Good Death

Mercy, Deliverance, and the Nature of SufferingPatricia Anderson

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"Your mind state at the
time you draw your last breath
is crucial, for upon this hinges the
subsequent direction and
embodiment of the life force.
Only with a disciplined and
spiritually prepared mind can
you hope to resist the pull
of old patterns of craving and
clinging as your final energies
are slipping away. The
impulses of thought, feeling, and
perception all gather together
in this last breath with
great potency ... "

—Philip Kapleau Roshi

So exactly which last breath is the roshi talking about here? The last breath taken before lapsing into coma or vegetative state? The last breath taken before being placed on a respirator? Or the last breath taken when a court orders the respirator removed, one year later?

Dying in the midst of modern technology is a complicated matter. Western medicine's tendency toward aggressive treatment has joined with our cultural antipathy toward death to create an extraordinary situation: afraid of being caught alone and suffering in an impersonal technological nightmare, people are fighting for the "right" to die. 

Euthanasia is an ancient issue. There have always been instances in which people killed either themselves or another as a humane act to end suffering. In this country, in the early part of the century, the act commonly evoked euphemisms such as putting a sick animal "to sleep." After World War II it became associated with concentration camps, murder, and Nazism, acquiring a stigma that persisted for years. In fact, euthanasia means "good death." Of course, what is "good" and what is not depends on your point of view. 

The current debate covers a spectrum of possibilities from "allowing death to occur to causing death to occur." The phrase "passive euthanasia" is sometimes used to describe the removal or refusal of life-sustaining treatment, allowing "nature to take its course"-even though the means to intervene are at hand. (Many argue that this is not euthanasia at all, as it is not killing, but rather, not interfering.) "Active euthanasia" describes causing death directly by some active means, such as the administration of a lethal injection. 

For the Buddhist, euthanasia raises new and demanding questions in the light of traditional teachings. Theoretically, you can wind up in a situation where the precept against taking life and the commitment to compassionate action appear to be at odds. Contemporary practitioners are dealing with dilemmas that simply didn't exist until very recently.

In the West at the beginning of this century most of us died before the age of fifty, from infectious disease and injuries we didn't know how to treat, in our own home, with familiar care-givers in attendance and our loved ones at our side. After we died the family bathed us, watched over us, and buried us, with the help of friends and the community.

Today we live longer and die longer. Lingering degenerative conditions are "managed" by high-tech medicine, in big institutions with schedules to maintain. If our family can arrange to get to our side, they're either bewildered or extremely nervous. After we die, a business concern "takes care of it."

These changes have come together to make death, as often as not, a decision rather than an event. In one form or another the question of "pulling the plug" has become commonplace. Seventy percent of us will find ourselves involved in a "negotiated" death; required to make a decision whether to undertake, or not to undertake, some medical procedure that will prolong the process of dying.

Of course, anyone would choose to maintain life while recovery or healing takes place. The problem arises when death is postponed without any chance of healing or rehabilitation, or when treatment becomes a painful invasion making the last days before death a nightmare of suffering and confusion.

This concern has engendered living wills and medical proxy legislation, best-selling books on "self-deliverance" and physician-assisted suicide, and proposals to legalize euthanasia or mercy-killing. For many, to champion the right of the individual to "choose" death is to protest the manner in which we die today. From a Buddhist point of view, all this confusion and its attendant suffering is the result of a misunderstanding about the nature of death and dying.

BIG DEATH, BIG DIFFERENCE

"... from the tantric perspective the point of actual death is tied not to inhalation and exhalation but to the appearance of the mind of clear light ... " —Jeffrey Hopkins

The differences between Buddhist and secular approaches to euthanasia are grounded in dissimilar views about the very biology of the dying process. Basically, Buddhism and Western medicine see death very differently. In Highest Yoga Tantra, one of the most advanced Vajrayana teachings, there are particularly detailed descriptions of the dying process, wherein the experience is shown to be a complex interaction of physical, metaphysical, and spiritual events. Based on a medical model that presupposes an intertwining relationship between consciousness and physiology, this teaching delineates the changes that take place as we die.

