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Ayurvedic Philosophy, Theory...

Ugra Karma: End of Life Ethical Considerations
Suddha Ayurveda:The Lineage of the Bhagavata Kavirajas
Vikriti Vijnana: Ayurvedic Pathology


by Kj. Nimai Nitai Das

Sooner or later, every Ayurvedic preceptor and practitioner must answer inevitable queries from a student or patient regarding extreme medical interventions. Although I have responded often to such questions over two decades of instruction and practice, a recent inquiry from an allopathic medical student has triggered a deeper examination of the ontological and moral underpinnings that inform Ayurvedic ethics.

An Indian student currently in the midst of a rotation as part of her residency in organ transplantation at a leading medical school in Boston recently participated in “harvesting” a working heart from a 12-year-old boy in a persistent and irreversible vegetative state. Her questions were both sober and sobering:

“Does the removal of the live heart constitute hatya (killing, slaying)? What is the Ayurvedic perspective on donating organs after death? What are the implications for the jiva (soul) upon leaving the body, if one or more organs are transplanted and the rest of the body is cremated?

“What are the implications for organ recipients? If the body is so ill that vital organs are beyond repair, should we accept that as an indication to forego the transplant and simply prepare for death?”

The traditional Vedic understanding is that the jiva (soul) resides in the heart (Prasna Upanishad 3.6, Brhad Aranyaka Upanishad 4.3.7). When the jiva departs the heart, that is the actual moment of physical death. There is no mention in the sastra of any other measure or standard for ascertaining physical death (Chandogya Upanishad 6.11.3). So, if the heart is beating, one must conclude that the jiva is animating the body, and harvesting the organ is considered hatya, killing.

Donating organs after death does not involve killing the patient, but does present other problems. The jiva (except in the case of divine personalities, such as paramahamsa sannyasis) is attached to its physical frame, and will hover and linger over it while in a recognizable form, even after physical death. Therefore, cremation is meant to accelerate the process of disintegration of the material form. As a rule, the skull is crushed during cremation, so that the incineration is complete, and the life force together with the senses (traditionally known as the pranas), are properly released. Thus, those who are attached to embodied life should not donate their organs, as their sukshma and karana shariras (subtle and causal bodies) may transfer such attachment to the physical body of the recipient. Conversely, for these same reasons, anyone receiving organ donations is subject to the influence of the donor’s sukshma and karana shariras.

Important as these specific considerations are, the central issue raised by these questions is how much do we resist the natural processes of aging, decay, and death? When do we accept the inevitable? The sastra say clearly, “One who has taken his birth is sure to die.” (Bhagavad-Gita) And that is certainly the uncontroverted experience of all embodied beings throughout history. We do not and cannot “save lives;” we only postpone death –but at what personal and social cost?

Organ transplantation is but one of the medical procedures that unquestionably fall in the category that Srila Bhakti Vinoda Thakura has labeled “extraordinary endeavors to keep body and soul together.” Not only do they constitute bhukti (attachment to and gratification of the physical and subtle bodies), but also should be avoided as ugra karma, a term defined as “difficult action with limited rewards.”

End of Life
The death process follows the following general pattern, although some stages can be abbreviated to the point of imperceptibility, while others can be extended considerably. In the terminally ill, prana (life force) becomes debilitated and begins to withdraw from the sthula sharira (physical body). In most patients, this gradual retreat of prana is accomplished in an orderly fashion, with the life force withdrawing in set ways: from the periphery to the center; from less vital to more vital organs; and from the lower torso towards the head. Once prana has retreated from the physical body, the karmendriyas (faculties of action) are inoperative. The second stage consists of the withdrawal of prana into the sukshma sharira, consisting of mind, intelligence, and ego. When prana retreats from the jnanendriyas (faculties of perception), the patient loses awareness of the external environment and sinks into unconsciousness.

In the third stage, prana withdraws into the karana sharira (causal body, consisting of ahankara). Because the sukshma sharira is incapable of exerting its organizing influence over the physical body through the medium of prana, the four elemental states of matter begin to disintegrate. (The fifth state, ether or space, is the field in which the other four states manifest, and thus cannot disintegrate, having no parts.)

