Do Not Resuscitate
"Do-not-resuscitate" (DNR) laws are one of the successes of the bioethics movement, which replaced the traditional model of physician-dominated paternalism with an emphasis on patients’ rights. — Barron H. Lerner
Let’s talk about dying, medicine’s dirty little secret. For 99 per cent of us, it’s going to be a slow and physically, financially, and emotionally draining process, with the added kicker of diminished cognitive ability. If COVID-19 is involved, it’s also going to be alone. That certainly doesn’t sound like something we’d like to last any longer than it has to, does it? Given the inevitability of death, the quality of life during our transition is clearly more valuable than the quantity of minutes by which we can postpone it. At least that’s the Buddhist view—we can’t outrun our karma. Non-harming and compassion must be carefully weighed when deciding on heroic measures such as life support, do-not-resuscitate (DNR) orders, or medically assisted death.
Often, death becomes a conflictual situation where patients, loved ones, and the medical establishment are at odds over how to proceed. For example, there is still plenty of debate about when we actually die, and patients in persistent vegetative states or being considered for organ donation are often involved in lawsuits over the validity of life support. Similarly, recent acceptance of medical assistance in dying (MAID) has opened the way for a radical re-think of how we die. Traditional Buddhist discussions on this topic usually center on the dying person’s previously stated wishes, whether that person was able to form active consent, and on whether the intervention complicates one’s karmic consequences.
The resources section of this essay includes several Buddhist responses to the question of whether or not withdrawal of life support is appropriate. For example, from the perspective of non-harming, withdrawal of artificial nutrition and hydration (ANAH) would be considered contrary to the first precept: non-killing. From the perspective of compassion, ANAH may be considered an unwanted intervention that is preventing a person from their natural karmic transition through death. These discussions show the blurred lines between withdrawal of life support and active euthanasia. To complicate matters further, they certainly don’t address the ethical dilemma for healthcare professionals of deciding who receives a ventilator in overwhelmed, under-equipped hospitals during a respiratory viral pandemic.
Palliative care is a recognized branch of medical practice, and there are thousands of hospices in North America. There are many, many caring professionals dedicated to diminishing the mental, emotional, and spiritual turmoil of dying. Chaplains are often on the front line here, and we’ve seen an increase in training programs for Buddhist chaplains as North American Buddhism goes more mainstream. The problems arise when these institutions—such as the San Francisco Zen Hospice, which closed recently due to lack of funding—do not receive the type of governmental support they deserve.
There are always going to be dramatic stories of miracle cures, amazing advances in organ transplant technology, and sensational lawsuits swirling around the topic of life support. It’s important to remember that these are outliers. As long as they remain the focus of our attention, end-of-life care for the masses will be starved for oxygen.
For example, the University of Toronto recently launched a graduate Buddhist Chaplaincy program as a development of their Buddhist Psychology and Mental Health program. For all its merits, it is offered as a fulltime program, which means students cannot continue their day jobs while attending, and the university freely admits that there are few paying jobs for chaplains upon graduation. To my way of thinking, there is an unfair expectation that Buddhist chaplains will volunteer their services while earning a living elsewhere, which is a guaranteed recipe for burn-out and a condition that will hobble the program’s success.
We’ve seen the value of chaplains as they go to great lengths to work with COVID-19 patients dying alone. We praise them as essential workers, but like healthcare workers, grocery store clerks, cleaners, and personal support workers, we treat them more like sacrificial lambs.
Why aren’t more Buddhist teachers actively writing and speaking about real-life end-of-life in professional magazines and the popular media? Buddhist Care for the Dying and the Bereaved, edited by Jonathan Watts and Yoshiharu Tomatsu (Wisdom Publications 2012) is one of a very short list of practical contemporary Buddhist books on the subject.
Merely restating time-worn tropes about the need to be aware at the moment of death, resolving karmic debts, emergence of the Clear Light in the bardo, or other transcendentalist teachings are not going to cut it. Let’s pull the plug on outmoded responses to end-of-life care.
There is no doubt that humans have a fearful fascination with death. Our culture ruminates obsessively over violent deaths—murder mysteries, freak accidents, serial killers, and so on—and the pathos of loss—medical dramas, bereavement rituals, the tropes of obituaries. . . . Now, faced with the real thing on a scale from coronavirus that is unprecedented, we are incapacitated by trauma and grief.
We speak of loved ones “passing.” The phrase used to be “passing away” but we can’t seem to bring ourselves to even say that. We create elaborate afterlife scenarios rather than face the possibility of a universe without us in it, whether the scenery involves heaven, hell, rebirth, or some other plane of existence.