Speaking very simply, during the dying process gross levels of consciousness, which are dependent on various physiological elements, dissolve as those elements deteriorate. More and more subtle levels of consciousness are revealed as grosser consciousness dissolves, until conceptuality ceases and eventually the dying person loses all awareness for a brief period.

There follows the revelation of the most subtle consciousness of all. This quintessence has many names, depending upon the school and the sutra, or text, some of which include: the clear light, Buddha-nature, the welcoming light of spontaneous presence, ultimate transcendent knowledge, or awareness resuming its essence. But, as pointed out by Tsele Natsok Rangdrol in the classic seventeenth-century Tibetan text The Mirror of Mindfulness, "The general teachings common to all systems know it as the luminosity of the first bardo." (There are many ways of interpreting "bardo," but most commonly it describes the state between death and rebirth. The Tibetan Book of the Dead, for example, describes the various stages, or bardos, that exist between this life and the next.)

The dawning luminosity is nothing less than ultimate truth revealing itself, and for Tibetan Buddhists this defines the moment of death.

For Western medicine, the moment of death is more of a legal matter. In 1980, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research established the "Uniform Determination of Death Act." It reads: "An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead."

This definition allows for a kind of "purgatory" status, in that the brain itself can be very badly damaged and the brain stem can still function. Thus people with no "cognitive" powers can continue to breathe, their hearts can pump blood throughout their bodies, and they can maintain sleep-wake cycles for as long as you force nutritional fluids into them intravenously. This macabre predicament has generated lawsuits and legislation. For example, Karen Ann Quinlan "lived" this way for nine years after she was taken off a respirator.

Such radically different approaches lead to radically different ideas about what makes a "good" death. There is the assumption in the West that it is good to die while unconscious or otherwise unaware that death is coming. Dying in one's sleep is seen as a great blessing, and people will often say, "Well, at least he never knew what hit him." This wasn't always the case. In fact, when the Judeo-Christian influence dominated Western culture, a sudden death was considered a disaster. ("From fire, flood, and sudden death, O Lord preserve us," is an old English prayer.) Having time to prepare properly was believed critical to assuring a benificent outcome. Only with the advent of scientific materialism do you see the notion that it is better to be unaware of one's death. And indeed, if death is the linear end of material existence why not soften the blow.

For the Buddhist, death is seen as a critical phase of a cyclical process, and is to be entered into with as much awareness as possible. It is considered important to die knowing what is going on.

Obviously, if you believe consciousness is extinguished at death, you will treat the experience differently, than if you believe that consciousness is changing, and that those changes can be influenced by the circumstances of the dying process.

Active euthanasia usually involves a lethal injection or overdose precipitating unconsciousness and leading to respitory failure—being completely unconscious at the moment of death is the goal. According to the Tibetan model, there are a number of additional stages in the dying process that occur after external respiration has ceased. A heavily drugged state clouds the experience of these stages and negatively influences everything that follows. And, for the Buddhist, everything follows.

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robbenwainer@verizon.net's picture

As sad as the truth is My Mother and I have been institutionalized. I have been sent to a housing program, while my Mother at seventy three lives in a nursing home. I feel she must be allowed her sorrow of all the death she has carried with her from being sent from hospitol to hospitol in this life. It may be she would always appreciate the right to die. I believe her life won't end, and that she does have an afterlife. She was a scholar and a fine Marxist Socialist who constructed a method for American Socialists to have a path of their own. During her divorce from My Father she faced a great deal of gossip, criticism and rumors all set out to ruin her reputation. My Mother had been extremely attractive but due to her consternnation of being critically bi polar, a conflict with substance abuse, and a rejection of those who fell from her service, when it seemed like she was being committed they found her a place in a senior home, where she can at least rest in some peace. I feel it is her integration in what Buddhists consider to be pure land that is so interesting. Now apart from the hospitol that had lead her to such hysteria and alienation she has time to understand that we share the same solitude in one way or another, and that her ability to trascend this life to recreate it into something of human value is a testimony that she has given to us by her own divine grace.

