moralobjectivity.net: home page moralobjectivity.net discussion forum 'A New Buddhist Ethics' contents pageA New Buddhist Ethics
copyright Robert M. Ellis 2008. Also available as a paperback book or pdf download.
copyright Robert M. Ellis 2008. Also available as a paperback book or pdf download.
Chapter 8: Medical Ethics
We now finally reach an area which for many people typifies “moral issues”: difficult life and death decisions made on the frontiers of human life, often in the context of a hospital and involving medical personnel. Unless we work in some branch of medicine, such problems are not everyday fare for most people. However, it is well worth having thought about them in advance, for when such issues do arise, they may be unexpected and dramatic. For philosophers, too, these issues exert a fascination which arises from the apparently intractable moral difficulties they pose. I will be arguing that, in the light of the Middle Way, such issues do not need to be intractable, for they are only turned into impossible riddles by the dogmatic assumptions with which they are often approached. Much Buddhist discussion of these issues so far has simply got dragged into these unnecessary assumptions, especially when they can be superficially justified by traditional Buddhist material.
The central question of medical ethics is that of the value of human life, when this value is brought into question by having to be weighed against other things we value. For example, in the issue of abortion, the worth of a human foetus has to be weighed against, say, the health, freedom or other needs of a woman wanting an abortion. When deciding whether to give medical treatment to a patient who has only a small chance of benefiting from it, a doctor has to weigh up human life against medical resources (such as staff time and money) which could be given to other patients. How much is human life worth in these circumstances?
Particular difficulties have been caused in medicine by the moral tradition that human life, in itself and regardless of other things that accompany it, is the prime good which outweighs everything else. Some people believe this because they believe humans were designed by God to have a special status, others by a confused over-application of the general rule that it is good to treat others with respect and not to harm them (like the First Precept in Buddhist tradition). However, if we avoid the dogmatic assumptions in these positions and try to identify exactly why we tend to think of human life as good, it is only because of other things such as human self-consciousness, human potential and human participation in society. These are attributes which humans can develop, and which humans sometimes lose before their deaths, but they are not an inevitable part of being a living creature with human genes. We need to distinguish, then, between human beings and persons. Human beings have a certain set of genes, but persons are worthy of a certain moral respect because of actual or potential attributes which are specific to humans.
As I have already argued in chapter 3 in relation to contraception, I believe it is important for Buddhists to make a clear choice in rejecting some traditional Buddhist beliefs here which contradict more important core Buddhist teachings. We cannot be justified in treating all human beings as persons, even if they are only fertilised eggs (at one extreme of life), or in a persistent vegetative state when only their brain stem is operating (at the other), simply on the grounds of a dogmatic metaphysical belief about rebirth which has no practical relationship to our experience.
Not only are such beliefs entirely speculative and hallowed only by tradition (or by evidence which is open to many other interpretations), but the assumption that rebirth operates in precisely this way, with a garbha entering the fertilised egg at conception and leaving only after brain death, is also speculative. It contradicts not only the Middle Way as a general principle for judgement, but the doctrine of anatta, which implies that personhood cannot be assumed to exist in any such fixed forms. Personhood, on the other hand, is a conventionally recognised moral category dependent on our experience of people as having a certain moral status.
The assumption that all humans are persons, then, is an eternalist view, not a Buddhist one. It is thus not always automatically right to put human life before all other priorities, before first considering why and how that human life is valuable, and how it relates to personhood.
On the other hand, however, we also need to avoid the opposed nihilist view about human life, which does not give it any particular value, and regards all values as contingent. In this type of view, if its suits society to get rid of tiresome old people, it will be acceptable to do so. Similarly, if a woman wants an abortion, why shouldn’t she have her desire? In this type of view it is only individual desires and/or social conventions which decide ethics, so we have no right to judge wrong the actions of, say, the ancient Spartans in exposing weak infants on mountainsides. Nihilistic ethics may not respect persons, let alone human beings.
If persons are not absolute, metaphysical things, then, how do we know who or what is a person? We do not know absolutely, for “person” is a convenient label we give to a bundle of characteristics which are actually both debatable in nature and varied in intensity. A foetus, and perhaps a young child, is on its way to becoming a full person, and has many of the attributes we would normally recognise in a fellow adult person to some degree, but not others. In many situations we simply have to respond appropriately, treating the creature as a person in the respects in which it seems to be, but not in those in which it does not. When it comes to life-or-death decisions in medicine, though, we probably need a generous definition of a person which makes it clear who is worth saving, perhaps drawing on a whole bundle of attributes which we conventionally accept as those of a person: consciousness, self-consciousness, language use, reasonable potential, and social recognition might be amongst these.
Some examples might begin to make this clearer. An unconscious dying patient in the last stages of a terminal disease has no consciousness and no reasonable potential. Only social recognition, which here might mean the feelings of his friends and relatives, provide much reason for prolonging his life when he is continuing to take up medical resources. A fertilised human egg likewise has no consciousness or other human qualities: only a potential for them which is so far quite marginal. Though this potential would still justify us in treating the fertilised egg with respect, we probably do not need to treat it as a person. A 24-week foetus, on the other hand, has developed its potential much further and has begun to develop some consciousness: we would be much more justified in treating it as a person.
