A Dialogue between Hindu and Catholic Perspectives in Taking Care of Newborns at their End-of-Life

Abstract

Hinduism is considered one of the most ancient religions in the world. Although the technological innovation of modernization has undermined the reliance on their traditions, Hindus may still rely on Hindu Scripture when making decisions. From their standpoint, contrary to Western medicine, human lives cannot be reduced to statistical and empirical facts. They focus more on preserving the spirit, rather than considering survival as one of the goals of medicine. Consequently, when a preterm infant is born, Hindu parents might struggle to understand the goals of Western neonatologists. This divergence may create misunderstandings when discussing end-of-life decisions. Since they value relational aspects to be of utmost importance, they may accept treatments only in the likelihood of good neurological outcomes. Being able to interact allows Hindus to act virtuously with the aim of purifying their soul toward moksa. When it comes to end-of-life decisions on behalf of newborns, Hindu parents may opt to forgo treatments and let the baby peacefully die, while praying for their soul to have a better rebirth. This paper aims to evaluate quality-of-life assessment in the Hindu tradition in comparison with the Catholic tradition. It draws parallelisms between these two different religions to investigate whether an inter-religious dialogue is possible. This work will help Catholic, and more broadly Western, doctors to have a better understanding of the Hindu end-of-life views.

Introduction

The death of a newborn may result in a traumatic event for the parents. When facing a devastating loss, religious and cultural beliefs may play an important role in helping those involved find answers and establish coping mechanisms. Western healthcare providers committed to the care of infants may engage in conversations with families that share different cultural and religious backgrounds compared to Western traditions. This paper aims to highlight differences and draw potential parallelisms between Hindu traditions and Catholic perspectives on the topic of end-of-life. The purpose is to help Catholic, and more broadly Western, healthcare providers take care of seriously ill newborns and support Hindu parents with difficult decisions at their child’s end-of-life. This becomes even more important if considering that as for a 2015 publication, there are 1.2 to 2.3 million Hindus living in the USA. Hindus are a small minority, yet they adhere to a very complex and rich tradition. Failing to inquire into their culture may lead to a lack of trust and disruption in delivering care to Hindu patients (Dewar et al. 2015).

The first section provides a brief history of Hinduism in order to grasp what makes this Eastern religion different from Western traditions. The paper questions whether Hindu bioethics exist and demonstrates that the virtue ethics framework may be of help when looking at Hinduism through the lens of Western ethics. Understanding different ethical paradigms is of utmost importance when dealing with ethical dilemmas at the end-of-life of sick newborns.

The second and third sections focus on neonatal end-of-life decisions in regard to the withdrawal of life-sustaining measures. This paper frames end-of-life decisions within Hindu Scriptures and looks at contemporary empirical and qualitative studies to understand how Hindu parents may face these situations. A lack of research in the pediatric population has led to the necessity of deriving information from data gathered from adult patients.

Finally, the fourth section compares Hindu with Catholic perspectives regarding end-of-life decisions in neonatal bioethics. Although both religions consider life to be sacred, their divergent sets of beliefs may drive them toward different conclusions when dealing with lifesaving decisions at the end of life. Overall, the purpose of this paper is to inquire whether an inter-religion dialogue between Hindu and Catholic adherents is possible in the context of helping Hindu parents take care of their sick newborn.

Virtue Ethics as a Bridge between Hindu and Western Bioethics

A Brief History of Ethics within Hindu Traditions

Hinduism is believed to be the oldest religion in the world. B. K. Smith defines Hinduism as “the religion of those humans who create, perpetuate, and transform traditions with legitimizing reference to the authority of the Veda” (Smith 1989). However, a lack of homogeneity among those who call themselves Hindus makes it difficult to clearly define Hinduism. Yet, Hindus have shared a wide variety of traditions for more than 5000 years and have begun identifying themselves as Hindus through years of ritual and religious practices. As a result, their social order is greatly variegated and their moral obligations are extremely differentiated (Gielen 2020; Prabhu 2005). In contrast to Christians, Jews, or Muslims, Hindus do not have a categorical or universal code that determines the qualities and behaviors of a good Hindu. Hence, Western ethicists and philosophers have questioned whether Hindu ethics exist (Clooney 1995; Perrett 2005).

