ETHICS, PUBLIC POLICY, AND MEDICAL ECONOMICS
Attitudes of Asian-Indian Hindus Toward End-of-Life Care
Ohm Deshpande, BA, M. Carrington Reid, PhD, MD,w and Arun S. Rao, MDw
The population of older adults in the United States is in-
creasing in cultural diversity. Thus, an appreciation of cul-
tural perspectives regarding end-of-life care may benefit
practicing physicians. This article addresses end-of-life care
issues from the perspective of HinduismFa faith embraced
by a growing demographic of the U.S. populationFand
also reviews basic Hindu philosophical concepts salient to
caring for patients at the end of life. J Am Geriatr Soc
53:131–135, 2005.
Key words: end-of-life care; attitudes; ethnicity; religion
A s the American population ages, issues regarding the
treatment and care for individuals nearing the end of
life are becoming increasingly important. Census statistics
indicate that in 2000, 12% of the American population was
aged 65 and older, and this percentage is projected to rise to
20% by 2030.1 The cultural makeup of this country is also
diversifying. Although significant attention has focused on
the growth of the African-American and Hispanic-Ameri-
can populations, the Asian demographic, and specifically
the Asian-Indian population, has experienced rapid growth
as well. Asian Indians began to immigrate to the United
States after the passage of the 1965 Immigration and Nat-
uralization Act, which opened the doors for Asian Indians
possessing professional skills and training needed in the
United States. The Asian-Indian population increased
126% in the first decade after the passage of this act, and
recent estimates indicate that between 1.5 million and 1.7
million Asian-Indian immigrants or Americans of Indian
descent currently live in the United States,2–4 Now, nearly
40 years later, the first wave of Asian-Indian immigrants is
From the Williams College, Williamstown, Massachusetts; and wDivision
of Geriatrics and Gerontology, Weill-Cornell Medical College, New York,
New York.
Dr. Reid is currently supported by a Paul Beeson Physician Faculty Scholar
in Aging Research Award and a Robert Wood Johnson Foundation Generalist
Physician Faculty Scholar Award. Dr. Rao is the recipient of a Geriatric
Academic Career Award (1 K01 HP 00036–01) from the Bureau of
Health Related Professions/HRSA.
Address correspondence to Arun S. Rao, MD, Assistant Professor of
Medicine, Division of Geriatrics and Gerontology, Weill-Cornell
Medical College, 525 E. 68th Street, Box 39, New York, NY 10021.
E-mail: arr2003@med.cornell.edu
JAGS 53:131–135, 2005
r 2005 by the American Geriatrics Society
approaching an age at which end-of-life issues increase in
importance.
In light of the aging of the American population and
its increasing cultural diversity, studies have been conducted
to explore the attitudes of various ethnic minorities toward
end-of-life care, primarily in European-American, African-
American, Hispanic-American, and certain Asian-Ameri-
can groups,5–11 but data concerning Asian Indians are
sparse. The objectives of this article are to summarize Hin-
du philosophy and its approach to end-of-life care; review
the existingFalbeit limitedFliterature regarding Asian
Indians, Hinduism, and end-of-life care issues; and illus-
trate a Hindu perspective on several ethical dilemmas that
may arise in geriatric care, using the case-based scenarios of
a previous article.22
HINDU PHILOSOPHY AND END-OF-LIFE CARE
Approximately 80% of Asian Indians are Hindu, and the
rest are Muslim, Sikh, Christian, Buddhist, Jain, or Jew-
ish.12,13 Hinduism is believed to have originated in the In-
dus Valley around 3000 B.C., making it one of the oldest
philosophical traditions in existence.14 Buddhism and Jain-
ism both evolved as offshoots of Hinduism and hold some
of the same fundamental philosophies concerning life and
death outlined in the following sections. Sikhism also has
influences from Hinduism and originated approximately
500 years ago. Nevertheless, this article will concentrate on
Hinduism and its philosophies about the end of life because
it is the philosophy accepted and practiced by the vast ma-
jority of Asian Indians living in the United States and else-
where. Although certain basic central beliefs tie Hinduism
together, its practice varies dramatically among its individ-
ual followers. It has evolved constantly since its inception
and has given rise to various social customs that are seen as
indivisible from basic Hindu beliefs.3,12,13,15,16
Hinduism is more of a philosophy than an organized
religion. It does not mandate specific customs, rituals, at-
tendance at temples, or practices; most of what Asian Hin-
dus practice are cultural interpretations of aspects of
Hinduism.17 Hindu philosophy is codified in several scrip-
tural documents, the most important being the Vedas, the
Upanishads, and the Bhagavad-Gita. The latter two texts
most clearly illustrate many of the fundamental philosoph-
ical ideas of Hinduism. Issues related to end-of-life care are
not specifically addressed in traditional Hindu philosophy.