My goal here is not to delve deeply into our sick relationship with death. Instead, I simply want to explore how Buddhist thought, combined with design thinking, might lead to more meaningful and sustainable death practices.
Theravada Buddhist discussions of “a good death” focus on acceptance, awareness, and a clean karmic slate. The first precept (non-killing), along with a wish to not interfere with the workings of karma, are the pivots around which the debate for healthcare workers swirls. However, the locus of death is still firmly identified as the individual in transition. The death-centric practices of the Vajrayana—such as chod, phowa, bardo prayers, and recognition of tulkus—may prepare us for death, but the narrative focus is again on the individual.
From a Mahayana or Zen perspective, there is no self and no individual who is dying. The transition is a pulse in the cosmos that we misconstrue as termination. When “we” die, we are reabsorbed into the dynamic flux of the universe, which is constantly birthing new life in all its infinite possibility. It’s actually a source of awe, not grief. This view best expresses my limited understanding.
The modern scientific paradigm looks at death in a different way, as an organic process rather than as a morality tale or mythic narrative. Sherwin Nuland’s book, How We Die, should be required reading for anyone attempting to pontificate on the nature of death, and I would venture to say he does a better job of describing the process than any Buddhist text I’ve read or any initiation that has been conferred on me.
So let’s run with the no-self scenario, since it seems to fit most closely with our modern scientific understanding. Less than 10 per cent of us are likely to be conscious at the time of our demise, and the likelihood of bliss or awe is vastly less than that! Stephen Jenkinson’s Die Wise goal and Katy Butler’s The Art of Dying Well are mostly out of reach, even though the Good Death business is booming. Right now, we’d even settle for a bit of common decency and basic dignity for the dying. If we can set aside our concern for the individual and think about death as a design problem, what would we say? For example, consider working conditions and low pay in long-term care homes for seniors and the infirm.
What if we saw the biosphere as a loved one, or even as our own super-self? Would we strive more diligently to protect it from death? Our attachment to our individuality is the very reason for our short-sighted behavior, careening from death denial to delusions peddled by the death industry. All in all, we suffer from a lack of grief literacy. How do we then discuss seeing refrigerated trucks full of corpses awaiting mass burial?
Even though we now know that our corporeal existence is a symbiotic relationship, with more bacteria within us than we have human cells, and that we need those bacteria in order to live, we still find it difficult to see our own microbiome as part of the larger system of Gaia. Indeed, we even have difficulty seeing any parallels between the deaths we fear for ourselves and the deaths we so blithely inflict on the animals we eat. Add to that our extremely recent awakening to the fact that there are literally millions of different types of viruses in animal hosts that could jump to humans as SARS-Co-V-2 has done. Our senses of self and invincibility have been shattered.
Most of our media portrayals of death ignore the social conditions that lead to the fateful outcome. To play on a frequent Buddhist image, we focus on saving the drowning person without ever questioning why there are so many people in the river. Solving public health and infrastructure problems, funding pandemic preparedness, providing clean water, removing barriers to healthcare caused by greed and corruption, or improving our disposal of the dead may not be as glamorous as a handsome young detective catching a killer, or as heroic as a psychologically complex and sexy doctor striving to save a child, but the long-term effects are much more profound. Ponder this.
Nuland, Sherwin. 1995. How We Die: Reflections on Life’s Final Chapter. New York: Vintage Books
Watts, Jonathan and Yoshiharu Tomatsu. ed. 2012. Buddhist Care for the Dying and the Bereaved Somerville, MA, Wisdom Publications
Building Buddhist Chaplaincy in Canada (Buddhism Canada)
Life is Uncertain. Death is Certain. Buddhism and Palliative Care (PubMed)
Buddhist Ethics and End-of-Life Care Decisions (Taylor and Francis Online)
The Vegetative State – A Syndrome in Search of a Name (US National Library of Medicine)
Buddhism and euthanasia (Wikipedia)
Buddhist Funerals (The Buddhist Society)
Buddhist View on Death and Rebirth (Urban Dharma)
Buddhism and Death (Access to Insight)
Being with Dying (Upaya)
Related features from Buddhistdoor Global
Buddhistdoor View: Embracing Fear and Uncertainty
Medical Torture and Why We Do It
Death and Dying in Japanese Buddhism
Rethinking Death with Natural Burial Practices
Midwifing Death with Love – Applied Buddhism for Animal Care