If ethics can be described as “a set of substantive proposals concerning how to live, how to act, or what sort of person to be” (Perrett 2005), the lack of guidelines has led some authors to doubt the existence of Hindu bioethics. Within these authors, Deepak Sarma, a professor of Indian religions and philosophy at Case Western Reserve University, claims that scholars who have spoken about Hindu bioethics are mistaken. He believes that in the absence of shared texts that can impart a systematic set of behaviors and beliefs, it is not possible to generalize any concept about Hindu bioethics (Sarma 2008). On the other hand, according to the Indian philosopher Roy Perrett, Hinduism can be seen as a religion that provides a general universalistic set of behaviors that underpin moral judgments within Hinduism. Thus, he argues that Hinduism may be not only seen as a “moral theory, but one of a uniquely pluralistic sort” (Perrett 2005), suggesting that Hindu bioethics may, indeed, exist (Prabhu 2005).

Before diving into the concept of ethics from Hindu and Catholic standpoints, it is important to take into exceptional consideration that a lack of homogeneity among Hindus still lingers today. On one hand, it can be claimed that Hindus generally agree on reaching moksa as their ultimate goal (Seetharam 2013). On the other hand, it is not clear how they aim to achieve this goal. While the Vedas and the Upanisads are considered the Scriptures that underpin their beliefs (Seetharam 2013), Hindus may still rely on epic literature (Dewar et al. 2015). As a matter of fact, ethical dilemmas are leitmotiv of epic literature, such as the Mahābhārata and the Rāmāyana. When dealing with end-of-life crises, for example, the Mahābhārata may help make decisions in stressful situations. It refers to “duties in distress” to suggest that a code of conduct can be dismissed if the situation requires extraordinary measures (Crawford 1995, 8). This concept aligns with the Bhagavada Gītā in stating that sometimes “the dharmic thing to do is to be guided by the demands of the situation” (Crawford 1995, 7). In neonatal end-of-life, the concept of “duties in distress” may play an important role, leading to decisions that exceed the usual code of conduct. Therefore, the importance of epic literature cannot be undermined.

Nevertheless, despite the great variety of traditions, the concepts of dharma and karma have shaped the moral life of Hindus. They believe that acting morally has become difficult for humankind because the natural order has lost its stability. In order to regain social and cosmic order, Hindus should behave in a way that resembles the past where chaos was non-existent, and morality and ethics regulated the cosmos. To re-establish the missing order, they need to observe dharma which is not interpreted as an objective truth, but instead as the result of human activities and moral events that together constitute a behavioral code necessary to maintain the natural order (Monius 2005; Heim 2005). Yet, even though Hindus agree with the importance of living according to dharma, they do not share strict guidelines that define behaviors.

Another aspect commonly accepted among Hindus is the concept of karma. However, because other religions such as Jainism and Buddhism believe in karma, some scholars have argued that it cannot be considered a unique feature of Hinduism (Sarma 2008). In the early tradition of the Vedas, the concept of karma was deeply steeped in rituals that would have allowed priests to recreate the cosmic order that has been destroyed through the ages. Afterward, it acquired a more abstract meaning. In the Upanisads, the rituals were replaced with the idea of achieving moksa, a state in which the soul has finally freed itself from the cycle of rebirth and has reached knowledge. In this period, karma became a guide to free the soul (Monius 2005). However, as it often happens in the Hindu tradition, there is not a clear explanation or set of directions on how to achieve karma.

Karma can be described as “the conviction that every deed will have a consequence in this life or in a future one” (Gielen 2020), leading to the idea that previous actions may affect not only this life but also subsequent ones. Karma determines “the character of one’s present nature [as a] result of activities performed and dispositions developed in previous births” (Heim 2005). Thus, Hindus believe in the potentially endless cycle of rebirth, which can be terminated only when knowledge is gained. When Hindus have fully comprehended the distinction between the soul, ātman, and the matter, prakti, they will free their soul and will no longer be subjected to diseases, bodily functions, and death (Lipner 1989). If Hindus act according to dharma, they will purify the soul from bad karma derived from their previous lives. Through the accumulation of good karma, they can eventually reach the ultimate goal of liberation, moksa.

In conclusion, even though dharma and karma are two concepts commonly accepted within Hinduism, Hindus do not have a clear code of conduct. Consequently, from a Western standpoint, this lack of homogeneity creates difficulties when framing Hindu bioethics.

Western Virtue Ethics and Hindu Traditions

On the other hand, Western philosophy has tried to create strict paradigms wherein ethical principles suggest how to act properly. In this light, normative ethics, such as deontological, utilitarian, and virtue ethics, may point toward resolutions of ethical dilemmas. Specifically, within the models of normative ethics, virtue ethics “emphasizes the development of virtuous character traits” (Gielen 2020) that may help reach the most ethical course of action without providing a strict list of right and wrong behaviors. Similarly, karma encourages Hindus to act virtuously even though Hindu Scriptures do not impart a rigid code of conduct (Gielen 2020). Thereby, within Western ethical frameworks, Hinduism may be best understood in terms of virtue ethics.

