This chapter on EUTHANASIA from chapter 7 Suicide and Euthanasia - The question of the criteria of death pp. 305 - 310
"An Introduction to Buddhist ethics" by Peter Harvey. Cambridge University Press, 2000. ISBN 0 521 55640 6 paperback.
EUTHANASIA from chapter 7 Suicide and Euthanasia
"From a Buddhist perspective, death is the most important and problematical 'life crisis', as it stands at the point of transition from one life to another. Within the limits set by a person's previous karma, his or her state of mind at death is seen as an important determinant of the kind of rebirth that will follow (see p. 25, and Sogyal, 1992: 224). Buddhism thus supports many of the ideals of the hospice movement, directed at helping a person to have a 'good death' (de Silva, 1994). Thus a San Francisco Zen Center has offered facilities for the dying since 1971, and it started a full-scale training programme for hospice workers in 1987  In the U.K. the Buddhist Hospice Trust was formed in 1986 to explain Buddhist ideas related to death, bereavement and dying, and develop a network of Buddhists willing to visit the dying and bereaved, if requested.
The ideal is to die without anxiety regarding those one leaves behind (A. m.295-8) and in a conscious state which is also calm and uplifted. Thus it would be preferable not to die in a drugged, unconscious state. To die in a calm state, free of agitation, anger or denial, and joyfully recollecting previous good deeds rather than regretting one's actions, means a good transition to a future life. Clearly it is best to know that one is dying, for then one can come to terms with death and talk to one's family freely about it, with an open and mutual sharing of feelings, uninhibited by a desire not to talk of the coming death.  In Buddhist cultures, family and friends of a dying person do their best to facilitate a 'good death'. Buddhist monks may be invited to chant calming chants, to help inspire a tranquil and joyful state of mind. Some of the chants (those known as parittas in Southern Buddhism) are seen as having a protective effect, and, if a person is not seen as certain to die, they are regarded as aiding recovery. The dying person will also be reminded of good deeds that he or she has done in his or her life, so that he or she can rejoice at these, contemplating goodness (Terweil, 1979: 256). Monks may also be fed on his or her behalf, so that he or she approaches death while sharing in a karmically fruitful act.
In Northern Buddhism, a person will be read the Parto Thotrol (Bar-do thos-grol), commonly known as 'The Tibetan Book of the Dead,' as he or she approaches and passes the point of death. This is to guide him or her through the experiences undergone in the between-lives period, so as to help him or her overcome lingering attachment to his or her body and family, and enable him or her to gain liberating insight into the processes of life and death, or at least to avoid an unnecessarily bad rebirth.
In Eastern Buddhism, Pure Land Buddhists may put a painting of Amitabha Buddha at the foot of a dying person't bed, and place in his or her hands strings attached to Amitabha's hands. This is to help the person to die peacefully with the thought of being drawn to Amitabha's Pure Land.
'Euthanasia', which is derived from the Greek words eu and thanatos, literally means a 'good death'.  As defined by the Concise Oxford Dictionary (1976), it means 'Gentle and easy death; bringing about of this, esp. in case of incurable and painful disease'. Though dying while receiving care and comfort in a hospice might be seen to come logically under the definition, this is not how the term is normally used, for it is seen to apply to cases involving the sick where death is the intended result of some action or inaction, hence the terms 'active euthanasia' and 'passive euthanasia'. Active euthanasia is intentionally hastening death by deliberate positive act, such as giving a lethal injection. Passive euthanasia is intentionally causing death by a deliberate ommission, such as by withdrawing food, including intravenously administering nourishment or withoholding or withdrawing medical treatment which would otherwise have delayed death. (cf. Hammerli. 1978:191)
Whatever the means of euthanasia, it can also be differentiated as regards the nature of the volitional involvement of the person who dies as a result of it (cf. Keown. 1995a: 168-9):
1. Involuntary euthanasia would be that carried out against the wishes of the patient. This was done by the Nazis against psychiatric patients and other 'inadequates' and is universally condemned. It is simply equivalent to murder.
2. Voluntary euthanasia occurs where the patient requests the action which is then taken by a doctor, or where the doctor provides the patient with the means of ending his or her life, which is a case of assisted suicide.
3. In what one might call pre-voluntary euthanasia, a patient makes a 'living will' to the effect that, if he or she becomes mentally incapable in the future then, under such and such medical conditions, he or she would want his or her life terminated. Where the medical condition is such that the patient canjustly be seen as deat the action is taken. howerver - for example turning off an artificial ventilator if it is inflating the lings of a corpse (see below) - this is not actually a case of euthanasia.
