Above all else, do no harm.
This is a basic tenet of a physician’s oath, but this oath does not always align with the religious and cultural beliefs of each patient. A recent review on ethics defined ethics as what is considered right and wrong, given the circumstances in each individual culture. This review of ethical standards asserted that ethics is not static and that it evolves with the variations in the cultures that are created in each era.
In cases where beliefs of faith, salvation or religion play a major factor in a patient’s desire to commit suicide, it can be difficult to draw the line between the traditional ethical guidelines of patient autonomy and non-maleficence. Consider a patient with major depressive disorder who has an expressive wish to die despite being given multiple treatment options, and who believes that their faith will allow their salvation. What if the patient’s plan for death was delineated to not be active, but rather passive suicide? Passive suicide, such as not eating, not drinking and not even wanting to get out of bed. If those suffering from depression chose such a method of passive suicide, and base their beliefs on their faith, how can physicians seek to understand and care for such patients?
The Hindu tradition, being one of the oldest religions, believes in a natural death, but there are multiple Hindu texts that provide different viewpoints on what natural death means. The Garuda Purana is one of eighteen texts that focus on Hindu philosophies but is largely devoted to life and living, with some aspects of death and cremation. This text states that people who commit suicide, along with a series of other individuals go to hell. “There are people who are dead by fasts, killed by fanged animal … who commit suicide, who fall from a peak and die, who hang themselves to death, who are drowned in tank, river or ocean — listen to their plight. These go to hell.” The belief is that Hindus who commit suicide will not have their soul reincarnated, but rather that the soul will be a “ghost” on the earth.
On the other hand, Hindus also have a concept of “honorable suicide” where there is a distinction between suicide with the use of unnatural means such as guns (atmahatya) and self-sacrifice (atmayagaya) related to pain or great disability. In the honorable death, once an individual reaches a point of having no desire in life or responsibilities, they may attempt natural methods of killing themselves, including self-starvation (prayopavesa), voluntary drowning (jalprevsa), or entering fire (agnipravesa). Studies show that Hindu countries have a higher rate of suicide compared to Islamic or Christian countries, but still lower than Buddhist or atheist countries. This study looked at various countries including Fiji and the United Kingdom and concluded that the Hindu belief of karma and reincarnation could serve as both protective and precipitating factors. With regards to these views, it appears that Hindus can justify physician-assisted suicide through the grounds of “ahimsa” meaning “to not injure.” In ahimsa, the pain and suffering of the individual are what causes injury; assisted suicide is acceptable in alleviating this when all else fails.
Comparatively, there are significantly higher suicide rates in Japan compared to Islamic and Jewish countries. It is argued that Japanese culture focuses less on autonomy, in contrast to the West, but more on the society as a whole. In ancient Japanese culture, the idea of Seppuku was the traditional form of ritualistic suicide used by the upper-class samurai. This tradition, along with the idea that the Japanese consider suicide as an honorable way to take responsibility for one’s actions, has contributed to the increased rates of suicide in Japan. Despite this phenomenon being associated with culture, religiously, many Japanese follow Shinto beliefs with some influence from introduced Buddhism. In the Shinto religion, the belief is that the body and soul are delivered into existence by nature. This belief system has no direct guidance on how to regard suicide and its teachings are considered ambivalent on this matter. Interestingly, however, Shinto organizations advocated “being natural” when medical treatment became futile in a terminal setting and were more accepting of passive euthanasia, further demonstrating the differences in culture and religion. With regards to the Japanese patient, it appears that honor plays a significant role in the full story that embodies the patient’s wishes.
A religion that has strictly forbidden suicide is Judaism. The text originating the Jewish belief system arises from the Torah; however, the Talmud is considered the book that encompasses ethical principles of the religion as interpreted by thousands of Rabbis. Religious beliefs in the Jewish faith are focused strongly on the preservation of human life. With regards to suicide, the Talmud is direct, in that it states, “With regard to one who injures himself, although it is not permitted for him to do so, he is nevertheless exempt from any sort of penalty.” With regards to the mourning observed in this situation, “For him who takes his own life with full knowledge of his action rites are to be observed … There is to be no rending of clothes and no eulogy.” Even with regards to assisted suicide, there appears to be direct discouragement by stating, “Do not put a stumbling block before the blind,” in which “stumbling block” refers to behavior that leads to sin or other destructive behaviors. With regards to research on how this belief system correlates to suicide rates, it appears that holding on to this doctrine resulted in a negative correlation of -0.26 between the Jewish population and suicide rates. The Jewish patient’s culture and religion play a significant factor in the fight against suicide, compared to the other two religious viewpoints mentioned earlier. This faith even prevents physician-assisted suicide, but if a patient requests this, then the autonomy of the patient and the religious dichotomy will need to be explored further.
In Pakistan, a predominantly Islamic area, it appears that the rate of reported suicide is fairly low. However, it is important to consider that the Qur’an also strictly forbids suicide and states, “And do not kill yourselves, surely God is most Merciful to you.” Within a culture that takes into account the religious aspects of suicide, the reported rates of suicide in Islamic countries is significantly low due to it being illegal in such countries. The Islamic Medical Association of North America (IMANA) also considers withdrawal of food and drink to hasten death impermissible and considers it homicide. A study looking at the rate of suicide among those who identified with the Islamic faith across 27 countries, even in countries that were not governed by Islamic law, showed a negative correlation between those who completed suicide and those identifying as Muslim, accounting for socioeconomic factors. This result shows that those who follow the Islamic faith are not swayed by migration to another country that does not have legal statutes in order to prevent punishment for suicide. This suggests that religion for the Muslim patient is an intrinsic motivator against suicide.
When considering these various cultural and religious views on suicide, it appears that religious views became more rigid on the topic as history progressed. It appears as if what can be considered “harm” has yet to be defined, whether it is considered the harm of death or the harm of pain. Furthermore, in our current ethical understanding, all physicians are asked to advocate for the patient’s interests. Recently, with the development of the idea of “rational suicide,” there appears to be more consideration given to the patient’s culture and beliefs. Advocating for a patient’s interests includes taking their religion and culture into account, however, this can effectively clash with the physicians’ beliefs and culture, and the ethical consideration of beneficence of the profession. The combination of the ethical oaths of physicians and the religious and cultural beliefs influencing the autonomy of the patient is a grey area that is difficult to resolve, but vital to consider in every patient encounter.