harvey, 296). Buddhists would emphasize the importance of dying with as clear and peaceful a mind as possible.

In Buddhism, the vow not to harm any living creature would rule out ASTI, since it would be regarded as the harm of depriving of life (Note 1). Assisting a suicide would be a harm both to the patient and the carer. Psychological harm could also be done by putting someone directly or indirectly under pressure to kill themselves.
Intention is a starting point in Buddhist ethics, and it would always be asked what is the intention both of the requester and the assister? Is the requester acting only out of fear, and is the assister acting out of selfishness, for example. Is the assister acting from disgust with the sight of suffering, or perhaps with mere pity, which is a narrow and often misguided notion of compassion. Has the assister fully considered the benefits of excellent hospice care? In any case, for most Buddhists suicide cannot be an escape from suffering, since the act continues through the cycle of life.
Since the state of mind at death is very important, the carer should do everything to ensure that the dying person is as lucid as possible, and would support the use of pain-relieving drugs where the suffering is so great as to make the mind incoherent. Drugs can also interfere with lucidity and a balance has to be struck by the patient himself, where possible.

For Buddhists "The best way through life, suffering and death is seen to lie in an honest and truthful understanding of a situation and the capacity to live through it, with the help and support of others". ASTI is not seen as an example of such an attitude.
Seeking balanced judgement and a 'middle way' Buddhism does not prohibit suicide with an absolute rule (neither does Hinduism, Confucianism or Taoism). Western religions seem perhaps more inclined to absolute prohibitions.

Renewal
Hinduism raises in a particularly dramatic form an aspect of the religious standpoint, which in one way or another is problematic for all religions. In Hinduism, generally, there is strong respect for all forms of life, and it is thought a person must wait for the 'right time' to die (kala), so euthanasia as we understand it is not acceptable. However, in a so-called 'willed death' a very sick elderly person may accept the imminence of death, having made preparations, and choose to refuse food and drink. For the Hindu the traditional context is that all human life follows stages, and when the end draws near the (male) person should become a 'renouncer' (samnyasi) who relinquishes concerns for this life. But would this context allow for medically assisted suicide as we understand it in the West? Almost certainly not.

However, here is an example of how a traditional religious context may not only lend support to arguments for resisting an euthanasia law but at the same time implicate us in other practices which would now be regarded as morally unacceptable, even reprehensible. Here I am thinking of the now illegal practice of sati (suttee) - in which the loyal wife sacrifices herself on the husband's funeral pyre. It does not lend any support to an euthanasia law, of course. But, to circumvent misunderstanding I need to say perhaps that I am definitely not making a case for the wholesale acceptance of all religions and all their practices. That would be absurd. This is not the place to explain my view of the relationship between the spiritual and religious and cultural institutions (See Hunt, 2005), for I am only trying to show here that secularists are presenting matters such as terminal suffering in a narrow, impoverished context. I am secondarily arguing that, in the simplest terms, we in the West should not be throwing out the baby with the bathwater. Spiritual renewal relevant to contemporary conditions is of the greatest importance. One would certainly have to consider whether religions are getting in the way of such a renewal.

Understanding Spiritual Context
One way one might try to convey the spiritual discomfort with the organised and formalised professional killing of terminally ill patients who request it, is through a story that provide a sense of what that 'something extra' is that provides the context for this repugnance. (Of course, spiritual people do not see it as 'something extra', but as the wider context in which all the elements and experiences of life have their place.)
Here is the story of an elderly woman who visits the grave of her son every week for years to place flowers, yellow ones which her son liked. I have no doubt rather overdrawn the story to try and get my point across.

The causal-rational account of the woman's behaviour is that it is essentially irrational. That is, since the son is dead and what is in the grave is a decomposing corpse there is no real point in visiting or placing flowers. The secularist, not understanding directly what the elderly lady is doing will seek an explanation instead, presenting us with causes. For example, the psychological needs of the woman cause an irrational identification between the grave and the memory of her son. Since the woman herself does not accept that such an explanation is relevant to what she is doing, the secularist then has to add that the woman is deluded. Thus the secularist puts himself in a superior position to the woman - she is ignorant, he is not. From where she is standing, it might be that he is not only ignorant but arrogant.