Along with the concepts of karma and dharma, the Vedic text Bhagavada Gītā highlights the importance of qualities inherent in humans, gunas. Hindus believe that everyone and everything is balanced through three properties, goodness, sattva, vitality, rajas, and inertia, tamas. They also believe that Hindus live through four different stages—studentship, householder, forest-dweller, and renunciation (Desai 1988; Monius 2005; Prabhu 2005)—that lead them toward liberation while learning how to regulate their behaviors. The gunas that influence their conduct not only are responsible for creating different materiality based on their balance but also for influencing a different psychological personality (Desai 1988). According to how these properties are balanced, humans can collect good or bad karma by acting more or less virtuously. Since gunas influence the outcomes of actions, they have moral implications. Hence, the concept of gunas emphasizes once again the importance of moderation and human qualities in a way similar to those who act according to virtue ethics in Western societies.

Moreover, virtue ethics in the Western tradition emphasizes the importance of taking care of each other. Virtue ethics perceives care as an essential feature of human relationships (Gielen 2020). Similarly, Hindus take into utmost consideration the act of taking care of those in need. In 1928, Mahatma Gandhi exemplified this idea when addressing the concerns of a woman suffering from paralytic attacks. She questioned whether killing herself would have been ethically acceptable within the Hindu tradition. On this occasion, Gandhi did not clearly state if suicide as a liberation from suffering would have been justifiable. Yet, he suggested that if her decision was driven by her perception of being a burden to her family, then she was acting wrongly in aiming to end her life. Indeed, every Hindu has a duty to take care of those in need, leading her family to have a responsibility to look after her. Gandhi did not address the duty to take care in terms of deontological norms, but he referred to it within the concept of living virtuously to accumulate good karma and eventually reach moksa. He interpreted the act of caring as a virtue that helps individuals pursue the ultimate goal. Consequently, Gandhi’s response in its lack of categorical reference can be framed within the paradigm of Western virtue ethics (Gielen 2020).

Furthermore, Hindus believe in the concepts of samskāras, which can be translated as “dispositions or character traits that make living beings do particular actions” (Gielen 2020). People not only are influenced by karma, are balanced by gunas, and are encouraged to behave according to their dharma, but are also driven by samskāras. By doing certain actions and performing certain rituals, they will build their own moral character and will purify their soul since the process of purification starts with bodily acts (Gielen 2020; Heim 2005; Monius 2005). However, it is not clear what samskāras are. They may be simply repeated actions that become habits; they may be good or bad deeds that have brought good or bad samskāras; or they may be the results of their education and their family nurture (Gielen 2020). Through the concept of samskāras, Hindus learn how to act good or bad according to the values that are considered more important. As a result, Western virtue ethics is once again helpful in understanding Hindu bioethics.

In conclusion, this section demonstrated that despite a lack of consensus around how to interpret Hinduism in terms of Western ethics paradigms, Hinduism may be formulated within the framework of virtue ethics. It has been shown that Hindu ethics may exist. Although Hindus do not share a strict code of conduct, the concepts of dharma and karma may drive them toward ethical resolutions of dilemmas in clinical settings. Hinduism may “show us that normativity should not primarily be focused on the outcome of the ethical argument, but rather on the process towards that outcome” (Gielen 2020). What they consider of utmost importance is their approach toward a solution that depends on their traditions, customs, and general popular publications which illustrate how to live a good, ethical, and virtuous life (Clooney 1995). Finally, they do not rely on a deontological code of conduct, but they are encouraged to act according to values that will generate good karma. This inclination emphasizes moral character development, in a way similar to exponents of virtue ethics in the Western tradition.

Neonatal End-of-Life from a Hindu Perspective: Forgoing Life-Sustaining Treatment according to Ancient Texts

As it has been demonstrated in the first section of this paper, a lack of homogeneity among Hindu communities makes it difficult to clearly identify a shared set of beliefs (Desai 1988). Contrary to other religions, such as Christianity, Judaism, and Islam, Hinduism does not rely on a Holy Scripture, does not require adherents to necessarily follow strict dogmas, and is not necessarily associated with a specific founding figure or founding event (Gielen 2020). As a result of a great variety of beliefs and practices, drawing an ethical framework that may anticipate how Hindu parents would face life-threatening conditions can be complicated. Consequently, to better grasp what Hindus may think about forgoing life-sustaining treatments, it is worthy to look at the Hindu Scriptures and ancient medical texts taking into consideration that such scriptures may not be strictly followed. Moreover, while it is true that Hindus generally act according to the concepts of karma and dharma, it is also true that many Hindus do not read or study these texts. As mentioned before, they may or may not apply epic literature in shaping end-of-life decisions. A lack of homogeneity leads Hindus to be more or less adherent to Vedic Hinduism. Therefore, drawing generalizations is not possible (Dewar et al. 2015).

