佛教生命倫理學對臨終倫理議題之探究

Abstract

佛教生命倫理學之主要特色乃在於其依據佛教之緣起法則所透顯之生命觀，即眾生長遠之生命流程乃以其心識之相續變化歷程為主軸，及其反映於佛教倫理觀中所重視眾生之心態品質與行為意圖之特色。本文乃根據上述佛教生命倫理觀作為探討當代臨終倫理課題之主要切入視角，首先由個人生命概念密切相關的死亡判準課題著手，進而探討佛教對器官捐贈以及便利死（即一般所謂的安樂死）之相關倫理課題。 在死亡判準課題方面，從佛教之身心整合觀與相續之生命觀來看，吾人應以全面而整合的視角看待整體身心和合之生命體之功能運作，死亡判定不應只停留在生物學之物質層面，也應包含心識層面之構成變化。從佛教壽、暖、識之死亡判準來看，必須待心識離體後，身體不再表現體溫與心識活動甚至已出現身體朽壞等跡象，始可謹慎將其判定為一期生命之結束。然而，當代死亡判準中無論是以整體腦部或腦幹功能為依據之腦死判準或以大腦新皮質功能為依據之高階腦死判準，甚至是無心跳器官捐贈所依據之心臟死亡判準，皆是將生命體之死亡判定依據逐步簡化為單一物質性構成之器官或其部分組織的滑坡式認定以達到其提前宣判死亡之目的。 當代死亡判準之形成與器官移植技術之發展息息相關，而死亡判定之爭議在器官捐贈倫理課題中，則顯示出臨終者之心態品質的維護與器官移植手術所強調之時效性間存在著難以權衡之衝突。從佛教觀點來看，吾人仍應避免因器官資源之短暫表面的醫療利益，而犧牲捐贈者死後之相續生命歷程之發展的長遠利益。在當今器官捐贈制度中的表態退出制度，實為一種未經當事者同意即剝奪其器官的殺害行為，而因此違犯殺生戒不與取戒。此外，表態加入制度雖訴諸當事者或代理人之同意作為其器官捐贈程序進行之必要前提，然而醫療人員亦應協助瞭解當事者本身之心態品質與其捐贈抉擇之考量背景，並詳加說明器官移植程序對其臨終過程可能造成之影響，以落實「知情同意」之倫理原則。 最後，在便利死相關課題方面，無論是積極便利死或醫師協助自殺，實質上皆為人工加速死亡之行為。依據佛教的業報輪迴觀，死亡並非一切存在之虛無，便利死亦無法真正幫助病患達致究竟解脫，更使其喪失面對與了悟生命之無常困苦而提升心態品質的良好機會。此外，為病患執行便利死之醫者也造作了殺生之惡業，因此佛教戒律亦禁止修行者參與殺生或協助自殺之行為。相對而言，放棄維生醫療之行為，若是出於同情共感之慈善意圖，並確實依據其病況與長遠生命歷程之發展的考量，不僅可允許其在自然邁向死亡之過程中減少不必要之醫療介入的沈重負擔，更可放眼於未來下一階段生命投生更好的去處。筆者認為當今安寧緩和療護若能落實病患預立醫療決定之制度，將可為臨終病患在身、心以及靈性方面之需求提供更為完善之照護與服務，協助其達致善終之理想目標。

Building on the core principle of pratītya-samutpāda (dependant co-rising), Buddhist bioethics displays its qualities in both view of life and of ethics. In Buddhism, life for the sentient beings is an incessantly reincarnating ever-long process, centralizing on the continually changing course of the mind. The ethical concerns of Buddhism not only focus on the intention of one’s actions, but also examine its outcome. In Buddhism, an action that is considered good is motivated by one’s kindhearted intention, which will improve one’s quality of demeanor and bring about positive effects to its subsequent journey to ultimate enlightenment. This dissertation attempts to deliberate on issues of death and dying in modern times, approaching from the aforementioned perspectives of Buddhist bioethics, firstly drawing upon the criteria of death which is closely related to the Buddhist view of life, then moving forward to discuss the ethical issues of organ donation and the act commonly known as euthanasia. First, this dissertation will explicate the boundaries of life and death and how one’s death is determined from a Buddhist philosophical viewpoint, and remark on the criteria of death in modern neurology. From the Buddhist view of life, the living body of a sentient being is composed of many properties, which can be classified into two categories: nāma(name) and rūpa (form). One’s birth and death are not singular incidents that happened at specific timings, but are part of an incessant process caused by one’s physical and mental changes of correlated properties. In Buddhism, determination of one’s death is based on three properties: vitality, heart and consciousness; when one’s consciousness is no longer attached to the physical body—meaning the body displays no sign of breathing, temperature and mental activities, and may even be showing signs of decay—they can then be ultimately declared dead. In comparison, modern neurology classifies one’s death based on cease of activity in the whole-brain, the brainstem or the higher brain, which merely establishes the determination of one’s death on the activity, or lack of, in their physical brain, so as to allow one’s death to be declared as soon as possible. Disputes regarding how one’s death ought to be determined show that there are irresolute conflicts between the appropriate timing to declare death and the maintaining one’s organ vitality. This dissertation will utilize the Buddhist approach to deliberate how organ donation protocols in modern times can affect the donor’s dying process, while examining the ethical controversies over the existing organ donation systems. In Buddhism, the organ donation protocol after brain death or cardiac death both overly emphasize the medical advantages to the recipient and consequently overlook the donor’s rights to dying a good death. Additionally, the modern-day opt-out organ donation system is in fact an act of killing which strips an individual of their organs without consent, violating the Buddhist precepts to not killing or harm any living being and not taking what had not been given. Although the opt-in organ donation system requires consent from the individual or their executor prior to organ harvesting, medical staff should proactively assist potential donors to obtain a full understanding of organ donation and explain the effects organ harvesting surgery may have on their deaths, so as to implement the ethical principle of “informed consent.” Finally, regarding end-of-life issues, this dissertation will discuss the ethical concerns of active euthanasia, physician-assisted suicide and forgoing life-sustaining treatment from the Buddhist perspective. According to the Buddhist doctrines of karma and reincarnation, death does not mean nothingness, therefore artificial means to advance the dying process, such as active euthanasia and physician-assisted suicide, would not only fail to help the individual achieve an immediate ultimate liberation, but also take away the opportunity for one to ultimately reflect on the impermanence and suffering in life and improve the quality of their mental state before departure from this world. Additionally, the physician who carries out the act of euthanasia or assisted suicide would also be guilty of killing, and followers of Buddhism are constrained from taking part in killing or assisting others to commit suicide. In contrast, should a physician forgo life-sustaining treatment for their patient under good intentions and made appropriate decisions based on the patient’s medical condition, they would not only be relieving the patient of unnecessary medical interventions and burdens during their dying process, but also help the patient to die a good death and move on to afterlife, which would be considered an act of compassion and wisdom.