0002-8614/05/$15.00
132 DESHPANDE ET AL.
This arises from the fundamental philosophy of Hinduism,
a central tenet of which is that a unitary life force, or Su-
preme Being, called Brahman (not to be confused with
Brahmin, a member of the ancient Indian social hierarchy)
connects all existence. Brahman has no form nor shape, is
timeless and eternal, and is believed to pervade everything
(animate and inanimate), and everything is it.
I am the seed that can be found in every creature . . . for without
me nothing can exist, neither animate or inanimate.
(Bhagavad-Gita, Chapter 10:39).14
As humans, Hinduism states that we are ignorant of
our fundamental unity of the cosmos; thus, a Hindu’s goal is
to engage in actions that lead to enlightenment and the
realization of the existence of one’s immortal soul, termed
the Atman or Self. The Atman transcends the temporal and
physical concept of birth and death and is in unity with the
universal Brahman.
The wise one (Atman)Fhe is not born, he does not die; he has not
come from anywhere; he has not become anyone. He is unborn
and eternal, primeval, and everlasting. And he is not killed when
the body is killed.
(Katha Upanishad 2:18).18
The way by which one may remove the layers of ig-
norance preventing one from being aware of the Atman is
the basis for karmic theory, which provides much of the
philosophy related to a Hindu’s thoughts and beliefs on
death and dying. One may remove the layers of ignorance
preventing realization of the Atman by following one’s
dharma, or personal righteous conduct. Different Hindus
may define dharma differently, but the impetus behind pur-
suing a dharmic path is the belief in karma, which essen-
tially dictates that one’s actions leave an imprint on one’s
mind and soul. Thus, by pursuing a righteous and just life,
one develops a positive karma that acts to remove ignorance
and slowly brings an individual closer to ultimate enlight-
enment (i.e., Moksha, realization of the unity of the Atman
and Brahman). Through the pursuit of dharmic actions,
including prayer and meditations, the Hindu recognizes the
fundamental permanence of the Self and escapes the grief of
death.
When he perceives this immense, all-pervading self, as bodiless
within bodies, as stable within unstable beingsFa wise man
ceases to grieve.
(Katha Upanishad 2:22).18
In the context of a discussion on end-of-life issues, it is
essential to understand that a belief in karma-driven spir-
itual salvation is not limited to one life span. Because the
Atman is immortal, Hindus believe that the soul must go
through many lives until the aggregated karma has suffi-
ciently removed the layers of ignorance. A common met-
aphor for the mechanism of deaths and rebirths is
comparing the body to an article of clothing. The soul in-
habits a corporeal form for as long as it can be useful and
then casts it off in favor of a new garment.
JANUARY 2005–VOL. 53, NO. 1 JAGS
As a man abandons worn-out clothes and acquires new ones, so
when the body is worn out a new one is acquired by the Self
(Atman) who lives within.
(Bhagavad-Gita, Chapter 2:22).14
Once an individual’s karma has successfully removed the
human imperfections obscuring the self-awareness of the
Atman, the cycle of deaths and rebirths is complete, and
the individual merges with the cosmic power permanently.
But when a man has understanding, is unmindful and pure, he
does reach that final step, from which he is not reborn again.
(Katha Upanishad 3:8).18
Because the Atman is viewed as eternal and continues
to circulate in a cycle of births and deaths, Hindu scriptures
do not view death as having finality. Thus, for many Hin-
dus, the fear of death may not exist or may be diluted. Many
may take comfort in the following lines from the Bhagavad-
Gita:
The wise grieve neither for the living nor the dead. There has
never been a time when you and I . . . have not existed, nor will
there be a time when we cease to exist. As the same person in-
habits the body through childhood, youth, and old age, so too at
the time of death he attains another body.