Hindus rely on a great variety of books not only when it comes to social and religious life, but also to medicine. The oldest and primary medical text is the Caraka Samhita, written in the first millennium BCE in the Vedic era (Desai 1988). Different schools of thought emerged between 800 and 700 BCE, in contrast to ancient priests’ practices when the Atharva Veda was the primary medical text and healing was based on magical rituals (Pandya 1999). In this period, Ayurveda, medicine, became a more rational science based on experiments and observations. The term “Ayurveda” itself determines the aim of medicine, wherein “ayur” means preservation and prolongation of life (Crawford 1995, 19; Pandya 1999). The main goal of medicine was to provide health as a “culmination of a sound mind in a healthy body as a means towards ensuring the welfare of the soul and ending the cycle of rebirth” (Pandya 1999). However, the value of life itself in ancient India was not absolute (Young 1989). Hindu medicine has never distinguished between the human body and the nature of the self, ātman, or the soul (Crawford 1995, 29; Desai 1988). According to the Caraka Samhita, physicians have a duty to treat the body, which cannot be cured separately from its spirit (Lipner 1989). Although some authors have argued that such texts may not be honored today, they may still underpin beliefs and traditions in India (Sarma 2008). Therefore, when caring for unborn children and newborns, investigating how ancient medical texts define the soul may guide toward a better understanding of how parents may face their child’s life-threatening diagnoses today.

Although two different schools of thought suggest the soul comes to the body either at conception or around the seventh month of gestation (Lipner 1989; Pandya 1999), Hindu Scriptures believe that life begins before birth (Coward 1989; Crawford 1995, 25; Das 2012). In the uterus, an embryo is created by the union of the mother’s blood and the father’s seed along with the principle of life itself (Desai 1988). According to Yājñavalkya, the family and the community have a duty to provide care to avoid the issue that, “by not giving what a woman, in pregnancy, wishes for, the embryo [may encounter] some shortcomings, either [in the shape of] disfigurement or death” (Crawford 1995, 27). When miscarriages, stillbirths, multiple pregnancies, or birth defects occur, Hindu Scriptures maintain that unnatural coitus, weak humors, or malfunctioning seeds may have caused that horrible outcome. Physiological reasons alone, however, are not deemed to fully grasp the complexity of this circumstance, since psychological impairments during pregnancy are also thought to affect the child’s life (Pandya 1999).

Because Hindu Scriptures maintain that the soul of a new individual is reborn in the body of a fetus at conception, abortion is considered one of the most atrocious acts, such as killing the purest in society: the Brahamins (Pandya 1999). However, exceptions are possible. The Suśuta Samhītā highlights that when the life of the woman is at risk, “in an irremediable situation, it is best to cause the miscarriage of the fetus” (Lipner 1989). Although Hindu Scriptures encourage saving the infant if there is a chance of survival, physicians are allowed to perform an intervention to remove the fetus when it cannot be rescued (Lipner 1989). This exhortation, however, is not justified only by the intention of saving the mother’s life, but also by sociological reasons. Hindus classify the mother’s life as more important than the child’s one in this circumstance. She, as an adult, has arrived at a.

karmic state in which there is much more at stake for her spiritual destiny and in which there are existing obligations to be performed for family and society, [that puts her] in a position to be favored over an equal human being whose evolution in this life is by comparison rudimentary, and who has not yet established a social network of relationships and responsibility. (Crawford 1995, 32)

Because a sick newborn, as well as a fetus, may not have yet built such relationships, ancient Hindu beliefs may help parents in the process of letting the child die.

Moreover, according to the Caraka Samhita, karma is responsible for causing diseases. Hindus believe that when a human being has paid their karma, they should embrace death as an opportunity to depart from this life and hopefully rebirth in a higher status toward reaching moksa. However, they still dread untimely death. Age, gender, marital status, quality of life, and psychological factors may play an important role in considering whether to let a child die (Desai 1988). Nevertheless, when it comes to infants born with congenital malformities, Hindus may hold in high regard the expected quality of life and attainable cognitive development of the child. According to the Vedas, the brain is the most important organ. When it is severely damaged, human life loses its value because the person lacks consciousness (Pandya 1999). In the Caraka Samhita, life exists only when body, mind, and self are preserved as a whole, since only “when a person lives in a higher state of consciousness (prajñā), he is ensured health and happiness, whereas when he occupies lower statuses he becomes prey to disorders, due to intellectual errors (prajñāparadha)” (Crawford 2003, 100). Thereby, Hindu Scriptures may be in favor of forgoing life-sustaining treatments when a newborn is likely to suffer from severe cognitive impairments.

