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Health Law / Medical Ethics

SALLEKHANA: THE ETHICALITY AND LEGALITY OF RELIGIOUS BY STARVATION IN THE JAIN RELIGIOUS COMMUNITY

Whitny Braun∗

Abstract: This article examines , the Jain religious ritual of to , from the American and Indian legal and ethical perspectives. Two cases are presented, the first involving a woman in her twenties who ritually starved herself to death to escape the torment of a voice in her head and the second case involving a woman in her sixties diagnosed with terminal cancer of the brain and liver who chose to starve to death rather than accept palliative care. Both cases of Sallekhana are analyzed with attention paid to the Jain theological rationale behind the practice and the social circumstances that predicate this vow of starvation. I argue that within the moral presumption should be that Sallekhana is a valid religious ritual of dying and therefore should be legally protected, if and only if, it is freely chosen by an informed person free from coercion.

Keywords: Sallekhana; ; India; religious suicide; starvation; medical ethics;

INTRODUCTION

Sallekhana, also known as santhara and samadhi-marana, is a centuries old religious ritual of starvation, considered by members of the Jain faith tradition to be the ideal form of death. For nearly two millennia the practice was an unquestioned and uncontroversial religious rite. However, the status of Sallekhana changed on

September 24th, 2006 when human rights activist Nikhil Soni and his lawyer Madhav

Mishra, filed a Public Interest Litigation (PIL) with the High Court of Rajasthan. The

PIL claims that Sallekhana is a social evil and should be considered akin to suicide under Section 309 and Article 21 of the Indian Constitution, which guarantees the . The legal petition also charges members of the Jain community who facilitate and support individuals taking the vow of Sallekhana with

∗ M.P.H., Candidate for M.A. in Biomedical and Clinical Ethics, Loma Linda University, Loma Linda, California, of America. 1

aiding and abetting an act of suicide.1 For the 4.2 million Jains living in India this legal petition is seen as a dismissal of the ancient philosophy they follow and a violation of Article 26 of the nation’s constitution, which guarantees the freedom of , and for the Jains, the right to die.

This legal battle has led to a debate over right-to-die issues in India, where bioethics is a relatively new phenomenon (Puri 2005). The status of Sallekhana as a legal form of death has been accepted because of its religious affiliation, but is banned and attempted suicide is an offense punishable by jail time. Hunger strikes are a common form of protest in India but often result in the protestors being forcibly hospitalized and charged with a criminal offense. In the 1996 case of Gian Kaur v

State of Punjab2 the ruled that the right to live cannot be interpreted to include the right to die an unnatural death curtailing the natural life span

(Mani 2003).

Creating a bioethic that satisfies the philosophical and religious teachings of the multiple faith traditions of India is a daunting task, but what is perhaps even more challenging is the task of establishing an inter-faith and legal dialogue to address the issue of Sallekhana in the United States where there are between 60,000 and 100,000 practicing Jains (Kumar 1996) and there has been at least one documented case of

Sallekhana (Davis 1990). The Jain community is adamant that Sallekhana is not comparable to suicide or euthanasia but is instead an act of spiritual purification and an exercise in autonomy. In a rapidly shrinking global community Sallekhana is increasingly becoming a matter of legal and ethical contention.

1 See Nikhil Soni v. Union of India and Ors. AIR (2006) Raj 7414. 2 See Gian Kaur v. State of Punjab. AIR (1996) Supreme Court; 83:1257-65. 2

RATIONALE OF SALLEKHANA

By virtue of its teachings, particularly the belief in the sacredness of

Sallekhana, Jainism poses serious ethical dilemmas for the medical community encountering practicing Jains in the clinical setting as well as for members of the non-

Jain community whose personal ethics contradict Jain belief. For many people raised in the Western monotheistic traditions and particularly those in the medical profession in the United States the notion of deliberately acting to bring about one’s own death is viewed as both immoral and illegal. In fact, for the of the Abrahamic tradition, Jain theology is anathema. On a theological level it could scarcely be more different from Christianity, Judaism or Islam (Laidlaw 1995). In the United States where the influence of the monotheistic tradition’s understanding of right and wrong is so strong, finding a common ground may prove challenging.