These are examples from medical ethics, but these general principles also have further implications for our attitudes to animals and possibly other sentient beings (such as computers and aliens). A chimpanzee who has learnt to use sign language, say (like the famous Nim Chimpsky), would have many of the conventional attributes of a person, and should thus be treated as such, as Peter Singer has convincingly argued. Similarly, a computer which was recognised as genuinely self-conscious (and here we enter philosophically very dangerous terrain, which I will not go into further here), should perhaps have some of its attributes as a person recognised by society.
I would not claim to have identified a determinate bundle of attributes for personhood here: they are a matter for continuing debate. What I do think is important in approaching issues of medical ethics is the recognition that personhood is conventional and yet still morally valuable, and that different beings can possess it to differing degrees. If we can avoid the twin dogmas either of the absolute value of humans or the non-value of persons, there will be a practical way forward which recognises the conditions at work in specific cases. However, the basic reason why it will be important to respect the lives of persons will remain the need to extend our ego-identifications. The first Buddhist precept (not to harm living beings), interpreted in this way, provides a training programme in extending our ego-identifications, first towards other persons, and secondly also towards those beings who share some of their characteristics to some extent.
Medical priorities become a moral issue when there are insufficient medical resources available to meet the needs of everyone who wants treatment or who would benefit from treatment. By “medical resources” here, I mean not just money, but trained doctors, nurses and other medical staff, and physical requirements such as beds, hospital infrastructure, operating theatres, drugs etc. The extreme type of situation where this kind of problem comes most to the fore would be a small local hospital suddenly overwhelmed by a natural disaster or a huge battle nearby, but the problem of medical priorities also affects hospitals and other medical facilities all the time when they have to deal with budget cuts, staff shortages, or simply a health service that is inadequate for the role the public require of it. We are generally assuming here a health service that is publicly funded either directly, as in the British NHS, or indirectly through a state health insurance system; but even in private hospitals there can be dilemmas of this kind.
Prioritising medical care is a perennial problem in health, because many people are suffering and the resources available to alleviate their suffering are limited. In many ways this is a situation which simply reflects the First Noble Truth in Buddhism, which suggests that suffering (or, at least, frustration) is likely to continue despite our constant attempts to avoid or alleviate it. Whenever a patient dies, the most conscientious medical staff may ask themselves whether with a bit more effort they could have been saved: perhaps they could in some cases, but even the greatest effort possible will not save every life or relieve every pain. Medical resources are finite, and will always be inadequate to the task (as some might mistakenly conceive it) of removing all suffering. Reconciling themselves to this situation must be a basic requirement for medical staff.
This problem has become increasingly acute in recent years, however. This can be seen in the UK, where at the time of writing (2006) the government has massively increased the healthcare budget, but still finds that many of the local healthcare trusts are in debt and laying off workers. The main reason for this seems to be the constant development of medical technology, enabling new and often expensive treatments which patients then expect to receive if it can help their condition. Throughout the developed world, the treatments which have become possible (and patients’ expectations of receiving them) are rapidly accelerating past what can be practically and economically sustained by health services.
So, this then creates a constant problem of who to treat first, or who to favour with limited attention or facilities. In the previous section I have already discussed some of the dogmas with which this judgement can be approached. One is that priority should always be given to saving human life. This would mean, for example, that health services would always give priority to areas like emergency treatment, heart surgery, cancer treatment, and intensive care for premature babies, even if that meant no treatment at all for areas like hip replacement, ante-natal care, physiotherapy or health education. Clearly, as I argued in the last section, if we think about the reasons why human life is good, it is the quality rather than the mere presence of human life which is of moral importance. Treatments which maintain the quality of human life, then, must be balanced with those which merely maintain its existence.
The other side of this point is that treatments which merely maintain human existence, but do not contribute at all to quality of life, whilst using medical facilities needed by others, should not be continued indefinitely. This means that it is OK to turn off a life-support machine for someone who is only being kept technically alive by that machine, and has no chance of recovery. There is also a point at which medical staff are justified in giving up trying to revive someone whose heart has stopped beating, or discontinuing a course of chemotherapy which is failing to prevent the spread of cancer.
Often this view of the debate between human existence and quality of life is identified with utilitarianism, which lies on the other side of the debate against those who would always prioritise human life. Utilitarianism suggests that we can resolve issues of medical priority simply by calculating the benefits on each side of the scale, and choosing the course which leads to greatest pleasure and least pain for all concerned. Some medical ethicists even use a system of QALYS, or quality-adjusted life years, to work out who would get most years of relative pleasure out of a treatment which has only limited availability. For example, if there was only one kidney available for transplant and two possible recipients, one a person of 30 who was otherwise relatively healthy, the other an 80-year old who was likely to die soon anyway of a heart condition, this kind of utilitarian reasoning would indicate clearly that the 30-year old should be given the kidney, because he stood to gain many more years of relative pleasure from it. This would be the case even if the 80-year old had been waiting longer for a kidney.