(Bhagavad-Gita, Chapter 2:11–13).14
Because death is viewed as a transition rather than a
final conclusion, Hindu attitudes on end-of-life care options
may radically differ from perspectives shaped by the West-
ern tradition of bioethics or other Asian populations in the
United States.
Buddhism, Jainism, and Sikhism are three other reli-
gious traditions practiced by some Asian Indians living in
the United States. A brief summary of their philosophies is
presented here, bearing in mind that although many Asian
Indians accept these faiths, Hinduism remains the predom-
inant religion/philosophy for people from India. Buddhism
grew out of Hinduism and was founded by Siddhartha
Gautama, a prince who renounced his royal status to seek
enlightenment after seeing all the suffering in the world
around him. Buddhism believes in the interconnectedness of
all things in the universe and the impermanence of all cre-
ated things. It holds that our primary problem as humans is
our failure to realize this. By doing so, we take actions and
thoughts that create suffering and attachment to things on
earth. Until we come to the realization of this intercon-
nectedness and learn to detach ourselves from these imper-
manent things, we will be reborn. Once we realize this
truth, our souls attain liberation (Nirvana) and are freed
from the cycle of birth and rebirth. Thus, Buddhism also
does not define our lives on earth as a finite event and ac-
cepts death and dying as part of life and a more permanent
cycle. A prince who renounced his status in search of truth
and enlightenment founded Jainism. The main goal for
Jains is also to attain freedom from a cycle of life, death, and
rebirth. Jainism also believes in a karmic philosophy and
holds that, under the influence of our actions, the soul seeks
pleasures, materialistic possessions, and other sins. By
practicing right faith, right knowledge, and right conduct, a
soul can attain liberation or enlightenment (also termed
Nirvana or Moksha). Right conduct is practiced by five
JAGS JANUARY 2005–VOL. 53, NO. 1 ATTITUDES OF ASIAN-INDIAN HINDUS TOWARD END-OF-LIFE CARE
great vows taken by all Jains. Jainism also maintains that
our life on this earth is not finite but is part of a continuum
of life, death, and rebirth. Sikhism also holds many beliefs
similar to Hinduism. Sikhs believe in one God that has no
form or sex. The ultimate goal of Sikhism is to realize this
God and thus to break the cycle of birth and rebirth by
living a virtuous and dutiful life. This is done by following
the teachings of the Gurus (teachers), meditating on God at
all times, and performing acts of service and charity. Sikhs
believe in the equality of all mankind and denounce super-
stitious beliefs and blind rituals. Thus, although these three
faiths have certain practices that differ from Hinduism, ul-
timately their philosophy toward life and death are similar.
LITERATURE ADDRESSING END-OF-LIFE CARE OF
HINDUS
Karmic thought is a strong influence on the behaviors and
perspectives related to death and dying for many Hin-
dus.3,4,12,13,15,16,19–21 Data on Hindu attitudes toward end-
of-life care options are limited and are often derived from
studies with few participants. To our knowledge, there have
been no published reports concerning the use of specific life-
sustaining or life-prolonging procedures in Hindu patients,
and these issues are not covered in the scriptures. However,
there have been a few small population-based studies ex-
amining the beliefs and use of advance directives and hos-
pice care in Asian-Indian Hindu immigrants.3,4 These
studies found that only approximately 9% of Hindus have
advance directives, well below the national average of 15%
to 20%. A familial decision-making tradition or strong be-
liefs in the importance of religion and rituals were nega-
tively correlated with having an advance directive.3
Furthermore, knowledge of hospice care was low in a
group of Asian Indians surveyed in the Midwest.4 In this
study, measures of cultural identity and affiliation were
correlated with knowledge of hospice care, with those in-
dicating stronger ‘‘Western’’ cultural beliefs reporting more
awareness of hospice care and services.
There are a few points to bear in mind when partic-
ipating in the care of Hindu patients toward the end of life.