For Jains Sallekhana is understood to be the most peaceful and satisfying form of death and so in discussing the rationale behind Sallekhana a critical question comes to bear: how exactly is Sallekhana a non-violent, and thus spiritually superior method of ending life? It would seem that slowly starving to death is an act of violence against oneself. Whether or not starvation is painful is ultimately unique to the individual but depending upon the person’s general health certain vitamin or mineral depletion or electrolyte imbalances, along with intolerance for cold temperatures, dizziness, hair loss, extreme fatigue and ringing in the ears can be extremely painful and distressing

(Keys, Brozek et al. 1950) (Kalm and Semba 2005). Jains acknowledge that while on the one hand Sallekhana is seen as a non-violent, even euphoric death, the suffering one experiences while in the process of starving allows the Sallekhana adherent to more fully understand the inherently painful and flawed nature of earthly existence.

Additionally Jains view the process of starvation as the ideal method of exiting this

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world in that they stop sustaining their own life at the cost of the other life forms they would otherwise consume.

The Jain’s preferred method of meeting death cannot be properly understood independent of . For Jains it is understood that the supreme goal of the individual is to minimize the damage one does to their environment and thus to tread as lightly upon the earth as possible. Also, for Jains it is accepted that religious devotion is difficult and often times painful. is revered and practicing ascetics are worshipped (Babb 1994). To appreciate the importance of asceticism and its ultimate expression in the form of Sallekhana it is helpful to know the origins of

Jainism.

ORIGINS OF JAINISM

The tradition, which may have originally began as a sect of , traces its roots to a succession of 24 individuals, known as Jinas or Tirtankaras, in ancient East India.

These Jinas are believed to have achieved the highest level of earthly incarnation and as a result Jains attempt to emulate the practices of these 24 people. Jainism is split into two sects, the Digambar and the Shwetambar. The exact reason for the split is not known but it is believed that sometime around the 5th century geographical factors played a role with the Jains of the Indian state of Gujarat evolving into the

Shwetambars and the Jains of the surrounding states evolving into the Digambars

(Roy 1984). While the doctrine of the two sects is largely the same, there is debate between the Digambars and Shwetambars over the issue of clothing, whether all of the Jinas were men, whether women are capable of achieving , and whether or not the Jinas were capable of experiencing disease. Shwetambars wear white robes, believe that the nineteenth Tirtankara was a woman named Mallahkumari and in the

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concept of Sabastra Mukti, that women can attain salvation. They also accept that

Jinas are capable of experiencing illness. Digambar Jains on the other hand, believe that a woman can observe the great vows and lead a true Jain life, but owing to certain physical infirmities peculiar to her sex, she cannot attain liberation in this life, but can do so in a future life if she is reborn as a man. Digambars also believe that

Tirtankaras do not experience illness and they believe that the ninetheenth Tirtankara was a man named Mallinath (Choudhury 1956; Jaini 1979). Despite the aforementioned debate over female religiosity, both sects hold the same negative understanding of female nature as flawed and associated with sexuality and sin

(Vallely 2002) . Interestingly, Shwetambar Jains, particularly Shwetambar women are statistically more likely to take the vow of Sallekhana (Baya 2006).

The rationale behind Sallekhana comes from the Jain belief in , rebirth, asceticism and spiritual purification. Jainism teaches that the every living creature has an immortal soul called a jiva, which has consciousness and intelligence and which ideally should be able to ascend to the summit of the universe and achieve omniscience (Varni 1999). However it is karma that prevents the immaterial soul from achieving liberation. It is important to note that the concept of karma in Jain theology is very different from the understanding of karma in American popular culture. In American popular culture karma is often associated with notion of “what goes around comes around”, and a generalized belief that good deeds are rewarded and bad deeds are punished. However, for Jains karma is a much more sophisticated and developed belief system. The physical body is viewed as a prison for the soul and it is believed that karma is responsible for keeping the soul trapped within the body.

Karma is understood to be an invisible supernatural substance composed of very fine particles that permeate the soul determining what physical form the soul will take. It

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is the accumulation of karma that determines the form in which a soul is reincarnated.

The deliverance of the soul from karma is achieved through strict asceticism whereby the soul hinders the or tiny particles of matter from infusing the soul and purge the old karmas before they are realized in the next life (Glasenapp 1991).

In order to limit the amount of karma a soul accumulates Jains adopt the vow of ahimsa or non-violence. By not interfering with the will of other creatures and not causing suffering Jains seek to accrue as little karma as possible and to be reborn into better circumstances than they experienced in their previous lives. Better circumstances can range from being reborn in a healthier more attractive physical form to being born into a wealthy and respected family. Conversely, the accumulation of karma can result in rebirth in a body with a disability or rebirth in the body of a lower life form such as a plant or an insect.