John Haspel's picture

The Buddha’s direct teachings on death do not treat death as something to understand separately from all other manifestations of suffering: "Now this, monks, is the noble truth of stress: Birth is stressful, aging is stressful, death is stressful; sorrow, lamentation, pain, distress, & despair are stressful; association with those loathed is stressful, separation from the loved is stressful, not getting what is wanted is stressful, receiving what one desires to avoid is stressful. In short, the five clinging-aggregates are stressful." (The Buddha’s first teaching, the Dhammacakkappavattana Sutta)

It is only preoccupation with physical form, that form contains a “self,” that any specialness at all is placed on physical death. The Buddha’s teachings on Dependent Origination, often misunderstood and misapplied, show that all suffering arises from ignorance, including the suffering of samsaric death.

The most important understanding of death is that the suffering of death is caused by the suffering of birth. It is in the clinging to any object or idea that has arisen from ignorance, including anything special or crucial regarding the karmic process of physical death, that proliferates confusion and suffering.

The issues raised in this article are all aspects of the confusion and suffering inherent in the conditioned phenomenal world that are abandoned once awakening has occurred. Physical death is simply another karmic process caused by ignorance.

The Buddha taught Four Noble Truths that provide the framework for understanding ignorance and for developing the cessation of the birth and death struggle. When the Buddha’s simple and direct teachings are diminished, or dismissed entirely, in favor of individually or culturally influenced “Buddhist” teachings the Dhamma becomes ineffective in bringing wisdom and ending ignorance and rebirth.

Like the Buddha, an awakened human being has no concern of sickness, aging or death, as they have developed understanding, extinguished karma, and have ended the cycle. An awakened human being lives in lasting peace free of clinging to any idea of “self.” An Awakened human being has developed the path leading to the cessation of confusion and suffering, the Eightfold Path.

John Haspel
http://crossrivermeditation.com

sschroll's picture

I want to express my gratitude for this insightful article. Almost 2 weeks ago I put to sleep my beloved cat Hercules, he was almost 15 years old. After this event I have been fighting and tormenting myself with the question: was it the right time? Your article gave me a wider perspective and it also reflects what I experienced. I don't have a completely certain answer, for now it will be a 'Koan', and it conn
ects me with my love for that gentle creature that was my friend for so many years.
Thank you.

whenrylyne's picture

Would someone please tell me from where the opening quote by Philip Kapleau Roshi came. I want to read the full quote in context.

ZenIrishChai's picture

According to http://kirpalsingh.org/booklets/death_and_dying_revised.pdf, it's an excerpt from The Wheel of Life and Death by Philip Kapleau Roshi available at http://www.amazon.com/Wheel-Life-Death-Philip-Kapleau/dp/038526058X.

jackelope65's picture

As a physician in western medicine, I have provided palliative care for the dying( Including my Mum in my own home). Most patients know when they are dying whilst their family around them are in denial. I have found that the most important step was to inform the dying of their impending death with the closest family member/members( no more than three people ) present. This allowed the the dying person to accept their own death and helped them to introduce this concept to their family. Often family members would initially remain in denial but the dying person would acknowledge their own impending death. My introduction, however, allowed the subject of dying as well as the associated worldly and spiritual needs to be openly addressed. I have witnessed many patients rejoice their lives and mourn their own death with family, often coming to terms with their spiritual beliefs. Most often, bringing the subject of dying into the open allowed free discussion, whether joyful, angry, or sad. My job was to very carefully titrate pain control so that pain relief, rest, and awareness were maximized as much as possible. My own Mum, who had not been eating and mostly resting in the weeks before her death, asked me for a bowl of broth and to take her for a ride in my car; she was very alert enjoying both the broth and the ride in a very beautiful environment, and then returned to bed becoming very peaceful, dying the next day. Nothing in my life and career in medicine have provided such long term satisfaction as providing palliative care, respecting both living and dying, for my Mum and my patients. It does take a lot of attention, effort, and caring to provide true palliative care, managing suffering without euthanasia, for people who are dying. In addition as a non-surgeon on the Trauma Team, I felt that my most important role was to help determine when intervention was not reasonable( i.e. an 85 year old person being placed on a ventilator after a severe traumatic brain injury in the presence of moderate to severe dementia with no hope of recovery based on both medical literature and extensive experience. ) Sometimes care becomes too mechanical, just looking at data than the whole person. Again much effort, attention, and caring are required to optimize the living and dying of a comatose injured or sick person to address both their worldly and spiritual needs. Fortunately, there are many members in the medical profession, including nurses and nurse aides, physician assistants, nurse practitioners, counselors, physicians, and others, who are willing to provide palliative care for dying patients. We must remind ourselves, however, to pay attention, and, if necessary, both respect and provide for spiritual needs, especially when people are dying without the support of families or friends.