In accordance with karmic theory, illness, pain, suffering,
and death are not seen as unique to the individual. Rather,
they may be interpreted as the result of prior actions, in this
life or a prior life.12,15,21 Thus, many Hindu patients de-
velop a passive, almost accepting attitude toward these
events. Second, Asian-Indian family culture usually pro-
motes familial decision making in these situations.3,12,13,15
Often, the family may wish that the patient not be told the
specifics of the illness and request that other family mem-
bers make decisions following a specific hierarchy already
in place. Third, instituting life-sustaining or prolonging
procedures may be potentially viewed as interfering with an
individual’s karma.3 Finally, in the event of a terminal ill-
ness or death, there are certain rituals performed by the
patient’s family.16,19,20 Allowing these to take place repre-
sents an understanding that families view these rituals as
smoothing the transition from life to afterlife for the dying
individual. The performance of these rituals by family
members is their dharmic duty. Interfering with this could
potentially incur bad karma for the family members and
create tension for them and the healthcare team. One of the
133
most important beliefs of Hindus is that a dying individual’s
thoughts and words should be focused on God because it is
a strong belief that the nature of one’s thoughts at the time
of death determine the destination of the departing soulFa
concept highlighted by the following quotations:
Those who remember me at the time of death will come to me. Do
not doubt this. Whatever occupies the mind at the time of death
determines the destination of the dying.
(Bhagavad-Gita, Chapter 8:5–6).14
Remembering me at the time of death, close down the doors of the
senses and place the mind in the heart. Then, while absorbed in
meditation, focus all energy upward to the head. Repeating in this
state the divine Name, the syllable Om that represents the
changeless Brahman, you will go forth from the body and attain
the supreme goal.
(Bhagavad-Gita, Chapter 8:12–13).14
Culturally, family members of a dying individual may
manifest this by reciting prayers or hymns around them and
placing holy water or a holy leaf (tulsi, basil leaf) on the
person’s mouth.
CASE SCENARIOS
In an earlier issue of this Journal,22 three cases concerning
important end-of-life issues were presented and discussed to
elaborate the perspectives of Judaism, Catholicism, and
Islam regarding these matters. Using the same cases, we
present an additional perspective for clinicians to consid-
erFthat of Hinduism, the philosophical tradition predom-
inant among Asian Indians living in the United States. As a
caveat, many of these ethical dilemmas may not arise for
traditional older Hindu patients because they would gen-
erally be more accepting of death.
Case Scenario 1
An 86-year-old cognitively intact woman with coronary
artery disease and atrial fibrillation presents with a massive
stroke. For 2 months, she remains unconscious with com-
plete hemiplegia. Her chance of significant neurologic re-
covery is virtually nil. She has no advance directive. Her
family has strong convictions and requests a permanent
feeding tube. Although this discussion occurs, she becomes
febrile and is diagnosed with pneumonia. The children in-
sist that the doctors must under no circumstances tell the
patient’s elderly husband her bleak prognosis, because ‘‘the
information would surely kill him.’’ He is cognitively intact
and keeps asking about his wife’s condition.
Questions
1. Is it appropriate to insert or refuse to insert a feeding
tube in this patient?
2. Should her pneumonia be treated?
3. How should one respond to the husband’s queries?
If this were a traditional Hindu patient and her family,
the likelihood of them insisting on a feeding tube would be
low. Traditionally, Hindus do not fear death because it is
very much a part of life. Furthermore, most Hindus inher-
ently believe that our soul (Atman) inhabits our bodies only
134 DESHPANDE ET AL.
transiently. As highlighted by the quote from the Bhagavad-
Gita that was presented earlier, once our body becomes
worn, the soul sheds it and moves on to its next incarnation
just as we shed old clothes once they are tattered. This
process continues until our karma has been fulfilled and we
come to the realization of the unity of our Atman with the
Brahman (God, universal spirit). Therefore, our life as one
person is not a finite event for our beings, but simply a step
in the long journey of our souls. Older Hindu patients and
their families are much more accepting of death than fol-
lowers of traditional Western religions, and thus, once the
prognosis for recovery was given as nil, the family would
likely opt for comfort care to provide the patient a com-
fortable death; it is important for family members of dying
older Asian Hindus to ensure a smooth transition from this
life to the next.3 Inserting a feeding tube could only prolong
the life of a dying person, and having accepted death as a
part of life, this would likely not be a desired choice for the
patient or the family. If treating her pneumonia would bring
her comfort without prolonging the dying process, then it
would likely be an acceptable option. Regarding the issue of
diagnosis disclosure to the husband, there exists, to the au-
thors’ knowledge, no literature addressing this specifically.