The understanding of karma as being the causal factor in the fortunes of individuals explains why physical infirmity is viewed as the fault of the individual afflicted with the disability. According to Jain scriptural law people are disqualified from inheriting property if they are suffering from impotence, a congenital disease or an incurable disease, a psychiatric disorder, lameness, blindness, deafness, amputation of a limb or having been born without a limb and any other disorder that is permanently crippling

(Jain 2004). Ultimately, regardless of the physical form one is born into suffering is inevitable, thus the goal is to achieve spiritual liberation or , breaking free from the mortal body and floating into the ether to spend eternity in a state of bliss.

Because the principal belief in Jainism is that of ahimsa or non-violence, Jains go to great pains to avoid acts of violence. Some of the measures they take include

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sweeping the ground before them so as to avoid stepping on tiny insects and plant life and wearing a mupatthi or piece of cloth over their mouths to avoid inhaling airborne microorganisms and insects. The tradition espouses a peculiar form of vegetarianism, allowing the consumption of milk because it does not harm the cow but forbidding eggs, which are viewed as potential life forms and thus potential bodies for souls.

Jainism also has a hierarchical ranking of foods according the amount of karma that is accumulated as a result of eating particular food items. For example, a strawberry carries more karmic weight than a mango because a mango has only one seed and the potential to create only one more life whereas a strawberry has multiple seeds and the potential to spawn multiple lives. Whether one eats a mango or a strawberry an act of violence is committed, however if given the choice, the mango would be considered the less violent alternative. The pursuit of non-violence extends into the workplace as

Jainism discourages professions which involve violence towards other souls, such as farming which disturbs plant life and any work with livestock which harms the animals (Jain 1999). Today, as a result of centuries of avoiding professions that are seen as “violent” towards life, many Jains are engaged in finance and commercial banking as well as the diamond trade.

Sallekhana exemplifies the emphasis that Jainism places on austerity. For Jains non- violence is intimately connected with non-action. Their elaborate practices of nonviolence are about neither minimizing death nor saving life, but about keeping life

‘at bay’ which essentially amounts to an attempt at the “avoidance of life” (Laidlaw

1995). The belief is that self-starvation, while engaged in mediation, serves to prevent the accumulation of karmas as well as assisting the soul in spiritual purification.

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Jainism is often confused with Hinduism but in is much more closely related to

Buddhism, both historically and philosophically, as both trace their origins to the same region of north India in the fourth century BCE. Both place significant value on world renunciation although Jainsim arguably emphasizes adherence to strict asceticism much more. One particular act that ascetics practice, and which is totally unique to Jainism is that of kesá-loca, which involves slowly and painfully pulling the hair from the scalp in five handfuls. This process of plucking head hair in this way signifies the ascetic’s determination to successfully meet the demands of a true Jain ascetic life (Jaini 1979). , the founder of the Jain tradition, is believed to have practiced kesá-loca and to have attained enlightenment after 13 years of strict asceticism when in 420 BCE, he took the vow of Sallekhana, thus ending his cycle of birth and rebirth. Since that time followers of Jainism have held the practice of

Sallekhana as perhaps the most sacred rite in the faith.

For centuries the practice of Sallekhana has been regarded in Jain canonical texts as an auspicious act in accordance with the highest ideals in Jainsim. It is ubiquitous, practiced and revered by laity as well as and nuns of the Digambar and the

Shwetambar sects. It has aroused almost no dissent or controversy within the Jain tradition and is vehemently defended against any threat or criticism from outsiders

(Tukol 1976; Laidlaw 2005).

THE FINAL VOW

Sallekhana, in Jain thought, is embracing death voluntarily. The origin and definition of the word are unclear but the most commonly accepted definition is “properly thinning out the passions of the body” (Jaini 1979). When both lay Jains and ascetics foresee that the end of life is very near either due to old age, senility, incurable disease, severe famine, attack from an enemy or a wild animal, etc. they take the vow 8

of Sallekhana, committing themselves to slow starvation (Tukol 1976; Sogani 2005).