Dhatus (bodily tissues) in the solid state lose cohesion, and the patient experiences a corresponding loss of body consciousness. Then the dhatus in the liquid state disperse, causing the mucous membranes to desiccate. As the dhatus in the radiant state disintegrate, the body loses warmth, and rigor starts to set in. Finally, the dhatus in the gaseous state dissolve, and the patient expires. It is at this point that the jiva leaves the heart, and is carried away with the sukshma sharira.

Ayurvedic practitioners aware of this orderly process can be immensely helpful to patients and their families, assuaging their fears and reassuring them of the immortality of the jiva, even in the midst of this experience. Chanting the Lord’s Names, recitation of prayers, scriptural readings, and the performance of other religious rites (according to the faith of the patient), are highly recommended, and constitute an integral part of Ayurvedic care of terminal patients.

Of course, palliative measures can and should be employed whenever possible to mitigate pain and suffering, but the clouding of consciousness through the use of excessive anodyne therapy should be avoided, as a conscious exit from this plane is beneficial for spiritual evolution. Death should be approached as sadhana (spiritual practice) by patients, relatives, and the Ayurvedic practitioner.

Prolongation of Life

Ayurveda classifies disease as either sadhya (remediable) or asadhya (irremediable). Among irremediable diseases, some are yapya (chronic but manageable, such as diabetes), and others are pratyakheya (terminal, such as metastasized cancer). In terminal conditions, Ayurveda considers that only palliative measures are indicated.

DNR Orders

Ayurvedic practitioners accept the natural rhythm of life and death, and do not engage in ugra karma to prolong life (suffering) at great effort and expense. An informed patient with a terminal condition should discuss his or her preferences, and make legal provisions to insure that they will be respected. If the patient has given an explicit Do-Not-Resuscitate order, it is the duty of the Ayurvedic practitioner to assist in its observance.

Removal of Life Support

According to Vedic principles, removal of life support systems is justified when the assistive device is the major impediment to the death process. Ayurveda also allows for suspension of hydration and nourishment at the request of a terminally ill patient who chooses to fast, even if such fasting will accelerate death. Prayopavesha, voluntary fasting unto death for those who are terminally ill, is to be undertaken only under the authority and with the blessings of senior members of the patient’s faith.

Assisted Suicide

Ayurvedic ethics do not condone so-called assisted suicide, deliberately causing the death of a patient at his/her request by any lethal means. If requested by the patient, Ayurvedic practitioners may describe —but not actively recommend— prayopavesha (voluntary fasting unto death) as a viable means to abbreviate prolonged suffering.

Suicide

According to sastra, suicide postpones and intensifies karma. However, as stated above, Ayurvedic ethics allow prayopavesha, voluntary death by fasting. The patient making such a decision must declare it publicly, to distinguish the act from suicide committed privately in traumatic emotional states of anguish and despair, and to allow for family and religious community intervention. Prayopavesha is allowed when the patient is unable to perform normal bodily purification, death appears imminent, and pain and suffering are extreme (such that mitigating them would entail loss of consciousness). Prayopavesha is gradual, and allows the patient to reflect and reconsider his/her decision. After due deliberation, voluntary fasting unto death should be undertaken as sadhana, with the support of a community of faith.

Autopsy, Dissection, Embalming

Invasive procedures performed on the physical body after death distress the departed jiva, unnecessarily postpone final disposition, and may affect family members negatively. For these reasons, Ayurveda understands that autopsies should be avoided unless required by law, and dissection of cadavers for the advancement of science is also discouraged. Embalming, or replacing the blood with a preservative fluid, is also contraindicated. In addition to the reasons mentioned above, embalming retards the decomposition of the physical body, promoting lingering attachment of the jiva for its deceased instrument.

Final Disposition

Cremation is the preferred system of disposing of cadavers, and should be performed within 24 hours of death. Due to the accelerated decomposition of the physical body accomplished by fire, cremation thoroughly releases the jiva from any lingering attachment to the physical instrument. Burial is not recommended, except for infant children and divine personalities.

