Health Law / Medical Ethics

SALLEKHANA: THE ETHICALITY AND LEGALITY OF RELIGIOUS

SUICIDE BY STARVATION IN THE JAIN RELIGIOUS COMMUNITY

Whitny Braun ∗

Abstract: This article examines Sallekhana, the Jain religious ritual of fasting
to death, 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 Jain communities 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; Jainism; India; religious suicide; starvation; medical

ethics; right to die

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 Indian Penal Code Section 309 and Article 21 of the Indian Constitution, which

guarantees the right to life. 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, United States 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

religion, 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 euthanasia 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 supreme court of India 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 religions 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

3
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 Jain philosophy. 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. Asceticism 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 Hinduism, 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 nirvana, 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

4
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 karma, 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

5
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 karmas 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 moksha, 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

6
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.

7
Jainism is often confused with Hinduism but in reality 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). Mahavira, 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 monks 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

grief, 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 cremation.

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 murder by proxy (Dorff 2005).

Traditional Christianity regards suicide as self-murder and physician-assisted suicide

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 Buddhism 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 monk 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, London: 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: 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 sati, in which Hindu

widows immolate themselves on their husband’s funeral 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

13
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 ghost 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

14
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

15
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 Los
Angeles, 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.

17
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, freedom of religion 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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