Any Jain who is faced with any of the above mentioned ailments can approach their guru and express their wish to take the vow of Sallekhana. They do so by saying the words:

Please instruct me sir. I have come forward to seek…Sallekhana, (the vow of) which will remain in force as long as I live. I am free of all doubts and anxieties in this matter. I renounce, from now until the moment of my last breath, food and drink of all kinds (Jaini 1979). Assuming that permission is granted the person either decides independently or consults with their physician as to the approximate amount of time he or she has left to live and then develops a program of fasting to coincide with their vow of

Sallekhana. Increasingly Jains are seeking the permission or at least an opinion from their Jain physician before asking the permission of their guru3.

According to Jain teaching, a member of the laity, who accepts this vow with should gives up all personal relationships, friendships, and possessions. He or she should forgive relatives, companions and servants or acquaintances and should ask for the pardon of all the sins he or she committed in his or her lifetime (Sogani 2005). He should then discuss honestly with his preceptor or guru all the sins committed by him including sinful acts which he asked others to commit, and sins he encouraged others to commit. During the period of this vow he should eliminate from his mind all the , fear, regret, affection, hatred, prejudice, passions, etc., to the fullest extent. It must also be understood by the person taking the vow of Sallekhana that should their disease be miraculously cured, or their diagnosis turn out to be a false positive the vow of Sallekhana may not be rescinded (Jaini 1979).

3 This trend was observed by the author during a series of interviews conducted with Jain physicians practicing in Madhya Pradesh, and Rajasthan, India in June 2006. 9

The actual act of Sallekhana is typically done in either the family home or in a special fasting hall. At times there may be more than one person practicing Sallekhana in the same building at the same time and a steady stream of pilgrims coming to pay their respects. While a person practices Sallekhana they do so knowing that they have no more worldly responsibilities. They will have turned all of their wealth over to their family and they will sequester them self away to avoid distraction. Though the person may be in relative seclusion, Sallekhana is not a completely private matter. Often the relatives will publicize the event by taking out ads in local newspapers celebrating the choice their loved one has made. When the person eventually dies it is not uncommon for the body to be displayed before .

SALLEKHANA VERSUS SUICIDE

Suicide and Sallekhana are two very different concepts in Jainism. In fact, suicide is absolutely forbidden in Jain teaching as it is considered an act of violence and thus a violation of the vow of ahimsa. Fasting is seen as the cessation of violent acts toward the living beings that are consumed for nourishment and the meditation that one engages in simultaneously serves to purge the soul of karma as well as preparing the soul for rebirth.

The notion of self-starvation as the ideal form of death is diametrically opposed to the western bioethic, which has been largely inspired by the monotheistic religious traditions’ understanding of the body as the temple of God.4 Jewish law forbids the taking of life but the Talmud gives the individual the right to ask God for death to come quickly. In Islam the Qur’an (3:145) says it is not given to any soul to die, save

4 The Bible in 1 Corinthians 3:16-17 reads, 16Don't you know that you yourselves are God's temple and that God's Spirit lives in you? 17If anyone destroys God's temple, God will destroy him; for God's temple is sacred, and you are that temple.” 10

by the leave of God, at an appointed time. In Judaism, because it is believed that every person’s body belongs to God, no one has the right to take life, and anyone who assists another in the taking of their own life commits by proxy (Dorff 2005).

Traditional Christianity regards suicide as self-murder and physician- and euthanasia are forms of self-murder and direct murder (Englhardt and Iltis 2005).

In Islam suicide is unquestionably wrong, and the killing of a terminally ill person, whether through voluntary active euthanasia or physician assisted suicide, is judged an act of disobedience against God (Sachedina 2005). But for Jains, the body is not the temple of God, rather it is the prison of the soul and this belief supercedes the scriptural basis and Kantian deontology employed by western bioethics as the guiding principle in end of life decisions for followers of the faith. The general understanding of the body and soul relationship can be ascribed to Hinduism and though in general Hindu bioethics holds to the position that no person may morally hasten his or her own death or the death of another person by direct means (Crawford 2003).

The practice of religious suicide through starvation is not totally unique to the Jains5, however what is distinctive about the Jain practice of Sallekhana is that such an extreme measure as slowly depriving oneself of food and self-inflicted suffering can be so entrenched in the belief system and culture as well as being so consistently practiced (Laidlaw 2005). Not every Jain takes the vow of Sallekhana but each and every Jain has the option open to them. It is a form of death for the young and the old, the and the nun, and the layman and laywoman. It is the ideal death for a

Jain, the ultimate goal of the living.