4. In non-voluntary euthanasia, the patient is not capable of either agreeing or disagreeing to terminationof his or her life - because of being in a coma, being in an advanced state of Alzheimer's disease, or being an infant with a brain abnormality - and the decision to end the life would have to be taken by doctors in consultation with relatives, perhaps with the permission of the courts. As with the last type, this type of euthanasia raises the issue of the criteria by which a person can be pronounced 'dead', which will be discussed below. Any action performed on a body that can justly be called dead is not any kind of euthanasia.'
Buddhist reasons for rejecting euthanasia
Active euthanasia is generally resisted by the medical profession and public opinion - though it is accepted, if technically illegal, in The Netherlands  - but some are willing to contenance some forms of passive euthanasia. As Buddhism sees intention as crucial to the assessment of the morality of an act, however, it would not differentiate between active and passive means if these were intended to cause or hasten death. The Buddha's strong condemnation of a monk or nun praising or aiding a sucide (see p 289) is here relevant. To kill a person deliberately, even if he or she requests this, is dealt with in the same way as murder. As is pointed out by Damien Keown (1995a: 170), one who follows the first precept 'does not kill a living being, does not cause a living being to be killed, does not approve of the killing of a living being' . (D. III.48). To request that one is killed would be to 'cause a living being to be killed', and would thus break the precept. This would be the case even if the request were in the form of a 'living will'. If a doctor is requested to administer euthanasia, this does not absolve him or her from responsibility for the act of killing. In the case of a prior 'living will', there is not even certainty that the patient, though now unable to communicate, has not changed his or her mind. The Buddhist emphasis that there is no permanent Self (see pp. 36-7) entails a recognition that people's views and intentions are often very changeable.
Now voluntary euthanasia for one in intense pain is often referred to as 'mercy-killing', especially if it is a case of active euthanasia, and some argue that this should be allowed for humans as for animals.  Buddhists though, are reluctant to carry it out even for animals (see p. 173).
It might be thought that the Buddhist emphasis on compassion would allow such an act, yet several episodes from the Vinaya show that this is not the case (cf. Keown, 1995a: 60-4, 171-3). In all of these, the monks involved are held guilty of an act entailing defeat in the monastic life. In the first, monks 'out of compassion' praise the beauty of death to a sick monk so that he takes some undisclosed measure and dies (Vin. III.79). The commentary (Vin. A, 464) says that they urged him to die so as to gain a good rebirth as the result of his virtue, so that he stopped eating and so died. In the second case, involving a condemned man, the executioner kills him quickly after a monk asks him to, so as not to prolong his pain and miserable period of waiting (Vin. III.86). The third case involves the case of a man whose hands and feet have been cut off. When a monk asks relatives looking after him if they want him to die, and they agree, he prescribes the feeding of buttermilk, which makes the man die (Vin III.86)
In all such cases, the motive for the act can be seen to have been compassion, yet the act is still condemned. Here, Keown makes a useful distinction between motive and intention, as made in the courts (1995a:62). Motive concerns the ultimate aim of an action, while intention concerns the more immediate goal of an action, an objective on the way to attaining an ultimate aim. Thus one who kills to obtain an inheritance has the motive of obtaining money, and also the intention to kill. Keown sees the above cases as showing that Buddhism has life as an ultimate value, or 'basic good', and that it should never be sacrificed even in the name of another value, friendship or compassion. This means that to have compassion as a motive, but to intend death in the process is unacceptable. This is one way of looking at the matter, though a Mahayanist might argue that sometime 'skilful means' implies that it is acceptable to kill if the motive is compassion (see pp. 135-8). However, Mahayana scriptural cases of 'compassion killing' are always to prevent the victim commiting some evil deed against others: they are to prevent suffering to others, and also bad karma being generated by the victim. .Such cases do not fit the euthanasia scenario.
In any case, perhaps a better way to interpret the Buddhist attitude to 'mercy-killing' is as follows. An action is unwholesome if it is rooted in greed, hatred or delusion (p.46). Here, 'rooted in' can be seen to refer to an action's intention, to its motive or to both together. To advocate death on the grounds of compassion would be seen as an unwholesome act rooted in delusion, so that the compassion involved was unwise. The Abhidharma-kosa-bhasya (AKB iv.36c-d) says that killing may arise from a variety of roots, including ignorance.  Examples of the latter are animal sacrifice and killing one's aged or sick parents as the "Persians" do. A note to Pruden's translation of the text (AKB pp. 735-6) cites the Vibhasa (p. 605c16) as saying a certain people in the West thought it a good act to kill a parent if he or she was decrepit or in pain so that he or she would attain new organs and a painless life. This clearly implies that it is delusion to try to end suffering by killing the person who is suffering. Indeed, the Upasaka-sila Sutra says that if one gives one's parent a weapon to kill himself or herself, or kills one of them at his or her orders, the atrocious offence o killing a parent is still committed (Uss.179).
