men-crossing“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. 

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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,

euth2describes 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.

MERCY AND DELIVERANCE

“Buddhism holds that because death is not the end, suffering does not cease thereupon, but continues until the karma that created the suffering has played itself out; thus, it is pointless to kill oneself—or aid another to do so—in order to escape. ” —Philip Kapleau Roshi 

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The most widely-known proponents of active euthanasia are Derek Humphrey, who wrote the bestselling Final Exit, a book that describes ways to “do-it-yourself,” and Dr. Jack Kevorkian, who has assisted a number of deaths with the use of a device the press has labeled a “suicide machine.” These men are at the forefront of a movement in support of legalizing physician-assisted suicide, or mercy-killing.

The argument in support of legalization says, in essence, that euthanasia is ultimately a matter of autonomy and self-determination. When individuals facing death wish to end their lives as a rational alternative to pain and suffering, they should be allowed to do so or aided to do so, with no moral or other judgment. This argument illuminates the differences between Buddhist thought and secular philosophies. Whether it concerns a matter of self-deliverance or mercy-killing, the ethical stance in support of active euthanasia is incompatible with Buddhist tradition and belief. Buddhism teaches that it is improper to take life, including one’s own, that every such act has its consequences, and that the nature of suffering is such that its consequences will almost certainly include more suffering in the long run.

In fact, Buddhism teaches that the very attempt to avoid suffering creates ever more suffering—and the current euthanasia dilemma is a good example of this problem. The unexamined effort to halt physical deterioration has created circumstances fraught with emotional, psychological, and spiritual suffering, (as well as continued physical suffering, since our attempts to stop deterioration do not avoid physical pain and often exacerbate it).

Misunderstanding the nature of suffering and ignoring the reality of impermanence in an effort to “defeat” death, modern science has added new levels of anguish to the dying process. In our single-minded rush toward “optimum health” we don’t have time to care for or comfort the dying. Now, as a solution to this additional suffering, it is suggested that we provide lethal injections as a quick and easy remedy for the messy and problematic business of dying. From a Buddhist viewpoint, this approach adds to the problem.

PAIN AND AN UNCLOUDED CONSCIOUSNESS

The bardo of dying is said to be painful because the process of passing away usually involves pain and suffering. Although the death process might sometimes be very quick and we may think that nothing much is felt, some pain is certainly involved. Even if one dies in a coma or during a faint, the mind still experiences subtle pain during what is called the interruption of the life-force.“—Chokyi Nyima Rinpoche 

Shakyamuni Buddha taught that all suffering can be overcome by understanding its true nature. This is a profound and subtle process. It can take a while. 

In the meantime, compassion is key. 

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If an individual is in such physical agony that it dominates their entire awareness, they cannot be expected to have a conscious death experience. In his recent book The Tibetan Book of Living and Dying, Sogyal Rinpoche says:

“The Buddhist masters speak of the need to die consciously with as lucid, unblurred, and serene a mental mastery as possible. Keeping pain under control without clouding the dying person’s consciousness is the first prerequisite for this, and now it often can be done: everyone should be entitled to that simple help at this most demanding moment of passage.”

While the indiscriminate application of medical technology can cause great difficulty for the dying, the advances made by that same technology, when used intelligently and attentively, can make a very positive difference. Pain management and palliative care is a new field, offering treatment that does not heavily sedate the mind and obviate the possibility of a clear experience. Specialized attention to pain and symptom control is most readily available through hospice care, a program providing assistance for those who wish to discontinue curative treatment. Many Buddhist teachers strongly encourage this kind of care as an alternative to the option of active euthanasia. That this kind of care is hard to come by is a disheartening comment on the priorities of our culture.

LIFE-SUPPORT OR DEATH-SUPPORT?