5 On the topic religious suicide in Buddhism see Damien Keown, Buddhism and Bioethics, 2001, : Palgrave, 58-62. Also see Martin G. Wilshire, “The ‘Suicide’ Problem in the Pali Cannon,” The Journal of the International Association of Buddhist Studies, 6:2, 124-140. 11

SALLEKHANA AND THE LAW

TRIUMPH THROUGH DEATH: THE CASE OF KIRIN6

Kirin, a Jain nun in her twenties, was in her first year in the monastery when she began reporting that she was being tormented by what she claimed was the spirit of her lover from a past life. As months passed Kirin’s complained more frequently about the disembodied voice harassing her. One night while the other nuns of the monastery were at prayer they heard screaming coming from Kirin’s room. An elder nun entered the room to find a fire burning in the center of the room and Kirin shaking and complaining of a headache. When the elder nun examined Kirin she found that her ponytail had been torn out and her scalp bleeding. Kirin told the elder nun that she believed the voice to be that of her husband from a past life and he had revealed to her that she had accidentally killed him. He still loved her but wanted revenge. Kirin also reported that the spirit planned to kill her so they could be reunited in the next life.

In the following months Kirin complained more often of instances in which the spirit would hurl objects at her and start fires in her room. She even spoke of attempts by the spirit to strangle her. Kirin exhibited signs of physical abuse and reported that she only experienced relief from the torment of the spirit when she engaged in meditation and fasting. She also reported that the intensity of the attacks increased when she not engaged these rituals.

6 The details of this case are drawn from Guardians of the Transcendent: An Ethnography of a Jain Ascetic Community, (2002) : Toronto University Press by Dr. Anne Vallely who conducted thirteen months of fieldwork in the Terapnathi Shvetamabar Jains ascetic community of Ladnun, Rajasthan, India. 12

Kirin believed that if she died before becoming a Jain ascetic or sadhvi she would be linked with the man’s spirit for eternity, unable to achieve nirvana. She felt her only choice was to renounce the world and take the vow of Sallekhana, thus freeing herself of the spirit in the next life.

With permission from her guru, Kirin took the vow of Sallekhana. She grew weak and became unable to speak as her mouth filled with sores. On her deathbed she was initiated as a sadhvi. After 49 days without food and very little water she died.

THE IDEAL END: THE CASE OF VIMLA DEVI

The case of Sallekhana that brought about legal action in the Indian state of Rajasthan is that of Vimla Devi, a 61-year-old Shwetamabar Jain woman diagnosed with a brain tumor and leukemia. With the blessing of her husband, family and Jain clerics Vimla

Devi died in her home after 13 days of fasting. Human rights activist Nikhil Soni attempted to break her fast by informing the local police and requesting they take action. He argued that Sallekhana is akin to the practice of , in which Hindu widows immolate themselves on their husband’s pyres. Police told him that they needed clarification as to what the legal precedent was for interrupting a person’s religious fast was before they could act. Vimal Devi died in the intervening time and as a result Nikhil Soni filed a civil writ with the court. Now the issue of Sallekhana as a legal means of terminating one’s life is being heard in the court for the first time in India’s history.

THE JUSTIFICATION OF SUICIDE

The concept of a terminal cancer patient fasting to death is not as distasteful to the

Western ethic of clinical medicine as perhaps the thought of a perfectly healthy

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twenty-something fasting to death for spiritual purification and yet it was the relatively uncontroversial case of Vimla Devi that served as the impetus for the

Sallekhana debate and not the case of the Jain nun Kirin whose story is the most celebrated case of Sallekhana in recent Jain history (Vallely 2002).

Kirin’s story poses some of the more challenging ethical questions related to

Sallekhana. Cases which involve the elderly, the chronically ill and those with terminal medical conditions fit more easily into the guidelines of the western medical ethical perspective. This is due in large part to the fact that the mental status of these individuals is not in question. The four moral principles of medical ethics: autonomy, nonmaleficence, beneficence and justice (Beauchamp and Childress 2001) give a framework for analyzing the ethics of Sallekhana practiced by these individuals. It can be argued that the terminal cancer patient is protected under the principle of nonmaleficence from having to endure the pain and suffering associated with chemotherapy and radiation. It can also be argued that the elderly person who has all of their faculties has the right of ending their life with quality and dignity under the principle of autonomy. But in the case of Kirin, a perfectly physically healthy young woman who believed she was being haunted by the of her dead lover from a past life, there are issues of mental stability and questions regarding her ability to make rational, beneficial decisions for herself.