Why is killing a person in pain an act based on delusion? In the case of the sick monk, the commentary explains that more proper advice is :'as the paths and fruits have arisen, it is not surprising you are virtuous: therefore do not be attached to residence etc., setting up mindfulness in respect of the Buddha, Dhamma, Sangha and the body, develop heedfulness in attention' (Vin. A. 464; cf Bapat and Hirakawa, 1970:326). This suggests that a person should use the process of dying as an opportunity for reflection, so as to see clearly the error of attachment to anything which is impermanent, be it the body, other people, possessions, or worldly achievements. Dying presents the reality of the components of body and mind as impermanent, dukkha and not-Self in stark form; it is thus an opportunity for gaining iinsight into these. An enforced death cuts short this opportunity.
In Theravada Buddhism, it is also commonly seen that 'no act of killing can be carried out without the thought of ill-will or repugnance towards suffering' (Ratanakul, 1988:310). In the case of 'mercy-killing' a doctor's motive of compassion is good, but it is mixed with aversion to the patient's pain, which disturbs the doctor, so that 'Subconsciously he transfers his aversion to the suffering to the one who embodies it' (p. 310).
Taniguchi, drawing on Theravada texts, also says that if a mother in severe pain asks her son to end her life, and he does so, they share the delusion that death is the only way out, and the son is motivated by attachment to his mother and aversion to her pain.  For such reasons, Pinit Ratanakul reports that in Thailand there is a growing consensus that euthanasia, active or passive, is morally unjustifiable (1990:27). He nevertheless observes that, as in the West, nurses 'reported' instances of lethal overdoses being given, of no-code orders [i.e. not to resusciate] being written, of withdrawal of life-support systems or orders to withdraw treatment' (1986:219). Though he says that such practices conflict with traditional Thai Buddhist values, he gives insufficient details of the contexts of such acts to give a proper moral assessment of them.
There is also the question of whether killing a sick person will actually end his or her suffering. For one thing, there is no guarantee that even a good person will have a pleasant rebirth in his or her next life, as there may be a back-log of bad karma to catch up with him or her (see p.25). For another, if the suffering of a sick person is due to karma, then killing him or her is unlikely to end the suffering, as the karmically caused suffering will cotinue after death until its impetus is used up. Thus, it is better to deal with the suffering here and now, while one still has a human rebirth and can deal with the suffering better. However, it is not held that all suffering or illness is due to karma, for it may arise from: winds, bile, phlegm, a combination of these, change of season, stress, suddenly, or from the maturing of karma (see p.23)
As regards death and karma, the Theravadin commentator Buddhaghosa says that death may be (1) due to natural ending of a normal human life-span, or due to the natural ending of the karma-determined life-span of a particular individual, or (3) an 'untimely (akaala-) death', for example by being murdered, due to karma which disrupts the normal life-span (Vism. 229; cf. KVu. 543-4). This implies that all death, except of those who are very old, is due to karma. The sutta passage says that the illnesses are not due to karma, however, could be seen to imply that some premature deaths are not due to karma. Indeed, the Karma-prajnapti-Sastra (ch. xi, as quoted at AKB II.45b) says that death occurs because of the exhaustion of karma leading to life, to objects of enjoyment or to both, or because of not avoiding a cause of harm, for example excess food. That some deaths have nothing to do with the results of karma is also implied by Miln. 150-4. This discusses the efficacy of parittas, Buddhist chants which are seen to have the power, in certain cases, of curing illnesses and so of saving a life. They do not work when a person is coming to the natural end of his or her life term, or when the illness is due to karma (p.151): they only work for the one who is in his or her prime and who has faith (p. 154). This admits that one in his or her prime might die even though he or she is not due to do so from karma, for want of the curative properties of such a chant.
If not all illness and death is due to karma, what follows? Firstly, that an illness should not just be passively accepted, as a 'just' result of karma. Doctors and relatives should do what they can to save a patient. Where an illness is clearly terminial, it then becomes likely, though not certain - particularly in the very old - to be due to karma.
If it is due to karma hastening death by euthanasia will not end the suffering involved, as karma will cause it to continue after death. If it is not due to karm, it is still important for the patient to 'see the death-process through', to learn from it. The case of those who are unconscious and so perhaps 'cannot 'see the death process through' will be discussed below."
Of course, one might say that it could be the patient's karma to die by euthanasia. This could, in principle, be the case - but it no more excuses euthanasia than a murder's being due to the victim's karma excuses the murderer. Wise compassion therefore should not include euthanasia.
