Mercy, Deliverance, and the Nature of Suffering
"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.