As is the case with so many of the feature book reviews in Lion’s Roar, Damien Keown’s “Would You Help Your Parents End Their Lives,” from our July 2009 issue, is much more than a mere book review—it skillfully, even-handedly opens up a difficult but vital discussion: where and how assisted suicide, compassion, and the end of suffering might interrelate.
In The Last Goodnights: Assisting My Parents With Their Suicides, John West, at the time a Seattle-based lawyer, recounts how he assisted the suicide of both his parents ten years ago. West’s father, Jolly, was a world-renowned psychiatrist at UCLA, and his mother, known affectionately as “K,” a respected clinical psychologist at the veterans’ hospital in West Los Angeles. Jolly was diagnosed with bone cancer at age seventy-four with a terminal prognosis of a few months, at a time when West’s mother, aged seventy-five, was suffering mid-stage Alzheimer’s, aggravated by emphysema and osteoporosis. They had been married more than fifty years, though not entirely happily.
Soon after the diagnosis, Jolly said he had no wish to linger on, possibly in pain, and asked his son whether he would assist his suicide when the time came. John West immediately agreed and began to make preparations during the frequent trips he made from Seattle to L.A. to be with his parents. After a fruitless attempt to seek help from the Hemlock Society, father and son decided to use an overdose of barbiturates issued on prescription for pain relief. Early in the new year, on his return home from a stay in hospital—and after moments of tragicomic drama in finding a pharmacy that had sufficient tablets in stock—Jolly ingested them with his son’s support. Jolly passed away in his sleep, and a death certificate was issued by the family doctor. No suspicions were raised and no inquiries were made by the authorities.
The remainder of the book, occupying by far the greater part, recounts the progressive decline of K and her own decision to end her life through assisted suicide, following the example of her husband. Assisted suicide was apparently becoming a family tradition, since Jolly himself had assisted the suicide of K’s mother, Harriet, some twenty-five years before. Once again, West agreed to help, and supported his mother through visits and phone calls during her remaining time before assisting her with a fatal overdose on the Fourth of July. As before, the manner of death raised no suspicions. K’s medical condition, personal and family interactions, and the minor details of daily life are recorded in the form of a diary.
In West’s view, the “right to die” is an unmitigated good that is self-evident and apparently needs no defense. As a progressive liberal, he assumes that the right to die is simply another personal freedom that will, inevitably, be won in the same way that reproductive and other rights were. For him, there is no contentious moral issue here, just the opposition of closed minds to the march of progress. In occasional asides, the familiar reasons in support of the right to die are mentioned—autonomy, mercy, and dignity. Approving mention is made of the Netherlands and Oregon, although his actions would have been illegal in both jurisdictions, both of which permit only doctors to assist suicides.
Yet, the ethical and public policy debate about whether to change the law and professional ethics to permit physician-assisted suicide raises many profound and complex questions, not least about the value of life, of autonomy and the protection of the vulnerable. Jolly had a terminal illness, whereas K did not. K was not dying; she was simply confused and depressed. One has to ask whether a patient in this state is capable of making an objective judgment about suicide. Even if we assume K was capable, many others are not.
Adding death as a “treatment option” would surely introduce an ambiguity into the practice of medicine. Most patients who do not want assisted suicide might no longer have the same confidence that their doctor’s only interest was in keeping them alive. This might undermine public confidence in the medical profession, particularly among more vulnerable members of society. West’s parents were educated people, affluent professionals who knew the medical system inside out. He was a lawyer. Not all families are as lucky, and not all sons are as devoted as West appears in this account.
The Last Goodnights gives the impression that assisted suicide is purely a private matter, a personal choice, and nobody else’s business. However, dying raises complex psychological and spiritual issues, and is not perhaps as easy to micro-manage as some people assume. Contending that it is a private matter ignores the fact that individuals live in society, not in a vacuum. The legal, medical, and social ramifications of permitting assisted suicide affect everyone, not just the tiny minority of patients who want it. Significantly, expert committees that have considered the arguments for changing the law have, overwhelmingly, recommended that assisting suicide should remain an offense, not least in order to protect the vulnerable.
Caring for elderly relatives can be burdensome, both emotionally and financially, and death can offer a seductive way out. The economic attractions of assisted suicide would not be lost on healthcare funders or financially pressed relatives. This does not necessarily mean that patients would be killed against their wishes, but it could mean that the system had less incentive to spend resources on keeping them alive.
There are also concerns about a “slippery slope” leading from assisted suicide to voluntary euthanasia, and from voluntary euthanasia to nonvoluntary euthanasia. After all, if death is a benefit, why should it be withheld from those who cannot request it? Despite reassurances by right-to-die campaigners about legislative safeguards against such “creep,” the evidence from the Netherlands suggests that once the genie is out of the bottle it’s very difficult to control. The Dutch started by permitting only voluntary euthanasia and physician-assisted suicide, but Dutch law now allows euthanasia for some patients who cannot request it.
