Article adapted from Student BMJ

Shaheen E Lakhan

Law of karma

In Hinduism your perpetual soul’s future and the quality of your rebirth and progress towards liberation depend on your actions in life. The law of karma states that every event has a cause and effect, and every cause has a destiny. It signifies the interplay between fate and free will. Hindus are not fatalists who believe that humans have no freedom, are subject to preordained forces, and are puppets of fate.

Karma is accumulated through prior existences and defines your character, tendencies, capacities, and caste. Hindus seek a high quality of birth as measured by your longing for God and not for worldly things. The system of karma perpetuates transmigration that results from ethical or unethical consequences. Hinduism also differentiates acts of death, according to the Vedas and Laws of Manu. Therefore, possessing some familiarity with Hindu ethics permits you to consider bioethical dilemmas through the lens of Hindu religious order.

Doctrine

Hinduism is one of the world’s oldest relig­ions and cultural systems, predating recor­ded human history, and has no one particular human founder. The underpinning scriptures, the Vedas, act as the universal Hindu framework, and the Bhagvad Gita and the Upanishads are the scriptures’ refinement and integration. 

The atman is the supreme universal self and the deepest essence of each being, and the Brahman pervades the individual. The physical portion of the human being is the human body, a vulnerable vehicle within the ceaseless atman. Akin to most other religions, there are generational differences in emphasis and interpretations, which extend to practice. 

The Vedas are the Indo-European Sanskrit texts, containing hymns, incantations, and rituals. The Upanishads incited intense philo­sophical speculation of such practices, but clarified the merger of atman and Brahman through contemplation and mediation. As the largest book in the world and the national epic of India, the Mahabharata pre­sents intriguing visions of humanity and the divine. 

Reincarnation

Hindus believe that all beings can move towards enlightenment through life actions and progression, through cycles of rebirth – a system of reincarnation. The atman holds the potential for infinite succession and permutation, transcending many lives and undergoing innumerable experiences before merging with the divine. Death initiates the disconnection between the physical body and the mind; with reincarnation, the body and mind keep returning to Earth until reaching supreme liberation.

Hindu doctrine accepts suffering as inevitable even in death. Hindus are urged to seek a good death through a conscious dying process and to select discomfort over drugs. The last moment of your life is especially important to determine the properties of your rebirth. Your extended family should be near and either you should chant a mantra or a family member should intone Aum Namasivaya, a powerful hymn that leads you along the path to enlightenment.

Biotechnology

Despite a lack of scholarly literature on Hindu bioethics, recent interest has prompted its articulation within the scope of issues of life and death. We cannot view bioethics merely as medical ethics conjoined with moral principles because bioethics are not the bastion of only medical professionals. Advances in biotechnology and medical treatments have yielded complex public affairs, so when a traditional code of beneficence fails to conjure adequate solutions, examining bioethics from other cultural perspectives such as Hinduism can be useful. For example, India, a predominately Hindu nation, created a National Bioethics Committee in direct res­ponse to biotechnological innovations, including stem cell research.5,6 On the other hand, India has been slow to consider issues of transgenic or genetically modified crops. 

Suicide and euthanasia

Hinduism generally perceives suicide as an act against humanity and a mortal, reprehensible act of destroying lives. Suicide would be considered a bad death because according to Hindu doctrine, bad deaths are violent, premature, and uncontrolled and occur in the wrong place and the wrong time. However, it makes two important distinctions between suicide and euthanasia. If you commit suicide for what Hindu doctrine considers selfish reasons, such as financial burden, it reflects the individual’s ignorance about the nature of life and human destiny. A person who commits suicide will still continue the samsara, the cycle of birth, suffering, and death. People who aid such suicides are burdened with karmic punishment because they have violated the principle of non-violence. 