Culturally, Asian Indians tend to make decisions in a com-
munal manner rather than individually.3 There usually ex-
ists a hierarchy of family members who would participate in
learning about diagnoses, prognoses, and making decisions,
although families may hold specific details from the older
patient because this could cause more distress and suffering
on the part of they dying person. The husband and the
patient’s children would play central roles in communicat-
ing with the medical team, and the husband would likely be
the primary decision maker for the patient with the support
of his family.
Case Scenario 2
An 84-year-old woman with mild dementia and compen-
sated congestive heart failure is admitted to a nursing home.
Her husband, the surrogate decision maker, presents the
attending physician with a signed and witnessed advance
directive that states that under no circumstances does she
want resuscitation, antibiotic therapy for life-threatening
infection, or to be transferred to an acute care hospital.
Questions
1. How should the staff respond to these requests, espe-
cially if they go against their own religious convictions?
2. The patient falls ill and is in a stuporous state secondary
to sepsis. How should the staff respond?
The issues raised in this case are universal, but the pa-
tient’s stated wishes in her advance directive are in line with
a traditional Hindu belief in accepting death and not pro-
longing life. If the patient, no matter of which faith, had
made her wishes known in advance, the healthcare team
should abide by them. Most Asian-Indian Hindus in this
country do not have advance directives, partially stemming
from their fundamental beliefs about life and death, and this
represents an ideal situation in which a patient has made her
wishes known. In this case, it would be appropriate for the
staff to follow the husband’s decision, which represents his
JANUARY 2005–VOL. 53, NO. 1 JAGS
wife’s wishes in accordance with Hindu beliefs. In the event
of a conflict between the healthcare team and patient, the
team should make every attempt to transfer the patient to
another team willing to abide by the care wishes outlined by
the patient. If the patient becomes acutely ill, and appears to
be dying, then her stated wishes should be respected, and all
attempts to ensure a comfortable death incorporating cer-
tain important rituals that her husband or her family wish
to perform should be made.
Case Scenario 3
An 87-year-old man with advanced metastatic lung carci-
noma admitted to an acute hospital is fed via a gastrostomy
tube and aspirates in the middle of the night. He is intubated
and put on mechanical ventilation. The morning of the
senior physician’s rounds, the children inform her that their
father had told all of them that he would never want to end
his days on a machine, as did his late wife, who died of
intractable congestive heart failure several months ago.
There is no advance directive.
Questions
1. Should he have been intubated?
2. Can life support be discontinued in accordance with the
patient’s request expressed directly or communicated to
the team by the children?
Unfortunately, the prevalence of advance directives in
the South-Asian Hindu population is low, as it is in other
older populations, but the patient’s previously stated wishes
are in line with the Hindu acceptance of death. Legally, the
intubation could not have been avoided without an advance
directive specifically stating the patient’s wishes against this
intervention. From a Hindu perspective, the intubation
could be viewed as an intervention impeding the natural
course of death and thus possibly interfering with karma. In
the context of a frail older adult, most traditional Hindu
patients and families would not want life-prolonging/sus-
taining procedures. This is rooted in the karmic theory and
perspective on life. Extubation would likely be an accepted
scenario provided that comfort is ensured.
CONCLUSION AND SUMMARY
In light of the growing cultural diversity of our aging pop-
ulation, it is increasingly evident that a multitude of phi-
losophies exist about end-of-life care. Many of these
represent significant departures from the Western bioethi-
cal model, which places importance on patient autonomy.
Furthermore, many of the issues and conflicts that have
been published arise in the context of Judeo-Christian
perspectives on life and death. An inherent but central
difference between these theological perspectives and that
of many Eastern religions is whether life is seen as finite
or as part of a continuum. This latter point, along with
karmic theory as outlined above, form the fundamental
differences between Hinduism and its approach to the end
of life and the Abrahamic religions (Judaism, Christianity,
and Islam).