Although there is no mention of Buddhism in this book, and neither of West’s parents was religious, we may nevertheless take it as a point of departure for a discussion of Buddhist perspectives. The three values that West identifies as supporting the case for assisted suicide (autonomy, mercy, and dignity) have already been mentioned, and autonomy is the one most often cited. Autonomy is a concept derived from political theory, where it justifies the right of a state to enact its own laws free of outside interference. In an ethical context, it gains support from Western philosophical views about the importance of the individual and comes to stand for the right to self-determination and free choice. It is reinforced by post-Enlightenment notions about personal rights, and in modern times has been elevated by liberal theorists to the status of a quasi-supreme moral principle.
One wonders, however, how well this quintessentially Western liberal notion fits with traditional Buddhist teachings. These do not lay such stress on individuals and their rights, and the doctrine of “no-self” may be thought to undermine the concept of individuality entirely. The discourse of rights is absent from Buddhist literature, and what one finds instead is talk of duties and obligations to the community. Buddhism emphasizes not so much that we have the right to choose, but that we are responsible for what we choose. Again, the law that is to be respected is not one enacted through personal choice, but the eternal law of dharma.
Indeed, far from stressing autonomy as a key value, Buddhism seems to tell us that we are not autonomous. A key Buddhist philosophical teaching is often said to be “dependent origination.” In terms of most popular interpretations of this doctrine, things are seen as interconnected, rather than autonomous, independent and self-determining. A Buddhist case for assisted suicide based mainly on autonomy, therefore, would seem to be on shaky ground.
Does what West calls “mercy,” or what Buddhists call “compassion,” provide a more secure basis? To accompany others in their suffering would seem to be a primary moral duty for all who follow the path of the bodhisattva. Suicide, however, can represent a flight from suffering rather than an acceptance of it. Perhaps the more compassionate response to suffering is to provide medical care, comfort and support, as opposed to terminating the life of the sufferer. We know at least, that this is what monastic law says, and the case histories recorded in the vinaya, or monastic rules, reveal that monks who assisted the suicide of patients, even with the most compassionate of motives, were expelled from the order. Yet, there are also reports in the Pali canon of monks who took their own lives, and some were even said to have attained arhatship.
The interpretation of these cases is complex, but what I think we see in the Buddha’s reaction to them is compassion for those who cannot endure suffering and are driven to desperate measures. This is not to say, however, that such actions were approved or condoned. Buddhist teachings on ahimsa, or nonharming, strongly oppose the taking of any life, including one’s own, and regardless of the compassionate motivation to end suffering, the first precept, not to kill, weighs heavily in the scales when any life-threatening action is contemplated.
The final value mentioned by West is dignity, for which there is no obvious Buddhist equivalent. However, Buddhism certainly recognizes and respects human dignity. We see this in the belief that humans have a special capacity to attain enlightenment, and in the notion that a “precious human rebirth” is a great blessing. Some schools locate this dignity in the possession of buddhanature, the inherent capacity for buddhahood in all living beings. If this is what dignity means for Buddhists, then it is objective and an attribute that can never be lost. It is constant in sickness and in health, in youth and old age, and from one life to the next. Subjectively, we may feel that it fluctuates as independence is lost and our physical and mental faculties deteriorate. But why should dependence on others imply a loss of dignity if, in reality, we are all inescapably interdependent? Perhaps what is at issue here is not so much dignity, but vanity. We do not like to think of ourselves as vulnerable, or as a burden on others, but these concerns may have more to do with self-image and pride than a loss of innate dignity. Perhaps such concerns are best dealt with by identifying less with the egocentric concerns of an illusory self and more with the inalienable dignity of one’s buddhanature.
There may be a lesson here we can learn from the life of the Buddha. In the last months of his life, the Buddha suffered from a painful terminal illness. He knew the end was near, but fought the illness and carried on as long as he could. If ever there was a case for cutting life short, surely this was it: he could have avoided any further pain and entered nirvana immediately with no ill consequences of any kind. So why didn’t he? We can never know for sure, but perhaps it has something to do with his own basic teachings. In the four noble truths, death is identified as the problem, rather than the solution. Death (often symbolized by Mara) is mentioned in the first noble truth, suffering, while the cessation of suffering, nirvana, is the third. To see death as a solution to suffering, as in the case of assisted suicide, gets things back to front, because choosing death only gets you deeper into the problem. For the Buddha to have chosen death would have been an existential choice that undermined his life’s work. It would have meant embracing Mara, as opposed to vanquishing him.
For those without religious beliefs, for whom death means annihilation (such as West’s parents), suicide may seem a rational choice. For Buddhists, however, death would not appear to be the recommended solution.