In the first chapter I have already discussed some of the limitations of utilitarianism, which come to the fore here. Amongst these are that it relies on limited human judgements of what will occur in the future, and that it relies on a limited idea of pleasure which does not take into account change and development of pleasures. The solution to the kidney problem above in many ways seems practical and sensible, but our perception of the example might be entirely changed with another layer of information. Supposing that, despite his heart condition (which can be controlled for now), the 80-year old is predicted by her doctor to probably live another five years of reasonably active life. She is also a very positive person loved by everyone, and is responsible for the upbringing of her 12-year old granddaughter following the death of her parents. The thirty-year old, on the other hand, despite his relative physical health, is a socially isolated alcoholic in a severe state of depression who has attempted suicide several times. Perhaps our sympathies have now switched, but perhaps yet another set of details about these people would change our sympathies yet again. Our perceptions of them are always going to be limited by the horizons of our knowledge and by our preconceptions.
So, judging such issues by “quality adjusted life years” is hardly likely to provide a judgement adequate to the conditions. Yet these judgements have to be made, so on what basis should we make them? From a Buddhist point of view, the purpose of human life is not pleasure but spiritual development. Yet potential for this is even harder to judge than future pleasure or quality of life, even if those who need to assess could agree about it (which is unlikely). Any solution has to maintain the goodwill and participation of all involved rather than simply impose what others may see as a religious dogma. So, we need a method of judging priorities between human lives which is likely to be accessible and acceptable to all, but less restricted and mechanistic than utilitarianism.
I can only briefly sketch here (very provisionally) what I think this might be. As I suggested above in relation to personhood, I would suggest that the solution is to use a whole bundle of likely factors, rather than one mathematically quantifiable one. Like the characteristics that make up a person, or the strands in a rope, none of these would be essential but together they would guide judgement. In the case of the two possible kidney recipients, we might want to look at social relationships, attitudes to oneself and others, dependent relationships, positivity of outlook on life, and other such factors as well as health, expectation of life and waiting time. A committee, or even an individual, might have to make such decisions relatively quickly, but they might do this through consensus in a way which allowed intuitions as well as reasoning to applied, but involved a check-list to help make sure that as many relevant conditions as possible were considered. There might be some situations, though, where there was no time to do this and we might simply have to rely on the judgement of a person who was both trained and virtuous.
Not all dilemmas of medical priorities are to do with how much priority one gives to saving a life. Some are also to do with long or short term treatment, or with prevention as opposed to cure. Here there are sometimes dogmatic assumptions in the model generally used in Western medicine, of a kind which have often been noted by Buddhist practitioners exposed to Eastern alternatives. Western medicine tends to concentrate on curing problems using a “magic bullet”: a specific drug or other treatment which will deal with an isolated problem in the body. However, the body is an interdependent system, and the “alternative” forms of medicine tend to be more holistic, trying to build up the conditions of health and prevent disease in the long-term.
The drawback with such systems (like Buddhist practice itself, which could be seen from the angle of therapy) is that they are more difficult to test. A double-blind test can help determine whether a particular “magic bullet” hits its mark and cures the patient of the problem. However, a system which merely aims to maintain health is very difficult to distinguish in its effects from other background conditions. If I do yoga for 5 years and in that time maintain good health, is it because of the yoga, or is it the zinc pills I took as well, or is it the satisfaction I get from my job?
We cannot resolve issues of priority between prevention and cure just by demanding evidence of the success of prevention and comparing it to the success of cures. This is not because there is no possible evidence of the success of preventive approaches, but because the standards applied to that evidence have to be set by the individual in relation to his/her life as a whole. I could set a time in the future when I would assess for myself whether preventive medicine had helped so far and decide whether to continue with it, and this would involve judgement based on time-framed evidence, so it would not just be dogmatic, but it would be far from scientific in the way demanded by Western medicine.
So, the obvious conclusion to draw here is that we need both prevention and cure, with a balance between them. To insist only on one without the other would be dogmatic. On some occasions we need life-saving operations of a kind which preventative medicine could never offer, whilst in others many minor illnesses which cannot be successfully “cured” would have been much better addressed in the context of general health, including both mental and physical well-being. However, given the current crisis in the provision of Western medicine which I noted at the beginning, perhaps the emphasis needs to swing back much more to prevention than has been traditionally the case in the West. Many medical problems are related to stress, inactivity, or a lack of purpose in modern life which require a spiritual rather than a medical cure.
Few moral issues create more entrenched and dogmatic argument than this one, and very often the positions fought over are ones very far from open-minded consideration of the conditions in which abortion may be contemplated. Usually those conditions involve a suffering woman with an unwanted pregnancy, and a developing foetus. The issue is certainly a legitimate topic for philosophical argument which aims to clarify the judgements that might be made, but from a Buddhist point of view the first philosophical task should be to disarm the dogmas which keep the two sides from understanding each other and keep them from approaching more of the realities of the situation. It is distressing to see that much Buddhist literature on this topic still merely condemns abortion through a purely deontological appeal to the principle of non-violence, and to traditional rebirth doctrines supporting the claim that the foetus is a person from conception (already discussed above in this chapter, and in chapter 3). These two dogmas put together prevent traditional Buddhists from considering what evidence experience actually gives us as to the nature of the victim and of the perpetrator of that violence, and thus developing a more adequate understanding of the degree of moral blameworthiness in that violence.