If an individual seeks death consciously and willingly for the spiritual intention of compassion or liberation, however, a different perspective surfaces. Concern for the wellbeing of others by hastening your own death consciously can be a sign of spiritual enlightenment and so would be considered a good death. Modern figures have sought deliberate spiritual enlightenment by way of self willed

death by fasting (prayopavesha). The Laws of Manu allow prayopavesha for ascetics, members of the Brahmin caste, and kings. If you permit your body a slow and wilful dissolution you are free from sorrow and fear and are ultimately liberated. However, you must publicly announce this intention and permit community intervention, if any is offered.  

If, in the face of physical suffering that hinders discipline the individual seeks spiritual liberation, Hindu doctrine permits the shortening of life. Yet, lack of consciousness due to pain, mental illness, or lethargy impedes full perception, which is necessary to ensure favourable rebirth. 

Extreme suffering results in attachment to the material world and hinders the pursuit of spiritual liberation. In cases of a lack of consciousness and extreme suffering, euthanasia by a doctor’s injection with lethal drugs is sometimes a compassionate act. However, any measure of assisted suicide preventing patients from comprehending their descent towards death or rendering them unconscious presents a moral quandary.  

Organ donation and transplantation

Cremation is a big part of samskara funeral ceremonies, and is both a destructive process and a course of creation. As the physical body and mind reunite with the Earth during the final act of cremation, the atman continues the samsara cycle after 12 days of wandering. If the body reunifies with the Earth without the original set of organs, will the atman be allowed to continue samsara, have karmic repercussions, and be reborn? Organ donation in Hinduism is considered charitable and possessing of karmic benefit, yet many people also believe that if the body is incomplete during samskara the atman of the dead is suspended in a “state of animation,” and family members assume a karmic burden as a result. None the less, no specific religious law forbids organ transplantation and donation. The benevolent act of organ donation, when permission is explicit, transfers tremendous karmic merit and virtue to the donor and would take precedence over organ withdrawn body cremation. 

Implications for the healthcare provider

Healthcare providers should be familiar with the convictions of this patient population to determine optimal management. Also, we must accept that our patient’s religious and spiritual bases must not automatically be deferred to clergy. If we show a basic understanding of our patient when deciding to undergo organ transplantation, for example, we can offer more than medical statistics and establish a more therapeutic doctorpatient relationship.

Clinical scenario

An 85 year old Indian born man presents with idiopathic fulminant hepatitis, with massive liver necrosis. He informs you he does not want to live his final days on a machine and does not fear death because he sees it as a process of life. His prognosis is bleak; without a liver transplantation he will likely die. He is at immediate risk of hepatic encephalopathy and cerebral oedema. Preoperative management would dictate airway protection by a nasogastric tube to prevent aspiration and intubation if a coma is imminent. 

Although liver transplantation is the definitive treatment, it may conflict with the patient’s beliefs. Even if he accepts transplantation, he is in a group at high risk of mortality and may not survive the procedure. This Hindu patient thinks that under anaesthesia he would not benefit from a proper dying process. 

Also, he does not want to live on intensive care support measures in his final days, either from direct medical management of the fulminant hepatitis or as a surgical complication of the transplantation. Doing so would conflict with Hindu doctrine and he will be left weak and severely ill. In this case, most traditional Hindu families would not prolong life through medical measures out of consideration for the patient’s old age as well as the perception that it may unnecessarily prolong an inevitable dying process. Therefore, we must apply palliative care to ease pain and permit a conscious comfortable death. 

Conclusion

In relation to modern medical and scientific issues, Hindu scripture is not prescriptive. Instead it provides insight into how to approach ethical dilemmas. Morality often leaves the decision to the individual, and intention, as in the case of suicide, is a key aspect. None the less, the significance of deeds in the current existence is diminished because the karmic profile is collected throughout the eternal atman journey of numerous cycles of birth, affliction, and death.

Original publication & references

This article is republished from Lakhan, S.E. Hinduism: life and death. Student BMJ2008;16:310-311.
All references are available online at http://student.bmj.com/issues/08/09/life/310.php

Photos by Marco Fedele, Gabisa Motonia and Dey Alexander (in order of appearance), shared under Creative Common License