Nevertheless, a Buddhist consideration which might be seen to support voluntary euthanasia is the importance of dying in a good state of mind: calm, conscious and so able to see the death process through. (Becker, 1990:553-5). If someone knew for certain that he or she would die soon, and that he or she would be in increasing pain, only maskable by drugs that rendered him or her unconscious, then he or she might choose to go sooner in a good state of mind, in which he or she could be reasonably calm, and learn from the death process, than later in a prolonged unconscious or pain-agitated state. Yet the dichotomy is, at least nowadays, becoming a false one. When morphia was used as a pain-killer, it could quite easily render the patient unconscious. There are now pain-killers which minimize this, so as to allow a state which is neither unconscious nor pain-agitated, but a semi-conscious state from which a person can be roused. (Hammerli, 1978:192). Pain will still be experienced to a degree, and the drugs may cause nausea and eventually lead to final unconcsciousness,  but to cut this short by euthanasia will abort a learning experience, albeit a difficult one. Moreover, if the person was not in fact bound for death in the near future, euthanasia would be throwing away the potential of human life. Keown also makes the fair point that 'Although it is important to die as mindfully as possible, it must be recognised that many people die peacefully, naturally and unconsciously in their sleep, without, one imagines, their spiritual progress being greatly hindered thereby' (1995a:185). That is, while it is not good to die in an agitated state, dying while unconscious avoids this. Moreover, at S.v.360-70, it is said that a person well practised in spiritual quallities, even if he or she dies while bewildered by the teeming bustle of a city, will gain a good rebirth.
It is clear,then, that on Buddhist principles,euthanasia is unethical and inadvisable. This does not entail, though, that completely self-administered euthanasia, without the help or connivance of another party - i.e. suicide in the case of a difficult illness - should be illegal. Indeed, of Buddhist countries, only Sri Lanka, because of British influence, criminalizes attempted suicide. In the case of Channa, a spiritually frustrated monk set on killing himself (M. III.263-6)), the Arahat Saariputta does what he can to dissuade him, but neither he nor the Buddha, on hearing of this, seeks to prevent Channa from carrying out his plan, since he is set on it and of sound mind; in the event he does so but manages to become an Arahat while dying (Keown, 1996). Suicide (if followed by rebirth) is unethical, but a person still has a right to do unethical actions. He or she should consider, though, that his or her actions may well have a devastating effect on relatives and friends, which gives additional reasons for not doing them.
A relevant case, here, is that of Elizabeth Bouvia, who in 1983 asked the California Supreme Court to be allowed to die by starvation while receiving pain-killers and hygienic care. She was a twenty-six-year-old who was suffering from cerebral palsy and quadriplegia, with hardly any motor control, and who felt 'trapped in a useless body' (Nakasone, 1990:72). After long and serious reflection, she felt that any option but death would be unfulfilling. The court refused her request, on the grounds that she was not terminally ill, that her death would be devastating for her parents and other disabled people, and that she could not ask a doctor to abandon the duty of care enjoined by the Hippocratic Oath (Nakasone, 1990:72). Here, Buddhist principles would mean that it would be a wrong action on the part of a non-terminal patient to starve herself to death (above. p. 290), (1)). It is less clear whether it would be wrong for doctors to let her starve, if treatment for pain was being administered. If the patient could feed herself if she wanted to, and was of sound mind, then perhaps she should be allowed to die. If she could feed herself, though, she would have been less likely to want to die. The problem here, was that she was completely dependent on others feeding her. This meant that she wanted others to kill her, by removing her feeding, rather than to allow her to kill herself. This would be asking them to commit an unethical act, and one which it is perfectly acceptable also to make illegal.
Cases of non-intended death
While Buddhist principles entail that genuine cases of euthanasia are unethical, this does not mean that cases which might be mistakenly viewed as euthanasia would be unethical. In one such type of case, death occurs as the result of an action, but is not the intended aim of the action. There are several scenarios which come under this description. The first relates to pain-relief for the terminally ill. Where the pain is intense, pain-relieving drugs might gradually kill the patient. As the body develops a tolerance to the drug, the dosage has to be increased gradually, and may reach a toxic level, so that the patient dies from the drug (Hammerli, 1978: 192). In such a case, Keown (1995a:175) points out that there is a useful distinction to be made between intention and foresight.
One may know that a side-effect of one's action may be a certain result, but unless one's aim is to attain that result, one does not intend it. For example, one may know that driving a car will kill insects, but if one does not drive so as to kill insects, this is not one's intention. That such a distinction is recognized in Buddhism is perhaps shown by a case in the Vinaya. Here, a sick monk dies as a result of medicine given by other monks (Vin. III.82-3). They are held to be guilty of no offence if they did not mean to cause his death, but of a grave offence, just short of one entailing defeat, if this was the intention. (Vin. III.82-3). Death as th unintended side-effect of pain-killers is seen by Van Loon (1978:76-7), Barnard (1978:208) and Florida (1993: 46-7) as an acceptable case of 'passive euthanasia', though it seems preferable to reserve the word 'euthanasia' for cases where death is the intended aim, as explained above.