So, on one side of the abortion ring we have the eternalists, who claim that the foetus is a person from conception for a variety of dogmatic reasons, and in this case include the traditional Buddhists mentioned above. This position implies that all abortion is the deliberate and premeditated killing of a person, and thus that women who have abortions (and the doctors who do the job) are murderers or accessories to murder. I have already discussed the problems with this position in the “value of human life” section above, where I argued that there is no absolute metaphysical basis for a person, only a conventional one. The Buddhists who oppose abortion by appealing to rebirth, then, are ignoring the implications of the doctrine of anatta. The conventional basis for judging the nature of a person is debatable, but it is clear that conventional personhood only develops gradually.
In the earlier stages of pregnancy, the characteristics that we might even conventionally judge as those of a person involve only the foetus’s potential, with perhaps also its gradual development of a recognisable human form. The potential of the foetus to become a recognisable person increases in strength as it clears the hurdles of development and its full development becomes more likely. One could obviously place differing degrees of value on this potentiality, but mere potentiality is clearly a value which falls short of full achievement. I do not treat an acorn like an oak tree, nor a brilliant student as the university professor he has the potential to become. Sperm and eggs by themselves are also potential persons to a slightly lesser degree than fertilised eggs, but for some reason we do not seem to consider this potentiality much, and perhaps with good reason. Potentiality alone may provide us with a strong reason to treat the foetus with a respect which increases as it develops, but not to treat it as a person.
The development of a recognisable human form may make a strong emotional impression, but this is a response we might also have to a doll. Biologically, a recognisable human form tells us more about the foetus’s genes than about its degree of personhood. Still, it may be a factor to take into account that, arguably at the age of around 10 or 12 weeks, a foetus starts to look human.
In the later stages of pregnancy we might also want to take into account the developing consciousness of the foetus. There is evidence, for example, that foetuses can recognise music and voices, at least by the time they near birth. This puts the foetus by this stage at least on the level of an animal with equivalent levels of sentience, and might make us increasingly inclined to recognise its personhood. Even by the time of normal birth at 40 weeks, however, the foetus lacks many of the normal features we would ascribe to persons, such as self-consciousness, and it is only after birth that it is given full social recognition as a person, and formally given a name.
So, although the details of exactly what conventional attributes of personhood one accepts and to what extent the foetus has them are arguable, the general picture emerges of a being which is gradually turning into a person. At the time at which an early abortion might happen (8 or 10 weeks), the foetus does have the beginnings of some of the features of personhood, and by the time a late abortion might occur (16 or 20 weeks) it has more and stronger, but probably still not enough to accord full personhood. On this basis, then, we could conclude that an early abortion is an act of violence against a living human being (which would need a very strong moral justification), but it is nowhere near a murder. A late abortion comes rather nearer to a murder, and perhaps might be seen as never justified except in the most extreme cases.
To consider the strengths of the possible justifications for abortion, however, we have to look at the other side of the story and the opposed dogma. The nihilist position typically does not accord any moral value to the foetus, but concentrates only on the rights of a woman to deal as she wishes with what is described as part of her body. This “woman’s right to choose” is nihilistic because its sources of value are nothing higher than individual wishes and conventional acceptance. The argument implicitly goes something like, “Because I want to dispose of this foetus, and at least the part of my society in which I move thinks it’s acceptable to do so, everyone ought to accept it as such and not interfere”. No higher moral claims which take the foetus into account are accepted. This position is every bit as dogmatic as the eternalist one, and it ignores the foetus as doggedly as the eternalist position ignores the woman’s needs.
The woman’s needs, however, are clearly part of the overall picture and part of the conditions at work, even if they don’t have the absolute status implied by the “woman’s right to choose”. A woman considering an abortion is also right to identify with her own needs as much as those of the foetus, though taking into account their different natures.
Where the woman’s need requires that she stop being pregnant because of its effects on her health, it is difficult to argue other than that abortion is justified. There is no alternative way of ending the pregnancy than abortion, and her needs unavoidably take precedence for much the same reasons that I argued in chapter 6 that human needs take precedence over those of animals for purposes of medical experimentation. Even if the woman merely does not want to be pregnant, perhaps this might justify a very early and prompt abortion (or the use of a morning-after pill), and her moral offence is probably less than that of eating a fish, or setting a lethal mousetrap.
Where the woman’s needs or wants involve not having the responsibilities of motherhood, though, the case is much weaker because there are alternative ways of ensuring this through adoption. That it is very difficult for mothers to give up a newly-born baby for adoption should be taken into account, but, if it is traumatic for her, it is certainly less traumatic for all concerned than an abortion. It is only if adoption is an impossible option that abortion might be justified in such a case. The case of a heavily disabled foetus that will require huge amounts of care may make adoption impossible and thus create such a situation.
Such is a brief attempt to weigh up the worth of possible justifications for abortion, and to weigh them against the claims of a foetus which is only developing into a person. However, it also needs to be remembered that abortion is an act of violence, and as such it will affect not only its victim but its perpetrator. As I argued in relation to animals in chapter 6, violence is likely to have a brutalising effect on the perpetrator which needs to be taken into account, even though this does not mean that violence is never morally justified.
In the case of abortion, the violence is done against a being with whom the relationship is so intimate that it shares the bounds of one’s body, and with whom (unlike a parasite) one also shares a very close genetic relationship. If such a being is not consciously close to the centre of the woman’s identifications, it will certainly be unconsciously so. Some of the psychological impact, then, must be something very close to tearing out a piece of oneself. That it can create long-term psychological traumas is thus surely not surprising, and is ignored by a woman deciding to have an abortion at her peril.