In the Jain community, especially among the Terapanthi Jains of Rajasthan, Kirin is regarded as an admirable and almost saintly example of a person conquering their humanity and attachment to worldly things for spiritual advancement. Kirin’s death, believed to be completely dispassionate, was cause for celebration. People filled the streets and cheered as a procession carrying Kirin’s body posed in the meditative

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position passed by. After Kirin’s cremation two books and several pamphlets recounting Kirin’s spiritual triumph were published and circulated, making her story a part of Terapanthi Jain folklore (Vallely 2002).

As there are no ascetic Jain communities in the United States it is impossible to analyze the medical ethical and legal ramifications of Kirin’s decision and the decisions of her fellow nuns in an American context. However if the geographical and cultural circumstances of the case are removed Kirin can be viewed as a young woman, suffering from psychosis with suicidal tendencies. If Kirin had been seen in the American clinical setting she would likely have been referred for psychiatric counseling and if she had insisted on proceeding with her fast she may have been forcibly fed through a nasogastral tube owing to her diagnosed impaired mental capability.

In the case of Vimla Devi, her choice to starve to death after having learned from her physicians that there were no further medical options available to her would very likely not have raised many eyebrows in the American Medical community. It is not uncommon for the elderly and terminally ill in hospitals and skilled nursing facilities in the United States to refuse food and water and pass away without objection or interference from medical professionals. In a study conducted by (Ganzini, Goy et al.

2003) questionnaires were mailed to all nurses employed by hospice programs in

Oregon and analyzed, with 33% of nurses reporting that in the previous four years they had cared for a patient who deliberately hastened death by voluntarily refusing food and fluids. Nurses reported that patients chose to stop eating and drinking because they were ready to die, saw continued existence as pointless, considered their quality of life poor and viewed of controlled death by refusal of nourishment as a

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good death. The survey also showed that 85 percent of patients died within 15 days after stopping food and fluids. Whether or not there was a religious aspect involved in the decision was not fully discussed but the parallels between the phenomenon of refusal of food and fluids by the elderly in the United States and the vow of

Sallekhana practiced by Jains in India and the United States are striking.

Kirin’s case raises ethical issues very different from those raised by refusal of nutrition and hospice care, but it somewhat parallels the case of Elizabeth Bouvia, a

26-year-old hospitalized quadriplegic woman who sued the state of California to keep the hospital staff from inserting a nasogastral tube to prevent her from starving herself to death. The court ruled that Bouvia had the right to refuse medical care and eventually Elizabeth Bouvia was released from the hospital7. However, after several months she entered a private nursing facility and was treated for pain associated with other ailments she suffered from. Today she is still alive but her wish to commit suicide remains. However she has not attempted suicide again because the prospect would be too painful given her pain management regimen.

In the non-Jain Indian, and American clinical and legal settings the fundamental difference between Elizabeth Bouvia and Kirin is the matter of competency.

Elizabeth Bouvia’s competency was never questioned and her quality of life was largely determined by her quadriplegia. Conversely Kirin’s physical state was never compromised, but arguably her quality of life was being lessened by her mental state.

The question to ponder is whether the suffering associated with paralysis from the neck down can be compared to the suffering associated with hearing voices, and if so

7 See Bouvia v Superior Court, 179 Cal. App. 3d 1127, 1135-1136, 225 Cal. Rptr. 297. (Ct. App. 1986), review denied (Cal. June 5, 1986) and Bouvia v County of , 195 Cal. App. 3d 1075, 1080, 241 Cal. Rptr. 239 (1987). 16

should that determine whether or not a person is qualified to make the choice to terminate their life? What is rubric by which a person’s quality of life can be measured? Also, because of Kirin’s social status and culture it is almost beyond the realm of possibility that she would have ever seen a psychiatrist or had the option of being on a prolonged psychotropic drug regimen. In a sense, her condition cannot be viewed as treatable. In this sense both Kirin and Elizabeth Bouvia faced life long pain and suffering.

SOCIAL ASPECTS OF SALLEKHANA

The social pressure to engage in Sallekhana cannot be ignored and perhaps in some cases the issue of social status is more important than that of mental status. Because people who take the vow of Sallekhana are elevated to a position of reverence, admiration and worship, it is difficult to parse out the individual’s true intentions in taking the vow of Sallekhana. For some Sallekhana is undoubtedly a purely religious expression of the desire to conquer the sensual pleasures and pains of this life.