In another scenario, a patient might rightly feel that he was tying up scarce medical resources, or bankrupting his famiy with high medical bills. He might therefore, from compassion to others, freely choose to forego the means of further life (Ratanakul, 1988:312) as in the Vinaya commentary case mentioned above (p.290, (2)). Of course, it is very important that a person would not feel pressurized by others to perform such an altruistic act. If this were the case, the pressurizers would in effect be committing murder. If a terminally ill person simply could not face eating, then it would be the duty of others to help him eat, and provide intravenous feeding if necessary.
In another scenario, in the advanced stages of a disease, for example cancer, there is the question of continuing with an excessively burdensome treatment if it is painful and not expected to produce a cure, so as to be futile and pointless.  The patient, or his doctor in consultation with him, might decide that another round of chemotherapy was just not worth it, as it would detract from the quality of the remaining life term, and would not actually prevent death. To continue treatment, here, would be 'to cling desperately to a life that is ending or to flail against the forces of impermanance' (Anderson, 1992:41). Sogyal Rinpoche affirms that:
"Life-support measures or resuscitation can be a cause of disturbance, annoyance, and distraction at the critical moment of death ... In general there is a danger that life-sustaining treatment that merely prolongs the dying process may only kindle unnecessary grasping, anger, and frustration in a dying person, especially if this was not his or her original wish. Relatives ... should reflect that if there is no real hope of recovery, the quality of the final days or hours of their loved one's life may be more important than simply keeping the person alive." (1992: 372).
Kalu Rinpoche has said that a terminal patient who himself chooses to be taken off a life-support system is doing an act which is karmically neither bad nor good (Sogyal, 1992:374). Yet as this would probably have to have been by a previous 'living will', it would have to have been very carefully worded, and there is the danger that it no longer expressed the patient's current wishes.
Dr. Elizabeth Kubler Ross, who has done much work with the dying lists five states that those approaching death go through: (1) shock and denial (2) anger, (3) bargaining with God and fate, (4) depression and (5) acceptance.  Buddhist counselling for those approaching death is to aid the acceptance process and teach them to let go (cf. M. III.258-62); to be aware of the feelings of fear, anger, denial, despair etc. that come up, but not to cling to them, and not to cling to the dying body, life, or relatives (S. v.408-10).
Meditation practice schools a person in letting go, and thus prepares him or her for this; indeed, there are meditations on the inevitability of death (for example Vism. 229-39). Dying though, is a time when a person has to learn to let go, even if he or she has not yet done so. The more attached a person is, and the more he or she denies his or her impending death, the more difficult it will be for him or her and his or her relatives. To develop acceptance of the process, as the natural ending of a conditioned phenomenon, is to prepare for an easier passing away. As expressed by Jacqui James, a Buddhist meditation teacher who helped her mother through the last two weeks of her dying from cancer:
"Learning how to die properly is all about learning how to let go, learning how to watch the natural ebb and flow of all things, learning that life is a process of continual beginnings and endings, continual birth and death. When you see this cyclical movement clearly then there is no more fear of death. When you have learnt that, not only have you learnt how to die, but you have also learnt how to live. (James and James, 1987:150).
The Amaravati Buddhist Centre, near Hemel Hempstead, England, is a place where some people are now going to die in good surroundings. In the cased of a nun who died there, the other nuns who attended her said that it was a privilege to be in the same room as her, as she had learnt to be at peace with her coming death, and exuded a radiance of spirit that was uplifting to share in (Sucitto, 1988). The Thai monk Mettanando also tells of a lady who was riddled with cancer and extremely agitated as a result. After she was tuaght a simple meditation, she became happy, and survived for six months rather than the two months that doctors had given her. She then died happy and at peace making a considerable impression on the doctors and nurses who observed her. (1991: 208).
Where treatment of a terminal illness is futile, the non-administering of treatment might give up a chance to delay slightly death due to natural casues, but it would not hasten it - make it happen more quickly than it would have happened naturally without treatment - and death would not be the aim. It would thus involve neither suicide nor murder and would be morally acceptable. The South African heart doctor Christiaan Barnard sees such a case as one of passive euthanasia, but as acceptable (1978: 208-9), 211), as does Florida, particularly if there are additional factors, such as the family being bankrupted by treatment, and a shortage of hospital beds in the locality (1993:44).Now, while withholding treatment would prevent the delay of death, as in passive euthanasia, unless its intention was to thus cause death, it does not come under the full definition of passive euthanasia given above. This also seems to be the opinion of Kubler Ross. She opposes all euthanasia, while she refers to as 'mercy killing', but finds it acceptable to allow a patient to die in peace if he or she is beyond medical help. (1989/90).