Much of the reason for avoiding any kind of abortion, then, (but, again, especially later abortions) involves reconsidering superficial ideas of the boundaries between ourselves and others. Abortion is often wrong not because it is “selfish”, or primarily because of its effect on the foetus, whose moral status is at the most not much higher than that of a higher animal. It is often (though not always) wrong because of the attitude to oneself which it reflects, and the way in which it is liable to set up conflicts within a woman’s own mind, of the kind which Buddhism primarily aims to address. Again, if not to have an abortion would set up still bigger conflicts, this point is overtaken, but the reason needs to be a strong one.
To sum up, then. Most of the traditional reasoning about abortion, both for and against it, is built on nothing but dogma, so the first task of a Buddhist thinking about this topic is to strip this away. Without this dogma impeding our thinking, we find a gradually developing foetus which is not even conventionally fully a person. This foetus should be respected as far as possible because of its development towards personhood, but if there is a strong conflict of vital interest with its mother, it is clear that the mother’s interests are more important. The mother’s interests, however, may prove to be broader and more far-reaching than was initially thought, and a concern for the long-term effects of abortion on the mother militates against it. So it seems clear that no abortion should be undertaken lightly without very strong justification, and that we must allow for our tendency to underestimate the long-term effects of such a violent deed, but that if abortion takes place, late abortion is much worse than early abortion.
From the situation of women who are pregnant and desperately don’t want to be, we pass on now to women who are not pregnant, and desperately want to be. The artificial aids which have developed in recent years to help them become pregnant have some degree of moral debate around them still. Depending on the nature of the fertility problem, the treatments can include sperm donation, egg donation, in vitro fertilisation (IVF), and surrogate motherhood. Developed only a couple of decades ago, IVF is now very widely used when other means of conception have failed.
The best starting point for this topic is probably the section on having children in chapter 2. There I suggested that there is no duty to have children, and that overpopulation should lead us to have children only if (and to the extent that), we really wish to do so and we’re happy for other people to do so as well, also provided that we are likely to be appropriate parents. Nevertheless, at that point I noted that some people have a very strong drive to have children which can hardly be ignored. These are part of the conditions at work in the world, and it is to meet these conditions that reproductive technologies have developed, even if it seems ironic that they have done so at a time of burgeoning population problems.
There is thus a strong case against fertility treatments and the justification for using them, based not on their innovations in the manipulation of human reproduction, but on their being a completely inappropriate use of resources. Much time and money have gone into the development of reproductive technologies, taking doctors and other resources away from other forms of medical practice, to encourage people to do what we should be strongly discouraging them from doing – reproducing. The development and practice of fertility treatments seem to be taking place in wilful ignorance of the wider context. A comparison might be with someone putting in huge amounts of effort to design cars which consume even more petrol in order to go even faster and produce even more pollution, in the midst of concerns about global warming etc, just because people want it. This is not an unlikely scenario (there is probably somebody doing it), but it’s hardly morally justifiable!
The natural response to this comment will be to return to the strength of the longing that some people have to have children, so strong that they feel unfulfilled and incomplete without them. It may be urged that they actually suffer through not being able to have children, and that fertility treatments are a response to this which is not very different from trying to treat a disease. Even if we accept this claim about the extent of their suffering, this is still not an adequate response because there are other ways of addressing such people’s suffering. The most obvious of these is for them to adopt a child, or at least partake in fostering or help to look after other people’s children.
This solution is not adequate for many because of their feelings of possession about a child, which is strongly associated with the ego. It must be their child, passing on their genes. This inability to come to terms with infertility (suggesting very fixed ideas about one’s own identity), plus this strong identification with one’s own child, on whom so much will then be loaded, are working against the breaking-down of ego-identifications and building up unhelpful boundaries.
All this suggests that anyone thinking of using fertility treatments should think again. However, it needs to be noted that there is a scale of complexity in fertility treatments, and near the bottom of it the justification for going to some lengths, but not too extreme lengths, to have a baby may be stronger. Artificial insemination with donated sperm, for example, is a simple procedure which enables lesbians (who may be very good parents, apart from this practical problem in conceiving) to have children. The main difficulties seem to be around the rights of children to know the identities of their biological fathers when they were sperm donors. Sperm donation is plainly an act of generosity, because it now involves the possibility of being contacted by future children after they have grown up, even if there is no legal possibility of being held responsible for the upkeep of children. Very similar issues apply to egg donation, although this is more invasive and complex.
It is when we get as far as IVF and surrogate motherhood that there seems to be almost no moral justification. IVF is in any case a drawn-out and chancy business for those who undertake it, with no guarantees that it will work. It involves the likelihood of producing “spare” embryos, which are then frozen in case needed, and eventually discarded or used for research if not: this is not as much of an issue as some “pro-life” campaigners have made it, perhaps, but still an undesirable side effect in which living human beings may die. It involves huge amounts of medical resources with still a high chance of continued frustration for the couple involved.