In conclusion, despite Hindus’ general disapproval of any action that destroys the life of an individual, they are also open to flexibility and tolerance. The Vedas aspire to live a long and vigorous life; however, they also recognize that physical suffering and intractable pain wreck self-control and hinder self-possession. Moksa, the ultimate goal in any Hindu’s life, is inaccessible when in pain and when self-control is lost (Crawford 1995, 122). Therefore, when a newborn is suffering, their quality of life is compromised, or their neurological development is impaired, ancient Scriptures may support the decision of Hindu parents to discontinue lifesaving therapies. However, because doctors and parents may not make decisions based on these texts, analyzing studies conducted in modern India may provide a better picture of how Hindus may handle end-of-life circumstances today.

Neonatal End-of-Life from a Hindu Perspective: Forgoing Life-Sustaining Treatment among Contemporary Hindus

The Legal Status of Forgoing Life-Sustaining Treatment in India

According to an article published in 2006, almost 25 million infants are born in India every year. However, the mortality rate in this country reaches 43.4 deaths for every 1000 children born, leading to the loss of 1.3 million newborns in their first month of life every year (Miljeteig and Norheim 2006). In spite of the high mortality rate, however, doctors still do not report discussing ethical dilemmas in their practices (Clooney 1995; Pandya 1999). Francis X. Clooney, a professor in the teaching of Hinduism, explained a lack of ethical analysis in medical practices by stating that efforts to create an ethical framework have been made mostly by Western scholars in their attempts to categorize Eastern cultures, traditions, and beliefs within Western ethical paradigms (Gielen 2020). According to his analysis of a book, Śrīvaisnava, published in Tamil by an orthodox Hindu in 1984, Hindus still do not discuss how new medical technologies in a new secular and modernized world may influence their set of beliefs (Clooney 1995). This lack of ethical discussion was reiterated in a more recent article published in 2022 which showed that only recently medical curricula have included a module on medical ethics (Pant 2022).

Nevertheless, Western scholars, such as S. Cromwell Crawford and Katherine K. Young, have tried to extrapolate ethical reasoning from ancient Scriptures, creating normative conclusions based on Western categories of ethics (Gielen 2020). However, they did not gather empirical data among contemporary Hindus, failing to recognize that although historical and traditional perspectives can grasp the essential nature of Hindu medicine, qualitative and empirical studies may provide better answers to normative inquiries (Sugarman and Sulmasy 2001). Thus, when analyzing end-of-life decisions for newborns, it may be helpful to take into consideration studies conducted in modern India.

Nowadays, India does not have clear regulations around withholding and withdrawing lifesaving treatments. On the one hand, when taking care of newborns, the Indian law against euthanasia prohibits physicians from withdrawing treatments in children unless they are anencephalic, born before the 23rd week of gestation, weigh less than 400 g at birth, or are diagnosed with trisomy 13 or 18 (Miljeteig and Norheim 2006). On the other hand, by virtue of Article 21 of the Indian Constitution which protects the right to personal liberty, Indian people can refuse medical interventions (Gera et al. 2023). However, a lack of guidance around withdrawing treatments that have already begun still lingers (Gielen et al. 2011; Pant 2022).

In 2006, the Law Commission of India published its 196th report, recommending the enactment of a law on end-of-life matters to protect the right to refuse life-saving treatments of terminally ill patients. This urge was reiterated in 2018 when the Supreme Court stressed the importance of safeguarding the right to die with dignity, allowing the withdrawal of life-sustaining treatments if three doctors agree that there is no hope of regaining health. Yet, the guidance they provide to request the withdrawal of care is extremely complex and, therefore, almost impracticable. In 2023, the above-mentioned guidelines to forgo treatments have been simplified—they now require the clinical judgment of two doctors instead of three; however, an Indian law on this topic still does not exist (Gera et al. 2023).

When it comes to extremely premature newborns, recommendations are not less confusing. In 2017, the Indian Academy of Pediatrics maintained that there are “no guidelines regarding not to initiate resuscitation in conditions where life may not be meaningful after resuscitation” (Mishra et al. 2017). In 2022, a lack of legislation and clearance on how to deal with periviable fetuses and do-not-resuscitate orders in perinatology still continues (Pant 2022). While the latest consensus statement on end-of-life promulgated by the Indian Academy of Pediatrics stated that do-not-resuscitate orders can be signed if an agreement between the medical team and the family is reached, it is not clear how such conversations should be carried out (Pant 2022).