However for others it is unclear whether or not their decision to end their life is motivated by pressure from family for reasons ranging from the economic hardship associated with caring for an elderly relative to the desire of an individual to redeem themselves for shame they may have brought upon their family in the past.

Regardless of the motives, speaking out against Sallekhana is rarely done and it is commonly understood in the Jain community that preventing or interrupting

Sallekhana invites social ostracism. Statistically Sallekhana is undertaken by more women than men (Baya 2006) and some have argued that in this way Sallekhana serves as a means of coercing widows and elderly relatives into taking their own lives and eliminating themselves as a burden to the family.

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Jains maintain that Sallekhana is never forced upon individuals, but it is an intensely personal decision and an exercise in autonomy. However, the case of a nun in her mid-thirties who left the monastery to live as a member of the laity and then returned months later begging to be allowed to return to the life of an ascetic only to be told that she could return on the condition that she take the vow of Sallekhana would suggest otherwise (Vallely 2002).

Proponents of Sallekhana defend the practice on two fronts: religious freedom and autonomy. Sallekhana is not the only case in which religious freedom is exceedingly difficult to define. In general, guarantees the individual the right to believe however he or she chooses. However, when belief manifests itself in an activity that is in direct opposition of civil law the religious acts become a matter for the courts. For example, when the actions associated with exercising one’s right to religious liberty violate other laws, such as Article 26 of the Indian constitution and the United States constitution’s guarantee of the citizen’s right to life, liberty and the pursuit of happiness, then the decision has to be made as to which law takes precedent.

The matter of paternalism in the medical community is especially relevant to the topic of end-of-life decisions. Because Sallekhana is a religious ritual, theoretically its practice should be protected by both American and Indian constitutions. However, the American interpretation of the Hippocratic oath often manifests itself in paternalistic behavior towards patients. It is difficult to imagine an American-trained physician treating a patient such as Kirin and not intervening. However the physician’s efforts may be in vain as case law in the United States has shown that the court favors freedom of the individual to refuse medical treatment over the medical

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advice of physicians (Cohan 2006), except in the case of children as evidenced by cases filed on behalf of the Jehovah’s Witnesses and Christian Scientists (Talbot

1983; Beauchamp 2003).

IMPLICATIONS FOR THE MEDICAL COMMUNITY

Sallekhana is being practiced in the United States. Though official numbers are unknown conversations with members of the Jain community reveals that it is increasing in frequency as more Jains immigrate to the United States. In order for the

United States to maintain cultural pluralism the medical community needs to become familiar with the rules, rationale and rituals associated with this sacred form of self- killing in order to offer Jain patients in the clinical setting effective whole person holistic care and possibly prevent the abuse of the practice of Sallekhana.

Non-Jain clinicians both in India and the United States can lay the groundwork for an inter-faith and inter-cultural dialogue that will help to facilitate a reconciliation of the

American healthcare system’s largely Christian-inspired bioethic with the Jain concept of right knowledge and practice. Is it not maleficence to deprive a person who believes that their soul will be harmed and their future lives negatively impacted by being prevented from engaging in their religiously sanctioned ideal form of death?

CONCLUSION

The normative ethics of Sallekhana constitute a larger and more complicated issue.

For health care professionals from different faith traditions Sallekhana is not only an ethically troubling practice but a morally troubling practice. If Sallekhana, as an institution, is indeed used at times as a means of coercing the elderly, infirm, widowed and generally unwanted members of the society into committing suicide

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then from a Kantian perspective the practice is unquestionably wrong. However, if

Sallekhana is a religious ritual and exercise in autonomy that brings comfort to the dying in their final days then Sallekhana can also be defended from the deontological perspective to be right. Thus, I would argue that Sallekhana must be addressed from a casuist perspective.

To outlaw Sallekhana would be unethical as it is a violation of the right to religious freedom guaranteed not only in the constitutions of the United States and India but by

Article 18 of the Universal Declaration of Human Rights. But for the sake of protecting vulnerable members of the community, both the Jain community and the larger global community attention must be drawn to Sallekhana to prevent its abuse.

For the sake of delivering culturally appropriate counsel and treatment to those members of the Jain community seeking health care it is imperative that medical professionals familiarize themselves with the rules, rituals and rationale of

Sallekhana.

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