If IVF is then used with surrogacy, another woman is paid to carry the foetus to the term of the pregnancy, but is then expected to give up the baby to the sponsoring couple (who will probably also be the genetic parents) on its birth. Like prostitution, this practice can involve a coercive use of economic power over a woman’s body and most intimate feelings, and the likely trauma of having to give up the baby at birth can hardly be overestimated. That anyone should want to go through such a distasteful and possibly coercive business in order to do something which works against the world’s benefit can only show a great lack of sensitivity and awareness of the broader context.
So, it seems that an attempt to confront the conditions around fertility treatments without dogmatic assumptions, and attempting to extend our awareness and identifications, can only lead to a thumbs down, at least to anything more complex than artificial insemination. The occasions when IVF and surrogacy would be morally justified are perhaps not beyond the bounds of possibility, but are very difficult to imagine.
The transplantation of organs from one body to another has been technically possible for several decades now. The medical technology continues to develop, success rates have improved dramatically, and the practice is now widespread. Organs are most often taken from recently-dead bodies, or bodies that are only being kept technically alive to keep the organs in good condition although death is inevitable; but sometimes also one of the two kidneys (surplus to requirements) can be taken from a living donor, usually a close relative. Kidneys, livers, corneas, hearts, and hearts with lungs, are all now often transplanted in this way.
The process raises a number of potential moral issues. The most basic one is whether there is anything wrong with accepting an organ which is not needed by a donor and incorporating it into one’s own body. This is not quite the same as accepting some other piece of less intimate property, either as a gift or as a legacy, and care is needed because of the sheer strength of our instinctual attachment to our bodies, to avoid the possibility of later regrets by a living donor. However, donating one of your kidneys to someone else is a remarkable act of generosity. Giving consent for your organs to be used after your death is also an act of generosity, in which you are forced to acknowledge the future reality of your own death and the fact that you will no longer need those organs. Organ donation, then, seems to usually be a praiseworthy act which should be encouraged, both as an act of generosity, as a practice of letting go of attachment to things we do not really need, and as a way of acknowledging the impermanence of our bodies. If we receive such a freely given organ, we need have no moral concerns, for far from coercing others we have given them an opportunity for generosity.
Concerns have sometimes been expressed about the effects of having someone else’s organ in your body. Medically, of course, this means that one needs to be kept on anti-rejection drugs which could continue to have side-effects. However, this still seems far preferable to not receiving an urgently needed transplant. Psychically, there are various mysterious stories in circulation about people gaining character traits or memories from the organ donor via the organ. These sorts of stories certainly need more investigation, and there may be conditions at work here which are not recognised by science. However, there is perhaps not enough clear evidence yet for this to give rise to serious concern for someone badly in need of an organ.
The other problematic area where accepting donated organs is concerned is where the organs have not been freely donated. In some circumstances organs can be stolen from those who are unwilling: for example, it is the Chinese practice to sell the organs of condemned prisoners who have received capital punishment. In many other cases organs are sold by poor people in the developing world and bought by richer people. Both of these kinds of cases can be seen as taking the not-given because of the coercion involved, either physical or economic.
A condemned prisoner conventionally owns his/her body (just as he should own his other property and his life), so that unless he gives consent to the use of his organs, using those organs is giving systemic support to both capital punishment (which I will consider in the next chapter) and theft. So we should not just consider the short-term consequences here, in which the executed prisoner certainly does not suffer any more than they would otherwise have done, but the long-term consequences in encouraging capital punishment by providing the executioners with a lucrative sideline.
Buying an organ from a poor person might help to give them individual short-term relief, but is systemically creating or supporting a system of exploitative trading (see chapter 4). Perhaps, in line with my suggestions for overcoming unjust trading in chapter 4, the best response here is not to refuse to buy the organ, but to also consider the wider situation of the seller and pay far above the market rate, using the excess to try to make sure that the need to sell organs does not arise again.
Some philosophers have argued that there is no reason why organs should be handled any differently from other objects of human need, and that there is nothing intrinsically wrong with trading them. Whilst they may be correct that it is not intrinsically wrong, the intimacy with which we relate to our organs (comparable to the intimacy of sex when sexual services are traded – see chapter 3) means that the scope for coercive practice and invasion of human dignity in organ trading is that much higher than it is in trading most other goods. The system in the UK (and many other Western countries) of organs being only freely donated seems far preferable in discouraging exploitation and the egoistic barriers it produces.
The problem in the UK at present, though, is a great shortage of donated organs. Many usable organs from corpses are not used because the person has not signed a consent card (or registered his/her consent) before death, or because relatives object to the use of organs. As a result of this many needy recipients do not receive organs in time, and some die because of this. It is argued that since very often consent is not given only because of laziness and ignorance, the law should be changed so that consent is assumed, and the organs automatically used, unless an objection has been explicitly made. This system is already being used with apparent success in some other countries.
The possible drawback of this system is that it might be seen as at least mildly coercive. If we should respect the wishes of the deceased in the case of the executed Chinese prisoner, discussed above, surely we should also do so where a person has not given consent to the use of their organs? The difference here, however, is that the Chinese prisoner would probably have withdrawn his consent had he been given the opportunity to do so. In the “opt-out” (as opposed to “opt-in”) system proposed, anyone who wants to withdraw their consent can do so. Assuming that their organs can be used when they have expressed no clear wish is thus not coercive in any way, though it takes advantage of an ambiguity. There seems to be no reason to oppose such a reform to UK law, which could certainly have the effect of saving lives, for in the absence of any expressed wishes, and given that the dead person really does not need their organs any more, it seems quite justifiable to adopt the most helpful and generous interpretation of the situation. In the process we would probably be avoiding too much dogmatic attachment to the idea of consent at all costs.