A study published in 2006 and conducted among Hindu doctors in Indian hospitals revealed that the lack of guidelines creates tension when making decisions. However, they do not discuss ethical issues in established institutional settings but instead deliberate with their colleagues when concerns arise. Physicians, interviewed for the purpose of this study, admitted that limitations in their conversations with parents may occur due to their poor educational backgrounds and their low socio-economic status (Miljeteig and Norheim 2006). Similar to the findings of another article published in 2011 by Joris Gielen et al. (2011), doctors acknowledged that decisions are often made not only in regard to that specific child’s needs but especially in light of other factors. Certain determinations can be made based on resources that the family can offer, their ability to take care of the child, and the presence of other children at home that require care as well (Miljeteig and Norheim 2006).

Forgoing Life-Sustaining Treatments in India Today

A shortage of resources and socio-economic dynamics complicate the picture in a country where 21.9% of the population lives in an extremely high poverty rate (Gielen 2020). These factors may lead Indian hospitals to offer limited intensive treatments to very sick newborns (Miljeteig and Norheim 2006). Indeed, while it is true that medical innovations and advanced technologies have made the survival of extremely premature newborns possible, decisions are still made based on financial constraints (Pant 2022). A 2022 article highlighted how financial factors play an important role when making decisions on treatments for sick newborns. The author mentioned that healthcare is delivered through public and private hospitals wherein private hospitals are unaffordable for most of the Indian population. When more than 80% of healthcare costs are out-of-pocket, families not only cannot afford the NICU expenses but also cannot raise a disabled child (Pant 2022).

Moreover, Joris Gielen et al. demonstrated that the majority of the doctors who participated in the study believed forgoing treatments to be mostly ethically acceptable. Although a generalization of beliefs, especially when referring to a society that embraces a great variety of traditions, cannot be drawn, he emphasized how Hindus mostly agree that prolonging life when hopes are low is not commonsensical. Despite participants admitting that factors such as age, life expectancy, family dynamics, and expenses may influence their choices, Hindus do not generally consider treatments that can only offer a “brief extension of life at the expense of [its] quality” (Gielen et al. 2011) ethical. However, when it comes to newborns, parents and families may be more reluctant to forgo medical interventions.

With their research, Joris Gielen et al. indicated that physicians find it ethically advisable to forgo treatments when there is no hope to improve the patient’s overall health or quality of life, when medical expenses risk bankrupt the family, and when resources, often scarce, need to be justly allocated (Gielen et al. 2011). Similarly, Shanmukh Kamble, an Indian psychologist, along with his colleagues have found that Hindu parents’ convictions, that see death as a progression toward rebirth, may facilitate this choice when suffering and pain are unbearable (Kamble et al. 2014). Moreover, this article concurs with two other publications: one written by a Western physician about his experience working in Indonesia, Bali, where 80% of the population is Hindu, and the other published by a Hindu doctor in 2005. These analyses pointed out that Hindu parents may take into consideration religious beliefs when making a decision (Firth 2005; Kamei 2003). However, even though they presumed that God is the ultimate decision-maker when it comes to life and death, this assumption does not prevent them from trying to avoid unnecessary pain to their children. Conversely, Joris Gielen et al. showed that most of the physicians who participated in the study did not make their decisions based on religious beliefs (Gielen et al. 2011; Miljeteig and Norheim 2006). According to S. Cromwell Crawford, these different perspectives between parents and physicians toward God may be explained by Indian doctors’ efforts to distance themselves from the traditions of Ayurveda and ancient medicine. Cromwell Crawford argues that Indian doctors may build their clinical evaluations based on Western medicine rather than Indian medicine (Crawford 1995, 35).

Finally, regardless of physicians’ approaches toward religion, they should not underestimate the importance for parents to perform rituals at their child’s end-of-life stage. Dr. Shirley Firth has reported that before-and-after-death rituals described in the Garuda Purana still affect the way Hindu families face death. This is clearly expressed by a Hindu couple that was not allowed to perform proper rituals when their aunt died. Although this case does not involve the care of a newborn, it provides an example of family long-term consequences if they do not comply with religious and traditional rituals. They said:

Today, after ten years it still affects the family. If they want to have a social occasion like a wedding in the family or something they must do some penances because she died without water, therefore her soul is still not free, and her family is not free. They’ve got to keep performing all these rites [for seven generations] that they weren’t able to during the death, until the soul is free. (Firth 2005)

Thus, qualitative studies have shown the significance of performing rituals, such as drinking the Ganges water, laying on the ground to be close to Mother Earth, and keeping a basil leaf on the mouth (Firth 2005). Such research has demonstrated that because rituals are executed by following religious texts, Hindu parents may still make decisions based on ancient Scriptures and religious beliefs. However, it must take into account that, as Prakash N. Desai pointed out, Hindus may rely on their “pick and choose attitudes” (Desai 1988) that allow them to choose which tradition they prefer to follow in a specific circumstance. Generalizations around common practices among Hindus are not easily drawn due to the great diversity of medical and cultural traditions that fall under the umbrella of Hinduism.