On the secularist's account we may infer that visiting the grave of a loved one with flowers is of little or no real importance; graveside visitors should at best be humoured, pitied or patronised. On this view there might grow a tendency of negativity about encouraging a person or a society in general to pay too much respect to the dead. A new leisure centre proposed for the site of the graveyard would generate more pleasure for society, and if a developer wishes to build one there then that should get priority.
The secularist is convinced that his view of things is 'objective', meaning that it rests simply on the undeniable facts. In truth the secularist view does rest on a set of values like any other views, a set which is very narrow, exclusive and rejecting (as I said above). However, the 'ignorant' elderly lady lives in a different universe from this modern young man who knows so much. In that universe, she is wise and he is ignorant. What he thinks about her is largely false. Thus, she does know very well that it is a corpse in the grave and not her living son. But for her that is a mere starting point, and very far from the whole picture. The secularist in fact knows nothing that she does not know too, but she has a wider vision than he, a broader canvas, a richer network in which the corpse in the box is not just that, but a candle flame gone out in a cascade of interconnected candle flames, a interlinked chain of rekindling flames that links her parents, her grandparents, her other children, her husband, her grandchildren and so on. Thus the son still is a flame that lives everywhere in flickers and influences and potentialities in the interdependent tapestry of life.

So, what is she doing when she takes flowers to the grave? Is she, as the clever secularist thinks, deludedly and superstitiously behaving as though her son is alive to comfort herself? But who is really the superstitious one of the two here? It is, in a sense, superstitious of the secularist to believe what is patently false - for she does not believe that her son is alive in the ordinary sense, but only in a much wider context. It is also a kind of superstition to think that she is only doing this to selfishly comfort herself, even if her action does also provide comfort. The secularist may have evidence that she is comforted, but not that she is merely and only 'comforting herself'.
The elderly lady may be silent about what she is doing, but that is because she does not expect any sensible and sensitive person to ask her about the meaning of it. But the secularist is clever and knows all about 'sad old ladies'. If the woman really found that the world has become so cleverly impoverished and self-destructive that she had to explain herself, she might be able to use these words:

"In bringing these flowers to this grave I am hereby showing though my action that I know directly though my own experience what human life is. This tribute of flowers shows that I know that nothing is permanent - not me, not my son, not my parents, not my grandchildren, not you; all is fleeting, all flows, all is connected, on and on without end; all that we experience moves on, we know not where or why, it cannot satisfy, cannot be explained, is full of tension, and one has to lose the self, lose what one loves, lose one's son to see all this for oneself. And I see it, and I show that I see it not by words and procedures and laws but by bringing these bright yellow flowers here and now."

Well, to return to the more narrowly conceived theme of this conference:

What then, we may ask is this suffering of the dying that 'medically assisted suicide' is supposed to deal with? Is it an isolated, unnecessary and tiresome event to be avoided with a professionally administered lethal injection? Or, in a wider context, an embedded step on life's unique journey, endured by all living creatures from the earthworm sliced in two by the spade to the bewilderment and misery of the teenager dying of vCJD contracted from a Happy Meal hamburger? Make your choice. It is not a choice between truth and falsity, between cleverness and ignorance, but between what kind of person you are and could be, between the kinds of life that are open to you to choose.

Notes
1 The Vinaya has three notable references to 'mercy-killing' situations and condemns all of them. (a) Some monks praise the beauty of death to a sick monk, so that he starves himself in order to benefit from the merit he has accumulated. (Vin. III 79).
(b) A monk asks an executioner to act quickly to execute someone so as not to prolong the anxiety of waiting (Vin. III 86). (c) A monk asks family if they want their limbless relative to die, so prescribes something fatal (Vin. III 86). Although the motive is sympathy, it is rejected.

References
Cheng-Tek Tai, 2004. (http://www.univ.trieste.it/~etica/2004_2/CHENG-TEK_TAI.htm) Accessed 5th June 2006.
Hunt, G (2005) The Dalai Lama on the Gospels: The Kingdom of God & Nibbana (Nirvana), Public Lecture at Roehampton University, Southlands College, 1st December 2005, at: www.modernbuddhaway.org/roehampton-lec.htm
Hunt, G. (2000) 'Buddhism and the care of the dying', Palliative Matters, Boehringer-Ingelheim, No. 19, June, pp. 3-4.
Harvey, P. An Introduction to Buddhist Ethics. Cambridge University Press, Cambridge, 2000. Chap 7: Suicide and Euthanasia.
Morgan, P & Lawton, C (eds) (1996) Ethical Issues in Six Religious Traditions. Edinburgh University Press, Edinburgh.