Perhaps the strongest objection to transplantation as a medical practice is connected to its sustainability. It involves very complex and expensive operations using a lot of resources, relative to most other types of treatment. At the beginning it also had very low success rates, and when successful might only provide the recipients with a few more years of life, though this record has steadily improved and may well continue to improve. Heart transplants and heart/lung transplants are perhaps the most risky and expensive of all the operations, and thus the most questionable from this point of view. However, we have to take into account that surgeons have to begin with low success rates in order to develop a medical technology which may subsequently reach more acceptable success rates. The idea that we should always pay for expensive treatments indefinitely, however, especially when there is not much chance of such improvement, involves the absolute priority to life dogma discussed in earlier sections of this chapter, and more balanced approaches are needed.
Up to now it seems that medical systems in developed countries have on the whole managed to sustain this expense, even if it could be argued that it diverts money from simpler treatments needed by the poor in the developing world. Whether all future developments of transplantation technology can be sustained in a similar way is another question. Perhaps it might be justifiable in future to require additional means-tested contributions from the recipients towards transplantations and other highly expensive treatments, which are then used not only to help support the cost of the transplant, but also to support other areas of medicine which have been less well-resourced because of it.
Euthanasia is the deliberate killing of another person in the belief that this will be better for them than being alive, usually to relieve suffering and usually by medical personnel. It must be distinguished from suicide, where a person kills themselves (though this is sometimes only a technical distinction). It seems, on the face of it, to offer an exception to the generally-accepted moral rule that it is wrong to kill someone else. It is probably important to start here with the question of why killing another might be wrong from a Buddhist point of view, to then see whether killing to relieve suffering might be a justifiable exception.
In the Buddhist first precept, one accepts the training principle to avoid striking living beings. This is generally understood to include killing, non-lethal violence, and any kind of deliberate harm. There are obvious reasons why this precept might be morally helpful. By doing violence to someone I cut myself off from identification with them in the most dramatic way, causing suffering which I must then be remote from. I assert my ego and cast another completely beyond its boundaries, closing the gates of human sympathy. I also enclose myself in the delusion of separateness from the person I strike, and probably launch a cyclic pattern of conflict in which we will continue to harm each other. Killing is the worst form of violence because it does this to the greatest extreme. I cut myself off from another to the extent that I have no identification at all with him and so become capable of annihilating him. I do extreme violence to my own capacity for sensitivity and sympathy, creating the likelihood of huge inner conflict and guilt, and am likely to cause even greater external conflict because of the reactions of others to the murder.
Euthanasia involves killing, yet on the contrary none of these reasons for the wrongness of violence and killing apply to it. Far from cutting myself off from identification with another, when committing an act of euthanasia I am likely to be in a state of enhanced identification with them, in which I am strongly concerned with their suffering. Far from creating conflict, I may end the conflict between the dying person’s wish to end their suffering and their sense of a duty to live, and bring relief rather than resentment to their friends and relatives. From the eternalist (e.g. Christian) perspective, then, euthanasia is wrong because it is killing, yet if we look at the reasons why killing is wrong, none of them apply to euthanasia. Rather it appears to be a praiseworthy and compassionate act involving the exercise of both sensitivity and courage.
From the other side of the debate, however, there are also nihilist attitudes (often associated with utilitarian argument on this topic) which are similarly to be avoided. These are likely to involve the denial of any values involved in the decision for compassionate killing than the wishes of the person and/or (especially where they cannot express their wishes) the avoidance of pain which we would assume they would prefer to avoid. This attitude can also neglect important conditions: a person giving consent to their death is not always a straightforward matter, and pain is not always negative in its effects or to be automatically avoided.
Firstly, in cases of voluntary euthanasia (where someone chooses to be killed), the fact that they have consented to their death, and expressed that consent, is essential to the justification. Conventionally, to consent to something (say a walk in the park), a person only has to clearly say that they desire it, and we feel justified in assuming they have consented to it. However, the Buddhist doctrine of anatta, and the fragmentation we probably discover in ourselves when we try meditation, makes it clear from a Buddhist standpoint that we are often confused and inconsistent about what we want. How consistent we are depends on how much we have succeeded in integrating our ego with other parts of ourselves. In a matter of deciding one’s own death then, at a time of great physical pain and stress, it is quite likely that we will be even less integrated than usual. We can try to guard against this legally by requiring several requests for death in front of witnesses, but morally perhaps the only way of determining how much someone really wants to die is on the basis of a judgement of how integrated they are. A person who is clear, rational, and requests death through compassion for themselves is one who has really consented. One who is gripped by fear and only wishes to escape, however, perhaps cannot be taken to be really consenting until they repeat their request in a calmer state of mind.