A Dialogue between Hindu and Catholic Views on Neonatal End-of-Life

When taking care of newborns whose parents are Hindus, Catholic healthcare providers may have to deal with different religious perspectives. This section compares Hindu and Catholic views in order to provide a better picture of how parents may face the sickness of their child. Highlighting similarities and differences may help Western Catholic healthcare providers understand that “sickness and disease [may be] more threatening to our [Western] sense of selfhood and self-assurance than they might be in societies less committed to individualism, less worried about using personal achievement as the measure of a person’s worth” (Crawford 2003, 94). Hindu parents who share a different culture of death than Catholic parents may face losses differently.

When deciding whether to forgo lifesaving treatments, adherents and professionals may inquire into the meaning of life according to their religious teachings. Interestingly, both religions consider life sacred. As it has been already demonstrated, Hindus believe that “there is no other gift greater than the gift of life” (Pandya 1999); human beings and the natural world are all manifestations of God, the eternal Brahman (Desai 1988). Roman Catholicism respects “the sacredness of every human life from the moment of conception until death” (United States Conference of Catholic Bishops 2018) as well. Although they both encourage preserving life, they allow some flexibility and tolerance to this principle.

From a Hindu point of view, “living is more important than being alive” (Pandya 1999). Although they condemn suicide as an act made out of passion or ignorance and abortion as an act of killing, they also support the choice of discontinuing life-sustaining treatments when there is no hope to regain health (Desai 1988; Pandya 1999). According to Gandhi, in circumstances of unbearable suffering and pain, “karma does not give us the right to keep such people alive and in pain when all they want is a peaceful death” (Crawford 1995, 129). The individual may, indeed, decide that their life is no longer valuable since they do not believe that mere survival has value in itself (Crawford 2003, 96). Similarly, Roman Catholicism accepts exceptions to the sanctity-of-life principle. Thanks to the moral and ethical distinction between extraordinary and ordinary means (Kelly 2007; Congregation of the Doctrine of the Faith 2020; Pontifical Council for Pastoral Assistance to Health Care Workers 2016, 108; Jonsen 1998; United States Conference of Catholic Bishops 2018), mechanical ventilators and artificial nutrition/hydration can be forgone when they are merely prolonging life and the dying process (Pontifical Council for Pastoral Assistance to Health Care Workers 2016, 108; Bretzke 2006; Congregation of the Doctrine of the Faith 2020).

Nevertheless, although both religions deny sustaining life for the mere purpose of keeping it alive, their religious convictions may lead to different conclusions when it comes to forgoing treatments. On one hand, Hinduism values the life of an individual based on the ability to build relationships within their community. Also, the ultimate goal of a Hindu is to gain the knowledge needed to reach moksa. The ability to make autonomous decisions will allow them to accumulate good karma, purify their soul, and hopefully attain moksa (Prabhu 2005). As Katherine Young pointed out, the body in which the soul manifests itself within a human life constitutes the means toward pursuing salvation. It is an individual responsibility to use their lifetime to purify themselves (Young 1989). On the other hand, from a Catholic perspective, human beings “are not the owners of [their] lives and, hence, do not have absolute power over life” (United States Conference of Catholic Bishops 2018). They justify this conviction because they believe that human life has an innate value and dignity inherent in itself. The value of life must be respected in any circumstance (Faggioni 2010). Clearly, Hinduism and Catholicism share different perspectives on the value of human life. Divergent perceptions of abortion reveal how parents may be driven toward different ways to deal with the birth of a sick child.

As it has been previously demonstrated, Hindus deem abortion to be one of the most atrocious crimes; abortion is perceived as an act of killing (Desai 1988; Pandya 1999; Lipner 1989; Crawford 1995, 26). However, they do not consider the value of a fetus’ life absolute. Hindu Scriptures suggest that if the well-being of the mother is at risk, an act of direct abortion may be performed to save her life (Desai 1988; Lipner 1989; Crawford 1995, 132). On the other hand, from the Catholic perspective, a child is created by God in His same likeness and image.1 According to the Pontifical Council for Pastoral Assistance to Health Care Workers (2016, 43), “no circumstance, no purpose, no law whatsoever can ever make licit an act which is intrinsically illicit, since it is contrary to the law of God”; abortion is, therefore, never justified. If the woman’s life is at risk, the principle of double effect justifies the death of a fetus only if it is an unintended consequence of lifesaving medical interventions. Contrary to Hinduism, this strict position does not allow flexibility, not even when the child may die before or after birth such as in the case of anencephalic fetuses (Pontifical Council for Pastoral Assistance to Health Care Workers 2016, 47). From this standpoint, the value of life must be evaluated in itself, and its dignity must be safeguarded in every condition. These divergent positions may lead Hindu and Catholic parents to face life-threatening diagnoses and potential disabilities differently before and after birth.

