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The Pali is transliterated as Velthuis (aaiiuu.m'n~n.t.d.n.l). Alternatives:
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[ Ethical Culture and Self Discipline ]

Pulling the Plug

Easier Said Than Done

A correspondant brought up the subject of the kamma involved in the idea of withdrawing life support in the case of irreversible coma and other "vegatative" states:

...last year I was emailed by someone who wanted to know whether it would be ethically correct, in terms of the Buddha's Teaching, to have his mother's life support turned off, since she was in an irreversible 'vegetative' state, could not communicate, was very obviously suffering, and while she had left no living will she had, in earlier discussions with him, spoken in a way that indicated to him that she would not wish to be kept alive in such circumstances. I found myself in a position in which an answer...would have to be very carefully phrased.

The dilemma of withdrawing life support is more of a problem of testing the will of the caretaker than it is an issue of what is ethically correct and what is not. In this society, dominated by trends, fads, incessant propaganda from the state as to what is and what is not morally correct, the 'good advice' of advocacy groups, doctors and health care providers (looking to their own 'bottom line'), and peer pressure, the existence of an advance directive and power of attorney to carry out a stated wish that one not be subjected to extraordinary life sustaining measures (or whatever) simply cannot be taken at face value. It doesn't matter what the person has said. There is very little basis for an individual to believe that either they understand the real wish of another or that the other's real wish was expressed in such legal arrangements. There is no mercy for caretakers in pieces of paper!

What most caretakers will be able to see with their own eyes is how much the one they are caring for clings to life and how much they fear death.

There are a thousand million signs that indicate clinging to life and fear of death so in order for any meaninful guidance to be given in this case, the examples must be broad and general, and because this is a Buddhist-oriented discussion, it will be based on the teachings of the Buddha. Some things to look for (the order is significant, going from least indicative to most indicative):

1. Is the person generous? The more generous they are, the less they cling to life and the less they fear death. The clinging to things of the stingy person can be seen to be the clinging to life; the giving, the ease with which one will be able to let go of life; the difficulty or ease will indicate the fear of death or it's absence.

2. Is the person careful in their ethical conduct? The more careful they are the more it indicates an understanding of the problem of death, the more an individual understands the problem of death, the less they fear it. (The observer needs to understand the notion that the idea that remains in the sub-conscious is the one that carries the most fear - is the most problematic; the idea that is out in the open is one which is near to resolution.)

3. Does the person exercise self-control (moderation in self-indulgence, moderation in eating and sleep, attention to what they are doing and saying), control over their expressions of liking and disliking? In the same way as with ethical conduct, the more the individual recognizes the importance of self-control the more they indicate an understanding of the problem of death and the less they have to fear from death.

4. Does the person show any indications of developing the mind? Do they meditate, train their memory, study the dhamma, cultivate energy, cultivate enthusiasm, impassivity, samadhi, detachment? Do they show any faith in the Buddha? Do they demonstrate any understanding of the Dhamma? Have they had any supernormal experiences that they can reflect on? The more of these states and conditions they evidence, the less they will have real clinging to life and fear of death.[1]

As you can see, this is almost backwards from the way "clinging to life' and 'fear of death' would be thought of as being indicated by those outside the Buddha's Dhamma, so that is the main issue for one in the caretaker's position: how well does the caretaker himself understand these signs? The more the caretaker actually understands, the clearer will be the alternatives when the issue of "pulling the plug" is faced.

On the emotional side, I have this experience which I hope will see me through: There was a friendly feral cat here. It got a scratch under it's eye and the eye became infected and cancerous. The conventional wisdom was clear: the cat should be put out of it's misery. With a great deal of emotional difficulty, I refused to do this and just allowed the cat to live out it's life to the end of its days in what could only be described as the most horrendous of ends. I believe I was correct (and as time goes by I see more and more that this was the correct thing to have done, and I gain a happier and happier outlook in consequence) in that on the one or two occasions when I attempted to confine it to keep it from the flies that endlessly harassed it, it immediately struggled to escape. A 'will to life in freedom' dispite everything was clearly visible to me in this struggle. This cat spent it's last hours mewing in dialog with me into the night.
The lesson for you in this?
Find some experiences in your life that relate to this issue and extrapolate the meaning out into this situation.