Secondly, pain is not always negative, and it is not always automatically right to avoid pain. There are many instances of pain leading to useful outcomes, such as undergoing dental surgery, and when a person is approaching death, their acceptance of their pain and of the prospect of death may have a hugely positive spiritual outcome. Keeping the person continually on strong painkillers such as morphine, which also dull the mind, as well as encouraging them to prematurely end their experience of pain, may prevent this spiritually positive outcome occurring. We do not have to think of the value of such spiritual progress before death in terms of rebirth, but of its value in itself in concluding a life, and of its enormous effect on other people, who are likely to be paying close attention at the time of the death of a close friend or relative.
Another way of putting this is that pain should not be merely rejected as an enemy. Our rejection of our pain is a rejection of an aspect of ourselves. If voluntarily embracing death, then, is a negative action which is primarily a way of getting away from pain, then it may be the avoidance of our final opportunity to break through the limiting bounds of our ego. If, on the other hand, a request for death is simply one which involves an acceptance of death and a recognition that further struggle will be useful, this is facing up to the conditions rather than rejecting them, and needs to be encouraged as a step forward.
On the other hand, if someone does not have the character or the spiritual resources to benefit from pain in this way (which may be in the vast majority of cases), then it is far better to allow them to end their lives with relative dignity before the pain gets worse. Many people respond to pain only with fear and rejection, and we should take this into account too in our thinking about euthanasia, allowing them a way out if they request one with relative clarity and persistence.
So, it should be clear from this that nihilistic approaches which talk merely of a “right to die”, or of a life which is no longer worth living (because its pains so much outweigh its pleasures) are missing the point. If a painful process of dying enables us to overcome our limited and deluded states, then it is a valuable one. Our approach to euthanasia needs to be flexible enough to take into account this possibility, even if it only emerges slightly. In between the calm deaths of great saints (who would not dream of requiring a faster exit), and the frantic deaths of the heavily deluded (who need as much sedation as possible and will only want euthanasia out of fear), there are many in between, who might toy with the idea of running away, but require a little encouragement from others to benefit at least a little from the opportunity offered by the process of dying. It is these to whom perhaps euthanasia should not be given too readily; but neither should it be refused.
None of these considerations apply to non-voluntary euthanasia, meaning cases where the dying person is not capable of giving consent, such as a person in a permanently unconscious or demented state, or a premature baby who is about to lose the struggle for life. In these kinds of cases there is no question of the person benefiting from the process of dying, and no reason for them to continue to live in a condition dominated by suffering, when there is no hope of recovery. It therefore seems to be our responsibility to end their lives painlessly.
Apart from the value of human life for its own sake and the intrinsic wrongness of killing, there are various other eternalist dogmas which still surround the euthanasia debate and unfortunately determine the law in many countries. One of these is the distinction between active and passive euthanasia, which is the same as that between killing and letting die, or actively interfering and “letting nature take its course”. Passive euthanasia involves the withdrawal of treatment which could be given, whilst active euthanasia involves a deliberate action to end life. The Catholic Church allows passive but not active euthanasia, as does the law of the UK, like many other countries.
The distinction between these two types of euthanasia, however, is far from clear, and this distinction leaves doctors in the absurd position of being able to give large doses of morphine to a patient if the main intention of this is to relieve pain, but not if the main intention is to hasten the end of life, even though they act in full knowledge that the morphine will do both. The complexity of human intention is very artificially simplified here in order to make it fit a dogmatic moral starting-point. The requirement not to actively kill someone, even when it is obviously the best option for them, also leads to much needless suffering that “nature” (actually an environment heavily controlled by humans) inflicts.
This law could be very easily simplified by allowing doctors to give euthanasia, with the consent of relatives, to those who clearly and repeatedly request it in front of witnesses, and to those who cannot express their wishes with the consent of both relatives and a medical ethics committee. Clearly there need to some legal safeguards to make sure that doctors do not abuse their position of trust, but the reasons one might avoid or hold back from euthanasia are moral and spiritual, not legal. The law should not restrain people from committing a compassionate act for those who request it, even if reflection may prevent Buddhists from personally making that request too readily.
In conclusion then, it seems that a Middle Way on euthanasia should support all cases of non-voluntary euthanasia where suffering can be relieved and there is no chance of recovery. On voluntary euthanasia we should be quite circumspect for ourselves, and not over-hasty in escaping from the opportunities offered by the process of dying. Where possible, others should also be encouraged to take these opportunities, but where they clearly cannot or will not be taken and a patient calmly and persistently requests euthanasia, we have no moral justification for withholding it.
 The problem of the contradiction between anatta and rebirth is one which has been appreciated and discussed through most of the history of Buddhism, going back to The Questions of King Milinda. However, the answer given in that text (which typifies a widespread Buddhist response) that rebirth is only the continuation of a karmic process (rather than a fixed self), does not seem to justify the way in which the Buddhist tradition continues to identify rebirth with individual personalities and their consciousness. There is no reason why a karmic process should remain an individual or in any way a personal karmic process, unless one adopts equally dogmatic traditional assumptions about karma which mesh with the belief in individual rebirth.
 E.g. Bhikkhu Nyanasobhano A Buddhist View of Abortion (pub. Buddhist Publication Society, Bodhi Leaf no. 117). This basic dogmatic view is not challenged by academic writers on Buddhism and Abortion (such as Peter Harvey, Damien Keown and Robert Florida) because they see their task as descriptive rather than normative.
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