“To use life-support mechanisms when a person has no chance of recovery is pointless. It is far better to let them die naturally in a peaceful atmosphere and perform positive actions on their behalf. It is not a crime to stop it, since there is no way in which the person can survive, and you are only holding onto their life artificially.” —Dilgo Khyentse Rinpoche

What is sometimes called passive euthanasia is more and more commonly practiced as people rebel against the mindless application of medical technology. In deciding whether or not to withdraw or withhold life-sustaining treatment, the bottom line is the same in both the Buddhist and the secular view: given Western medicine’s ability to interrupt the dying process, when should we do it and when should we not?

His Holiness the Dalai Lama has said: “From the Buddhist point of view, if a dying person has any chance of having positive, virtuous thoughts, it is important—and there is a purpose—for them to live even just a few minutes longer. If there is no such chance for positive thoughts, and in addition a lot of money is being spent by relatives simply in order to keep someone alive, then there seems to be no point. But each case must be dealt with individually; it is very difficult to generalize.”

Clearly, context is all. Compassionate practice is less dependent on rigid adherence to precepts than it is relative to the specifics of a given situation. This requires that we pay close attention to the dying person, and we really take the time and energy to try to perceive what will be the most help.

From a Buddhist point of view, the removal of life-support technology or treatment when there is no hope of recovery and death would otherwise naturally occur, can be considered a compassionate act—not “killing,” but rather “rescuing” the individual from a devastating interference with the profoundly important process of dying. And refusing treatment in order to prepare for death must certainly be considered appropriate. Having been blessed with precious human birth, one is expected to hold onto it, respect and appreciate it, but clearly not to cling desperately to a life that is ending or to flail against the forces of impermanence.

In actuality, however, it can be quite difficult to know whether or not to stop treatment. There is a wide spectrum of care that can be applied at varying stages of illness, injury, and debilitation. Rather than a single decision leading to a clear-cut result, one will often be faced with a series of decisions as circumstances progress and new conditions present themselves. Should resuscitation be attempted? Should a feeding tube be inserted? How long should someone be maintained in coma? What about a severely deformed and brain-damaged newborn, placed on life support and subjected to painful treatment with an uncertain outcome?

The only possible guiding principle is the need to allow for the unique nature of each case. And unfortunately, institutionalized medicine is not designed for that. We talk a lot about how awful this is when we’re sick and trying to get well. It is even worse when we’re sick and trying to die.

FACING REALITY

“It is such a terrible rejection, a fundamental rejection of love, that nobody is really willing to help a dying person’s state of mind. ”  —Chogyam Trungpa Rinpoche

The current euthanasia debate has arisen against a backdrop of cultural necrophobia. As a society, our refusal to come to terms with the fact of impermanence has made death seem an ignominious occurence, a failure, a shame.

An apt depiction of our samsaric dilemma is the image of a dying patient “attached” to the machinery of Western technology, trapped and alone in the crowded, noisy, and spiritually impoverished environment of the modern hospital.

Enough people have been emotionally and financially ruined, enough law suits have been instigated, enough popular concern has been generated to have brought these issues into the public arena. However, in that arena the discussion turns on rights and regulations, on long-term care costs, on the feasibility of “terminal management.” Even when we’re talking about death we don’t seem to be able to actually talk aboutdeath.

Stepping back and seeing the bigger picture is not so difficult. But stepping up to the bedside is another matter. The dread that arises when someone we know is dying, the shock or panic we feel when our own life is threatened—in these moments we get a glimpse of something very real, no pretense, no cover-up, no choice. Relating to that very reality, to that suffering, is a fundamental concern of Buddhism. Today in the West, death is the place where that reality can break through our defenses, providing a kind of crucible for practice, for grappling with the precepts; for sorting out for ourselves when to hold on and when to let go.

Patricia Anderson is the author of Affairs in Order: A complete Resource guide to death and Dying(Macmillian). She is currently at work on a book about the idea of progress.

Image 1: Blind Men Crossing a Bridge, Hakuin (1685-1796) Ink on paper.
Images 2-5: Paul Reps’ artwork reprinted with permission from Stillgate Publishers/Green River Press, Sunderland, MA.