Given the growth of the Asian-Indian Hindu popula-
tion in this country, it will be important and clinically per-
tinent to further elucidate this group’s beliefs and attitudes
JAGS JANUARY 2005–VOL. 53, NO. 1 ATTITUDES OF ASIAN-INDIAN HINDUS TOWARD END-OF-LIFE CARE
about end-of-life care issues such as the use of life-prolong-
ing/sustaining technologies, nutrition and hydration, ad-
vance directives, and cardiopulmonary resuscitation.
Because this ethnic group has now been in this country
continuously for close to 40 years and a new generation of
Indian Americans has been raised in this country, it will also
be valuable to examine the effects of acculturation on these
attitudes and beliefs. There have been no studies examining
attitudes about end-of-life issues of Asian-Indian Hindus
raised in Western cultures. It would be interesting to study
whether Asian-Indian Hindus being raised in these cultures
have different attitudes about death and dying because the
Hindu and Western cultural beliefs about end-of-life issues
may differ significantly. As with any ethnic study though,
these findings will need to be applied in a case-specific
manner to avoid stereotyping and broad generalizations.
REFERENCES
1. Hetzl L, Smith A. The 65 Years and over Population [on-line]. Available at:
www.census.gov/prod/2001pubs/c2kbr01-10.pdf. Accessed October 2, 2004.
2. Barnes JS, Bennett CF. The Asian population: 2000. Available at: www.census.
gov/prod/2002pubs/c2kbr01-16.pdf. Accessed October 2, 2004.
3. Doorenbos AZ, Nies MA. The use of advance directives in a population of
Asian Indian Hindus. J Transcultural Nurs 2003;14:17–24.
4. Doorenbos AZ. Hospice access for Asian Indian immigrants. J Hosp Palliat
Nurs 2003;5:27–33.
5. Blackhall LJ, Murphy ST, Frank G et al. Ethnicity and attitudes toward patient
autonomy. JAMA 1995;274:800–825.
135
6. Eleazer GP, Hornung CA, Egbert CB et al. The relationship between ethnicity
and advance directives in a frail older population. J Am Geriatr Soc
1996;44:938–943.
7. Berger JT. Culture and ethnicity in clinical care. Arch Intern Med
1998;158:2085–2090.
8. Blackhall LJ, Frank G, Murphy ST et al. Ethnicity and attitudes towards
life-sustaining technology. Soc Sci Med 1999;48:1779–1789.
9. Vaughn G, Kiyasu E, McCormick WC. Advance directive preferences among
subpopulations of Asian nursing home residents in the Pacific Northwest. J Am
Geriatr Soc 2000;48:554–557.
10. Kagawa-Singer M, Blackhall LJ. Negotiating cross-cultural issues at the end of
life: ‘You got to go where he lives.’ JAMA 2001;286:2993–3001.
11. Bowman KW, Singer PA. Chinese seniors’ perspectives on end-of-life decisions.
Soc Sci Med 2001;53:455–464.
12. Bhungalia S, Kemp C. (Asian) Indian health beliefs and practices related to the
end of life. J Hosp Palliat Nurs 2002;4:54–58.
13. Coward H, Sidhu T. Bioethics for clinicians: 19. Hinduism and Sikhism.
Can Med Assoc J 2000;163:1167–1170.
14. Easwaran E, translator. Bhagavad-Gita Translated for Modern Readers
Tomales. CA: Nilgiri Press, 1985.
15. Sharma K. A question of faith for the Hindu patient. Eur J Palliat Care
2000;7:99–100.
16. Laungani P. Hindu death and the use of hospices in the UK. Int J Health Prom
Educ 2002;40:120–128.
17. Pandit B. Hindu Dharma. Glen Ellyn, IL: B V Enterprises, 1996.
18. Olivell P, translator. Upanishads. New York: Oxford University Press, 1996.
19. Laungani P. Hindu deaths in IndiaFPart 1. Int J Health Prom Educ
2001;39:88–96.
20. Laungani P. Hindu deaths in BritainFPart 2. Int J Health Prom Educ
2001;39:114–120.
21. Francis MR. Concerns of terminally ill adult Hindu cancer patients 1986 to
2000. Cancer Nurs 2001;9:164–171.
22. Clarfield AM, Gordon M, Markwell H et al. Ethical issues in end-of-life
geriatric care. The approach of three monotheistic religionsFJudaism,
Catholicism, and Islam. J Am Geriatr Soc 2003;51:1149–1154.