Regarding such a case, Taniguchi, articulating a Theravada view, says: "If one chooses to die or refuses life sustaining medical treatment, one must be motivated by aggression towards one's state of suffering, or be passionately attached to pleasant states, or be deluded that death is a way to avod suffering" 
This might be true if treatment was refused when it could do some good, but it need not be otherwise. The Thai doctor Pinit Ratanakul also holds that even when a terminal patient refuses extraordinary treatments, so that he dies, this is an unwise act which prevents bad karma 'running its course', so that it does not continue into the next life (1988: 309), and the Dalai Lama holds that it is best to face suffering, which is karmically caused, in the present, human life, where one is better placed to bear it than in, say, an animal rebirth (Sogyal, 1992: 375). This is an argument not about morality, though, but about the wisdom of an act.
Here, three points can be made. Firstly, it is not certain that all illness or death is due to karma (see''. 297-8). Secondly, ideas about karma are not usually seen to imply that pain-killers should not be taken because this 'interferes' with the flow of karmic results. Thirdly, allowing a disease to run its course without (futile) treatment is hardly interfering with the flow of karmic results. Thus, in the case of a severe terminal illness, where death will soon come anyway, avoidance of futile treatment would be acceptable. Indeed, the Vinaya commentary (above, p. 290 (3)) even sees it as sometimes acceptable for a person in such circumstances to stop eating. One can see such a case as one where neither the motive nor the intention is to die, but to be peaceful, and thus better able to compose oneself during a dying process which is already under way irrespective of what anyone does or does not do. The Dalai Lama gives some degree of support to this:
"If a dying person has any chance of having positive, virtuous thoughts, it is important ... for them to live even just a few minutes longer ... If there is no 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. (Anderson, 1992: 41; Sogyal, 1992: 372)
This would support non-treatment, but only where treatment would make it difficult to have 'positive, virtuous thoughts'.
What of the avoidance of futile and/or expensive treatment when this is non-voluntary? Ratanakul raises the case of deformed infants - who of course may be severely mentally impaired - and says that it is morally unacceptable to Thai Buddhists to withhold treatment from them or allow them to die (1990: 27). In Japan, also, infants with severe brain abnormalities are sometimes cared for for years at the wish of loving parents (Becker, 1990: 545). Clearly, it is unacceptable to remove feeding from such infants. Anything should also be done which would improve their condition or maintain a viable state of health. Thus a child with Down's Syndrome, for example should be given every help. Where a child's condition is such that he or she would be constantly battling with infections or other medical complications, and this would be painful and expensive and tie up scarce medical resources, then perhaps he or she shold be allowed to die - for example by not having infections treated - if this is what the parents want.
Another scenario for avoidance of futile treatment is that of the non-resusciation of a terminal patient who has a heart-attack (cf. Keown, 1995a: 174-5). While non-resuscitation would be acceptable if it was what the patient wanted, perhaps in a prior 'living will', it would probably also be acceptable if he had not expressed himself on the matter, if he were clearly already in the terminal phase of his illness. To die amidst the unnecessary techno-frenzy of a hospital 'crash' team is surely a distrubing experience! Non-resuscitation would be unacceptable if the patient had affirmed that he did want to be resuscitated. It would perhaps also be immoral to resuscitate a genuinely terminal patient who had said that he did not want to be resuscitated. Hammerli suggests that a doctor who insists on prolonging the life of a hopeless case as long as possible may in fact be treating hiw own guilty conscience, so as to appear a 'good' doctor (1978:182), and Barnard sees this as possibly a case of selfishly not wanting to appear a failure (1978:204).
Another type of case in which an action would be acceptable as no intentional killing occurs would be that in which the action can be seen to occur after the patient has died. This, then, raises the question of the criteria for being 'alive' and being 'dead'. The type of scenario which particulary raises this issue is that of a patient in a 'persistent vegetative state' (PVS). Here, a person is in a coma as the neocortex of his or her brainhas beendamaged. If this continues for a long time, the damage may be regarded as irreversible. If the brain-stem of the person is undamaged,however, the person can breathe unaided (though artificial respiration may be added as an aid) and digest, his or her heart will beat (though help may be needed in regulating it), and his or her body will retain certain reflexes such as dilation of the pupils and, usually, swallowing, yet the senses do not seem to work, and no voluntary movements are made (cf. Keown,1995a: 160; Mettaanando, 1991:210). If someone is permanently without any sign of conscious awareness and the ability to make decisions, however, two questions arise:
(1) is the patient still a 'person' with value?