Dominic Gomez's picture

You remind us, jackelope, how far our technology dependent, secular society has drifted from life's spiritual component.

marginal person's picture

Thank you for your wise and thoughtful comments. Hopefully your experiences will help to put a human face on the abstraction of "Western Medicine".

marginal person's picture

Why not compare Catholic death practices with Tibetan Buddhist death practices That would be a fair comparison. They`re both religions and both have definite beliefs about life after death.
Western medicine is secular. It's composed for the most part of caring people doing a difficult job.
The Trungpa quote is a sweeping generalization besides being dead wrong.(pun intended). Of course people working with the dying care about the state of mind of the people they care for.
I don`t understand the writer`s need to set up Western medicine as the straw man but it does make me wonder.

celticpassage's picture

I think western medicine was chosen as a comparison because that is how the majority of western people die: at a hospital in the western medical machine and not in a culturally informed process surrounded by a supportive community.

"Of course people working with the dying care about the state of mind of the people they care for"... perhaps in palliative care. However, the attendants at the several deaths I have witnessed across a variety of hospitals didn't seem to be that concerned. Most of those attendants are nurses with different nurses at different shifts and usually a variety of residents.

I think the complaint of an impersonal medical machine especially when it comes to dying is a valid one.

mpoliver's picture

I look forward to natural death with great anticipation. I find so called western views on death in many ways to be disgraceful and often quite selfish, It is one of my greatest fears that when the time comes I will be trapped in a body that has become a prison, bound to machines in a souless sterile room, secluded in final but artificially prolonged moments from outdoor air and the sounds and smells of nature, unable to experience a natural passing with a clear mind.

To think many would consider such an experience progress.

celticpassage's picture

Western medicine is based on a scientific approach so it's unsurprising that death is considered simply a cessation of biological life, that being all there is. The efforts to make death as unconscious as possible is a natural outcome of those thought processes.
Physicians have often labelled death as 'negative patient outcome'.

Dominic Gomez's picture

Buddhism teaches us to live and practice faith "with the profound insight that now is the last moment" of life. Imagine if we challenged ourselves to approach life with this attitude, how much more alive we would feel. How much more appreciation we would have for our very lives. How much more of ourselves would we invest in every opportunity to interact with other people.
www.sgi-usa.org/memberresources/resources/buddhist_concepts/bc30_eternit...

schiasson's picture

Very thought provoking. I have a very painful, degenerative disease, and have wondered how much I can endure, as this will not shorten my life. The answer seems to be that I shouldn't be asking the question at all. As long as my judgement Is unclouded this suffering is what I am supposed to be doing right now and for the foreseeable future. It is, oddly enough, a comforting thought, and something I needed to hear, as there are days I am capable of little else.

We have done immense damage by making the entire process of death as unnatural as possible.

breginaolive's picture

Excellent article. We have one precious birth-and death. The intrusion of life-support during the dying process is barbaric, having just witnessed this while holding my mother for 20 hours until it was discontinued. Then she was able to die peacefully. Having held several family members as they died over the past few years, the importance of the quality of one's death has become a important issue for me knowing many, out of fear and conditioning, are not well prepared for their own or others. I wear a DNR bracelet and that in itself makes most people uncomfortable. No one want to really talk about death-but we need to. Thank you for your wisdom.