I trust that the discussion of these principles and guidelines will assist all practitioners of Ayurveda to face these unavoidable ethical dilemmas with greater aplomb and certainty. Even those who do not share these Vedic perspectives may gain from the experience, as they will have had an opportunity to consider these issues before confronting them in clinical practice.

I pray that our patients will be better served. For, in the words of Acharya Charaka: “Those who practice Ayurveda while holding compassion for all creatures as the highest duty have fulfilled their mission. They obtain supreme happiness.”


Kj. Nimai Nitai Das (formerly writing for this journal as Murari Chaitanya dasa) is a Preceptor in the Suddha Ayurveda Vidyalaya, and an Asst. Clinical Professor of Family Medicine & Community Health at Tufts University School of Medicine. He can be reached at PositiveAyurveda@comcast.net


Suddha Ayurveda: The Lineage of the Bhagavata Kavirajas

by Kj. Murari Caitanya-dasa, ND, MPH

sreyas ca preyas ca manusyameta-
stau samparitya vivinakti dhirah
sreya hi dhiro'bhipreyaso vrnite
preyo mando yogaksemad vrnite

Translation: "We can accept either that which is immediately appealing (preyas) or that which is permanently beneficial (sreyas). The wise, after careful consideration, accept that which is enduringly salutary, whereas those whose judgement is poor prefer fleeting gain and pleasure. (Katha Upanisad 1.2.2) "

Order complete article here

om namoh bhagavate dhanvantaraye

Kj.Nimai Nitai Das a is Sevaite-Preceptor in the Suddha Ayurveda Vidyalaya, which follows the traditional Tola system of Vedic education. He resides in the Guardian Sevaite Ashram in Boston, MA, where he is an ordained priest in the Bhagavata lineage. He is Assistant Clinical Professor of Family Medicine and Community Health at Tufts University School of Medicine. Email


Vikrti Vijnana
(A Traditional Exposition of Pathology in Suddha Ayurveda)

by Kj. Nimai Nitai Das

After submitting a number of discursive articles for Light on Ayurveda Journal, the author desires to introduce the esteemed readers to the traditional pedagogical methodology of the Bhagavata lineage of Suddha Ayurveda.

The sutras constitute an exploration of the doctrine of pathology (vikrti vijnana) in Suddha Ayurveda. Sutras (aphorisms) are concise statements that elucidate complex subject matters. Because they often require extensive commentary to facilitate understanding, aphoristic texts have fallen into disuse in the West, particularly in scientific exposition.
Order complete article here

om namoh bhagavate dhanvantaraye

Kj.Nimai Nitai Das a is Sevaite-Preceptor in the Suddha Ayurveda Vidyalaya, which follows the traditional Tola system of Vedic education. He resides in the Guardian Sevaite Ashram in Boston, MA, where he is an ordained priest in the Bhagavata lineage. He is Assistant Clinical Professor of Family Medicine and Community Health at Tufts University School of Medicine. Email


Ugra Karma
(End of Life Ethical Considerations)

by Kj. Nimai Nitai Das

Sooner or later, every Ayurvedic preceptor and practitioner must answer inevitable queries from a student or patient regarding extreme medical interventions. Although I have responded often to such questions over two decades of instructions and practice, a recent inquiry from an allopathic medical student has triggered a deeper examination of the ontological and moral underpinnings that inform Ayurvedic ethics.

An Indian student currently in the midst of a rotation as part of her residency in organ transplantation at a leading medical school in Boston recently participated in "harvesting" a working heart from a 12-year-old boy in persistent and irreversible vegetative state. Her questions were both sober and sobering:

"Does the removal of the live heart constitute hatya (killing, slaying)? What is the Ayurvedic perspective on donating organs after death? What are the implications of the jiva (soul) upon leaving the body, if one or more organs are transplanted and the rest of the body is cremated?

Order complete article here

om namoh bhagavate dhanvantaraye

Kj.Nimai Nitai Das a is Sevaite-Preceptor in the Suddha Ayurveda Vidyalaya, which follows the traditional Tola system of Vedic education. He resides in the Guardian Sevaite Ashram in Boston, MA, where he is an ordained priest in the Bhagavata lineage. He is Assistant Clinical Professor of Family Medicine and Community Health at Tufts University School of Medicine. Email


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