(2) is the patient alive?
Some would regard the life of a human who is 'not a person' as without value, so that it is not unethical to kill him or her. Buddhism, however, does not see the value of life as residing in personhood (Keown, 1995a: 27-30). This is shown by the fact that animals and humans in the womb have value and should not be killed. Some Buddhists would still say that a life without volition (Van Loon, 1978) or awareness/sentience  wouldbe without value. Yet even were one to accept these criteria, which are debatable,  there seems no way of knowing that, in the inner recesses of a patient's mind, these qualities are not present, albeit in an attenuated form. Buddhism accepts many meditative states in which consciousness behaves in non-ordinary ways. It also accepts 'formless' rebirths, where consciousness is not accompanied by any kind of body. It is therefore hard to be sure that physical tests will always be able to detect existing states of consciousness. Indeed, the remaining consciousness may bereflecting on the dying process, preparing for death, so as to attain as good a rebirth as possible. (Mettanando, 1991:210). Indeed Vism. 554 says that, as a person is dying, there is a phase inwhich the eye and other sense-organs stop working, but the sense of touch, the mind-organ and the vitality-faculty remain 'in the heart-basis alone' and consciousness is in the process of preparing for death.
Is a patient in a PVS alive, then? It seems that, by Buddhist criteria,he or she would be. Keown (1995a: 145-58) has a good review of the relevant textual material. Two passages (S. III.143 and M. I.296) affirm that a body is dead and 'will-less (acetanan) like a log of wood' when it is without three things: 'life (aayu), heat and discriminative consciiousness (vi!n!naa.na.m).' It is explained that 'life' and heat depend on each other, like the light and flame of a lamp, and that the five sense-organs depend on heat (M. I.195). The 'life-activities' (aayu-sankhaaras) are not states that are felt, otherwise one would die in the meditative state of the 'cessation of identtification and feeling' (M. I.296).  This is a state attained by advanced meditatiors in which all functions of the mind shut down, and onthe way to attaining it, breathing ceases (M. I.296 and 301). Unlike a dead body, which has no life or heat, and has the sense-organs 'wholly dis-integrated', a person in the state of cessation still has llife and heat, and his or her sense-organs are 'clarified'. It is left ambiguous whether conscioiusness still occurs in this state, and the different Buddhist schools had different opinons on this. In his study of the state of cessation, Paul Griffiths sees it as a state in which a person may seem dead (M. I.333; Vism. 380), as he or she does not breathe and 'heartbeat, blood pressure, body temperature and metabolic levels in general have all fallen to a very low level', and mentally, a person is in a state which Western medical observers might liken to a profound cataleptic trance (1986:10-11). It lasts for up to seven days (Vism. 707).
s The above shows that Buddhism holds it possible to be in a state in which there is no breathing, and no detectable mental activity, and yet be alive. A persistent vegetative state is not the same as the state of cessation, but shares some of its qualities. One difference is that a person continues to breathe, unaided, in the PSV. Buddhism would clearly not regard one in such a state as dead, the, and to remove intravenous or tube feeding from such a person would be to kill him or her.
A famous case of this type was that of Tony Bland, who in 1989 was crushed in a football stadium disaster and was in a PVS. In 1993, the UK House of LOrds ruled that the food provided to heim by a tube was a form of futile treatment, and could legally be withdrawn, even though this would lead to his death. He then died in a heavily sedated state (Keown, 1995a: 159-68). This was in accord with the recommendations of the 1988 euthanasia report of the British Medical Association, which opposed active euthanasia, but accepted that futile treatment, which it saw as including artificial means of feeding, could be removed from terminal patients.  Keown (1995a: 12-4) however, rightly disputes whether feeding could be regarded as 'futile treatment'. Firstly, he points out that feeding, even if done by nurses, could not be seen as medical treatment unless it was of a kind specifically selected to cure an illness which it was not. Evenif it were regarded as 'treatment', its ony possible aim was to sustain life. As it was succeeding in doing so, it could not be seen as 'futile treatment', i.e. treatment which was not attaining its goal. In a some what similar case in 1995, the Irish Supreme Court decided that a woman who had lain in a coma for twenty-three years could have her feeding-tube removed, even though she was not in a PVS but could still recognize people. The grounds were that feeding by tube was an intrusive and unusual method of feeding which interfered with the integrity of her body.  Yet the view of a dissenting judge in the Court seems correct: the action was intended to cause death by starvation. If someone cannot feed himself or herself, it is the duty of others to helphim or her, by whatever means.