This is the issue for the caretaker and the way I see "unplugging" life support: When you are driving a car, the car's forward momentum is sustained by your foot on the gas pedal. This placing of the foot on the peddle, and the pressure required to keep the pedal pressed down, is an act of doing. There is no kamma connected with stopping an act of doing. If there were kamma connected with stopping an act of doing (like the car going into reverse when one took one's foot off the gas-pedal), there could be no escaping kamma. The placing of the plug into the electric socket and the flow of electricity connected with a life-support mechanism is an approximation of the foot on the gas pedal and the flow of gas. It may look like "pulling" the plug is an act, but actually it is a stopping of an act. So then what this situation really comes down to is the intent of the plug-puller. If the act is erroneously perceived as "depriving another of further life," then there will be bad kamma in connection, if the plug-pulling is seen as ending the act of sustaining further life, then there would be no bad kamma.

So the thing that is necessary to see in terms of 'Plug-pulling' is that there are two separate individuals involved. The kamma of the individual under care is that individual's own kamma; the kamma of the caretaker is the caretaker's own.

The decision to supply life support mechanisms can well be made on a judgment as to the patient's clinging to life and fear of death: if, seeing hope of recovery and the attaining by that of opportunity for the lessening of the patient's fear of death and clinging to life, the life sustained by life-support mechanisms will have been greatly benefited and all is well and good. It is a decision that will have made good kamma for the caretaker.

The decision to terminate life support mechanisms must be very carefully made such as to be sure that what is intended is not 'termination' of life, but termination of life support. (Simple: keep in mind the idea that the person might not need the life support to continue on living.) This decision could also be made based on the criteria outlined above with the idea that providing life sustaining mechanisms would be a beneficial thing only for as long as there was hope that by such mechanisms the individual seen to be greatly clinging to life and fearing death would be given further opportunity to mitigate the fear and lessen the clinging. In the case of one in an irreversible coma or vegatative state there are no signs for the caretaker to judge, so the decision could be made at any time that it was time for the patient to face their kammic fate. There is no further benefit to be seen in sustaining the life of the patient and there is no further good kamma to be got from the situation by the caretaker. There is no bad kamma in making the decision to pull the plug.

So in a word: With the intent to 'terminate the life' of the patient by withdrawing life support: bad kamma. With the intent to 'terminate life support': no bad kamma. With the latter the continuance or non-continuance of the life of the one cared for is a matter of that individual's kamma and has nothing to do with the caretaker.




There is another issue here that is being neatly avoided by Doctors and Healthcare practitioners. In most cases the decision to give life support in the first place will have been made by them. It is just shucking responsibility for a tough decision for them to then put this decision into the hands of a relative or caregiver (with or without power of attorney and advance directives.) "You made the decision to sustain life, you make the decision you think you are making if/when you pull the plug." That's what we ought to be able to say, except that the humongous costs of healthcare in this country stick extraordinary complications into the decision. The Doctor gets to make the decision to turn on the meter, if you alow or force him to make the decision to turn it off it could likely bankrupt you needlessly...we won't go into the possibility that it might terminate the life of a loved one when there was still hope for recovery.



[1]This is interesting, but let's face it: most of those of us encountering this problem are not going to be encountering it in the form of an Arahant or even, likely, a Buddhist, consequently, from the Buddhist perspective, there is hardly anyone out there today that could be said to be anything less than absolutely clinging to life and fearing death, so this list is presented more as a way of making the issues rational than as a useful tool in determining anything helpful concerning this decision. If you can see from this list that one you are caring for has little clinging and fear, then this is a plus for you and makes the decision-making here much easier.

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