July 1988

Part 1; It's Difficult to Die Today

No longer do you need the supreme devotion of a Savitri to snatch a loved one from Lord Yama's noose. Paid-up insurance, a modern hospital and "heroic efforts" will suffice, for a time, to frustrate the God of Death. Advanced medical techniques are saving many people from once-fatal illnesses; but for those beyond saving, the same techniques extend the process of dying into agonizing weeks, months, even years.

We once died surrounded by our loved ones, quietly and quickly in the dignity and privacy of our home. Now we may die slowly and painfully (or stupified by drugs) in hospitals, hooked to equipment that makes the space shuttle look simple, tended by strangers, running up hospital bills that can bankrupt our family, possibly even using medical attention that could save another's life. All for a few semi-conscious extra months of existence. Man is now faced with the ethical and social problems of advancing medical technology.

A solution nearly made it on the ballot in California this year: legalized euthanasia (literally, "good death," but commonly called "mercy killing"). Proponents say we must demand "the right to die." Right to die? Who has the right, or the means, not to die? What has happened to bring us to a point where laws are proposed that doctors, pledged to cure the sick, are now to be asked to kill people? What are the ramifications?

To explore this complex subject, Hinduism Today interviewed Hindu swamis and doctors. In this first of a three-part series on euthanasia, we will examine dying today, the opinions and feelings of the doctors and the current proposals for legalized "active euthanasia." In the following issue, we will hear from the swamis - including Swami Bhasyananda of the Vedanta Society of Chicago, Swami Satchidananda of the Integral Yoga Institute, Swami Paskarananda of the Vedanta Society of Seattle, Swami Omkarananda of the Badarikashrama of San Leandro, California, and our publisher, Gurudeva, Sivaya Subramuniyaswami - on the ethics, morality, karma and general implications for the soul of euthanasia. In the last part, we'll share the responses of you, our readers.

Our four doctors are: Dr. Devananda Tandavan, Chicago, Illinois, a specialist in radiation diagnosis and therapy; Dr. Ranjani Chandramouli, pediatrician, Sunnyvale, California; Dr. Ravi Nadaraja, cardiovascular surgeon, Castro Valley, California; and Dr. Raja, pulmonary specialist, also of Castro Valley. You may be shocked by what they reveal here; yet they reflect typical American medical opinion.

When Are You Dead?

The first complication technology has caused is around the very definition of death. In the past, when a dying person stopped breathing and his heart stopped, he was declared dead. The unquestioned signs of death followed quickly: fall of body temperature to ambient, rigidity of the body and the settling of the blood. Today, the machines will not let those signs appear, even if "you" don't seem to be there anymore. In 1968, the American Medical Association offered a new definition of death, subsequently adopted by most states, "the complete cessation of brain activity," commonly known as "brain death."

So what did that solve? Possibly not much. In the U.S., 80% of us die in hospitals, 50% connected to life-support systems. While some will be clearly "brain dead" (in which case no one disputes the rightness of unplugging them), the rest of us will be in a whole range of states from "terminal" (meaning probably, but not certainly, having a short time to live), to "comatose" (meaning unresponsive to anything, but with an unpredictable life expectancy), to "vegetative" (meaning slightly responsive and often with normal life expectancy). There are presently 10,000 people in America in such a vegetative state, maintained at a cost of $300/day each. Unknown numbers any day are terminal or comatose (at $1000's/day). Add to this the seriously malformed at birth and you have an idea what doctors face when they go to work.

Living Wills and Substituted Judgement

Most states allow for a "living will," a legal declaration by a person to authorize his physician to use no life-sustaining treatments if he becomes terminally ill. The courts have upheld a person's right to refuse medical treatment, even if it means his death. The complication here is when treatment's already begun.

Dr. Tandavan explains the problem, "If there is no evidence of brain death, the overt act of pulling the plug would be the actual cause of death." It is ethical for the patient to make this choice and the doctor to carry it out, allows Dr. Tandavan, "if done when the patient is fully rational and in possession of all his faculties."

But if the patient hadn't decided - or changes his mind at the last minute - the ethical waters become murky; we cross the boundary from unplugging the already dead to removing the means of life from the still living.

With the patient terminal, incapacitated and undeclared as to intent, who's to decide? The doctor? The family? The courts? All of them? With no precedent as guide and an increasing number of cases before them, the courts consulted their legal oracle and came forth with a new revelation: the judicial doctrine of "substituted judgement." Under this doctrine, a court seeks to determine, then implement, an incompetent person's wish regarding medical treatment.

Practically speaking, the decision to cease life-support falls to the next of kin. That person can be easily torn between love for a relative and the emotional and economic burden of dying. What will he do, for example, when the dying grandmother's care is eliminating the family savings - or household budget - at the rate of several thousand dollars a day?

Mixed motivations, however are only part of the problem. Having decided to unplug the life-support, what happens if the patient goes on living anyway? Here we enter the medical, moral and legal twilight zone.

Passive Euthanasia

Many doctors have already solved the problem of terminating the patient. They let him die or they kill him - in any number of ways. They don't call it killing, and it may not be fair to say it, but that's what it is. It's called "passive euthanasia," where death is brought about by a means somewhat short of handing the patient a lethal dose of morphine, as can be done in the Netherlands [see sidebar]. Dr. Tandavan elaborates a few, "Overdosage of medicine, withdrawal of needed medicine, withdrawal of fluid and/or food, giving of excessive doses of opiates, injection of air to produce air embolism." Some of these actions bring doctors perilously close to breaking the law, though prosecution is unheard of.

Letting the patient die - "do not resuscitate - is the most common (and justifiable) approach. If the patient has a heart attack or respiratory arrest, nothing will be done to save him. This may be requested in the living will, decided by "substituted judgement" or by the doctor.

Overdose of opiates, morphine in particular, is apparently a prevalent way to hasten death. All of the doctors interviewed mentioned it. Discover magazine (October, 1987) published a chilling account by Dr. Perri Klass, a pediatrician, in which she tells of giving larger and larger doses of pain-killing morphine to a child. She explained, "The one thing anyone can do for this dying child and her family now is take away the pain, and I will do my best to do that even if it means she stops breathing."

Another doctor confirmed that giving morphine to dying children is common. "When we turn off the life-support system [having concluded the child cannot be saved], we always give a heavy dose of morphine."

The jump to active euthanasia, the proposed legalized lethal injections, is apparently only a short hop from some current medical practices. But the consequent ethical leap is wide.

Active Euthanasia

A recent poll conducted in California showed 70% of doctors feel active euthanasia should be an option to the patient. Our four doctors displayed the same ratio for and against.

Dr. Nadaraja: "Medicine is to relieve pain and suffering. Maybe there is a place for euthanasia, what right do we have to keep them alive and in pain?"

Dr. Tandavan: "The deliberate act of taking a life in the medical setting by an overt act of any person is wrong, morally and legally."

Dr. Chandramouli: "Yes, in some situations where patients are really suffering hard and have only a few days, then I would probably go ahead and do that [euthanasia, if legal].

Dr. Raja: "My primary alignment is with Netherlands. Their view is to facilitate a peaceful death."

Of 11 doctors asked in Chicago, only two expressed serious personal reservations about euthanasia. Several indicated they would go along with whatever the hospital administrative policy was, apparently having no particular position on the subject themselves.

We'll leave our readers to ponder the ethics of euthanasia, and the related personal quandary of doctors, dying patients and their families. Please send in your thoughts, experiences, and comments for the third part of this series. Next issue, we'll hear from the Hindu swamis.

Article copyright Himalayan Academy.