To say that a patient in a PVS is alive, and should not be starved to death, is not to say that extraordinary medical means should be used to keep him or her alive indefinitely. A patient in such a state is very prone to infections. As Keown argues, 'it does not follow that there is a duty to go to extreme lengths to preserve life at all costs' (1995a: 167). Such a person could be seen as beyond medical help, so that any medical treatment would be futile, as it could not restore health. If relatives wished medical complications such as infections to be treated, they should be, unless resources were genuinely not available. If not, the condition should go untreated, which could well result inthe patient's death. 
What, though, of patients whose brain-stems have died, so that they cannot breathe unaided (which those with live brain-stems usually can, and are without any reflexes: are they then to be regarded as dead, so that no action can be seen as "killing" them any longer? Keown (1995a: 151-8) argues that brain-stem death should be taken by Buddhism as the correct criterion of death. He points out that Vin. III.73 defines killing as the 'cutting-off' of the vitality-faculty (jivit-indriya)' and that Vin A. II.438-9 specifies this as the physical vitality-faculty rather than the mental one, which in any case depends on it (1995a:148). The commentary on M. 1.296 identifies 'life (aayu)' with this material vitality-faculty (M.A. II.351), and the Abhidhamma defines this as:
That which, of these material states, is life (aayu)', persistence, continuance, lastingness, movement, upkeep, keeping going, vitality, vitality-faculty. (DHS.sec.635).
Buddhaghosa says that it 'has the characteristic of maintaining conascent types of matter. Its function is to make them occur. It is manifested in the establishment of their presence.' (Vism. 447). It is identified with 'vital breath' (praa.na) (AKB. II.45b). It is thus clearly not identified with any organic structure or function, such as breathing, but as Keown says, seems to denote 'the basic biological processes of life' (Keown, 1995a, 149). As 'life' and heat are compared to the light and flame of a lamp, they can be seen as two processes which keep biological processes 'burning', i.e. functioning.
Keown refers to the meaning of praa.na in Buddhist medicine, and in Buddhist-influenced Ayurveda (Indian traditional medicine) as ranging 'from the gross physical process of respiration to the flow of subtle energy which was thought to regulate the internal functioning of the body' so as to regulate 'respiration, heartbeat, swallowing, digestion, evacuation, menstruation, and many other bodily functions. In this capacity it seems to be closely related to the autonomic system' (1995a: 149), . He goes on (p.151) to cite Mettaanando (1991: 204) as saying 'This group of interrelated bodily functions attributed to the praa.na we now recognize as bodily functions maintained by the nuclei of the brainstem.' While Keown holds that, as 'life' and heat always occur together, so permanent loss of body-heat seems to be 'the only empirical criterion offered by the early sources as a means of determining death' (1995a: 151), he concurs with Mettaanando in taking brain-stem death as signifying the end of life. Mettaanando sees this as entailing that praa.na and consciousness have gone (1991:206), and Keown sees it as meaning that there is nobody-heat, presumably as he sees the brain-stem as its cause (1995a: 152). Keown holds that early Buddhist texts see that 'death is irreversible loss of the integrated organic functioning which a living organism displays' (1995a: 155), as when M.I.1296 says that death involves the 'dis-integration of the sense-organs'. At death, often referred to as the 'break-up of the body', the operation of the sense-organs 'is no longer co-ordinated as it would be in a living, self-regulating organism' (1995a: 156). He regards the brain-stem as carrying out such a 'co-ordinating function', without which 'the organism ceases to be a unified whole and can no longer survive', even if components can survive a while longer: the heart continues to beat for up to an hour (1995a: 155), and remains alive for an hour or so even after this stops, and the skeletal muscles live for another six hours, (Barnard, 1978: 201). Thus irreversible brain-stem death is the criterion for determining that death - an end to integrated organic functioning - has occurred, this being simultaneous with consciousness leaving the body (Keown, 1995a:158). Keown does not actually identify 'life'/'vitality-faculty' with the brain-stem, but sees it as closely related to it.
Overall, it can be seen that Buddhism regards human life as a precious quality that should not be thrown away by suicide, and maintains that people should not incite or aid others to kill themselves. Euthanasia scenarios present a test for the implications of Buddhist compassion, but the central Buddhist response is one of aiding a person to continue to make the best of his or her 'precious human rebirth', even in very difficult circumstances, rather than prematurely ending this. The adage 'where there is life there is hope' is appropriate, though 'where there is humanlife, there is opportunity to reflect and learn' is one which Buddhism might emphasize. At a certain point in terminal illness though, it may be appropriate to abstain from futile treatments that reduce the quality of life on its last short lap. It may also be appropriate to deal with mounting pain in such a way that death is a known but unintended, and unsought, side-effect of increasing dosage of drugs. Any help for the dying that does not include the intention of bringing death is acceptable."
---The trouble is that you think you have time---
---It's not what happens to you in life that is important ~ it's what you do with it ---