Hindu parents may deem the relational aspect of human lives more important than mere survival. If the infant is not likely to build relationships due to brain damage and, consequently, to their low cognitive development, they may consider that life not worth living (Crawford 2003, 126). On the other hand, Catholic parents may refuse or withdraw treatments only “when inevitable death is imminent in spite of the means used [which allows] to take the decision to refuse forms of treatments that would only secure a precarious and burdensome prolongation of life” (Pontifical Council for Pastoral Assistance to Health Care Workers 2016, 109). However, their conviction that human life has intrinsic value in itself may lead parents to treat the child even when severe disabilities are diagnosed (Faggioni 2010). They believe that assessment based on expected quality of life must be taken into consideration very carefully. The value of a life should never be appraised on societal worth assumptions and/or physical impairments (Faggioni 2010; Scott-Joynt 2012).

Furthermore, regardless of different views, Hindu and Catholic parents may value the importance of rituals performed at the end of life. This paper has already highlighted the significance of guaranteeing to Hindus the possibility of executing rituals when death is approaching. They may ask to let the patient drink water from the river Ganges and keep a Tulsi or basil leaf on their mouth, as well as gathering temple garlands, icons, and images that would help the child’s soul reach its rebirth (Das 2012). Similarly, Catholic parents may undergo a spiritual crisis blaming God for the death of their child. Thereby, it is in the pastoral duties to provide support presenting death as a way toward God’s life itself. They should offer words of hope to the devastated parents, but also sacraments, such as a baptism for the newborn (Pontifical Council for Pastoral Assistance to Health Care Workers 2016, 39). Parents may perceive death as a journey. On one hand, Hinduism suggests that death should not be seen as the opposite of life, but rather of birth (Desai 1988; Pandya 1999; Crawford 1995, 118). The soul will be reborn hopefully in a higher status until it reaches liberation. On the other hand, Catholicism suggests that “death is not a hopeless adventure; it is the door of life that opens to eternity; it is the experience of participation in the mystery of Christ’s death and resurrection” (Pontifical Council for Pastoral Assistance to Health Care Workers 2016, 107).

Overall, although both religions consider the gift of life to be sacred, parents of sick newborns may face their death differently. Comparing these two sets of divergent beliefs may help healthcare providers in Catholic hospitals, and more broadly in Western societies, to understand how Hindu parents may handle end-of-life decisions. Indeed, according to Cromwell Crawford, “Hinduism sees the state of crisis in American medicine as a crisis of faith and theology. It arises from a compulsive need to make gods of the body, of health, and of life. A positivist style of heroic medicine finds itself technologically difficult to detach itself from the delusions of immortality” (Crawford 1995, 123). Therefore, regardless of the difficulties of such tragic situations and decisions, Hindus may perceive death in a less dreadful way than Catholic adherents (Desai 1988).

Conclusion

This essay aimed to compare Hindu and Catholic views on end-of-life to better understand how parents of different religions may face life-threatening diagnoses of their newborns. Because Hinduism lacks homogeneity and a clear code of ethical conduct, it may be difficult from a Western perspective to frame Hindu ethics within their ethical paradigms. In the effort to compare Hinduism to Catholicism, the first section compared Hindu bioethics to virtue ethics as an ethical framework that has taken shape in the Western world and the Catholic tradition. Once defined Hindu bioethics, ancient Hindu Scriptures and contemporary qualitative and empirical studies conducted among Hindu parents and physicians helped better understand Hindu end-of-life perspectives. While parents may still rely on Hindu Scriptures when making decisions, doctors generally do not take religious beliefs into consideration. Finally, some fundamental differences and similarities between Hinduism and Catholicism were drawn. Both Roman Catholicism and Hinduism, while considering the value of life sacred, also allow extraordinary care to be forgone. However, Hindu and Catholic parents may value their sick newborn’s quality of life differently. This paper may help Catholic, and more broadly Western, healthcare providers better understand how Hindu parents may face life-threatening conditions for their child.

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Competing Interests

The author declares no competing interests.