Dying begins when the five vital winds that sustain the body’s functions and the five secondary winds that sustain the senses lose power, causing their functions to fail with them. In a complex interrelationship, the energy centers of the body, known as the chakras, begin to fail. As the energy of each chakra disperses, a corresponding element of the body—earth, water, fire, wind—also disperses. 

These elements have a direct relationship to the body’s components. The earth element relates to flesh and bone, the water element to blood and fluids, the fire element to digestion and internal heat, and the wind element to breath and circulation. When these elements disassociate, one after another, their cohesion and function deteriorate. The physical, mental, and visionary experiences of dying rapidly accelerate. 

The first effects of dying are difficulty in digesting food, swallowing and lifting the arms, legs, and head. The breath is short and gasping. The limbs, then the whole body, are chilled and nothing warms them. The mind is agitated and thoughts arise uncontrollably. 

It becomes impossible to stay erect. We cannot lift our arms and legs, the head lolls back and there is a feeling of heavy pressure on the whole body. The agitation ceases and is replaced by drowsiness, a semi-swoon. We see mirage-like visions and flickering lights. 

There is dryness of mouth, nose, throat, and eyes. Bodily sensations are greatly reduced and alternate between pain and pleasure, heat and cold. The mind becomes irritable and we have visions of smoke. 

Then we cannot recognize friends or family. Sound and sight are confused. We see red dots like fireflies. 

We become totally immobile. The breath is shorter and more gasping, our exhalations longer. Sound and sight blur. Visionary experiences arise according to our karma. Persons whose activities of body, speech, and mind have been very negative may see terrifying forms or a replay of the bad moments of their lives. They might react with guttural sounds of fear. Those who have been virtuous and kind might experience blissful, heavenly visions and see forms of loving friends and enlightened beings. They would have little fear of death. 

Finally, there is one long exhalation, the “death rattle.” This is followed by the closure of sight, hearing, smell, taste, and touch as the winds retract toward the heart. Physically, one is dead.

—From Life in Relation to Death (Padma Publishing) by Chagdud Tulku Rinpoche.

Disciples, there is a realm in which there is neither earth nor water, fire nor air; not endless space, infinite consciousness, nor nothingness; not perceptions nor nonperceptions. In it there is neither this world nor another, neither sun nor moon. I call it neither a coming nor a going nor a standing still; not death, nor birth; it is without basis, change, or stability. Disciples, it is the end of sorrow. 

For that which clings to another there is retrogression, but where there is no clinging there is no retrogression. Where no retrogression exists calm exists, and where there is calm there is no obsessive desire. Where obsessive desire is absent, there is neither coming nor going, and where coming and going have ended there is no death, no birth; where death and birth do not exist there is neither this life nor an afterlife, nor any in between—it is, disciples, the end of suffering. 

Yet there is an Unoriginated, Unborn, Uncreated, Unformed. If this Unoriginated, Unborn, Uncreated, Unformed did not exist, there would be no liberation for whatever is originated, born, created, and formed. But since there is an Unoriginated, Unborn, Uncreated, Unformed, liberation is possible for whatever is originated, born, created, and formed.

—The Buddha

From The Wheel of Death by Philip Kapleau Roshi, published by Harper Colophon Books and reprinted with permission of the author.

Wherever I go in the West, I am struck by the great mental suffering that arises from the fear of dying, whether or not this fear is acknowledged. How reassuring it would be for people if they knew that when they lay dying they would be cared for with loving insight! As it is, our culture is so heartless in its expediency and its denial of any real spiritual value that people, when faced with terminal illness, feel terrified that they are simply going to be thrown away like useless goods. In Tibet it was a natural response to pray for the dying and to give them spiritual care; in the West the only spiritual attention that the majority pay to the dying is to go to their funeral. 

At the moment of their greatest vulnerability, then, people in our world are abandoned and left almost totally without support or insight. This is a tragic and humiliating state of affairs, which must change. All of the modern world’s pretensions to power and success will ring hollow until everyone can die in this culture with some measure of true peace, and until at least some effort is made to ensure [that] this is possible.