Relieving pain and suffering has been a primary goal of medicine and the physician’s promise to the patient since the Hippocratic Oath.^Footnote1 This goal is also an important ground for the supporters of physician-assisted dying (PAD).^Footnote2 Euthanasia and physician-assisted suicide (PAS) are two major forms of physician interference, which engender different ethical judgments in death. Albert R. Jonsen and his colleagues list arguments against and in favor of PAD and state the following approach as one of the arguments supporting PAD: “No person should be required to bear disproportionate burdens of pain and suffering, and those who relieve them of such burdens, at their request, are acting ethically, that is, out of compassion and respect for autonomy.”^Footnote3 Tom L. Beauchamp and James F. Childress underscore the function of the virtues of care and compassion, along with the principles of respect for autonomy and beneficence, in the rationale of PAD when there is intolerable suffering.^Footnote4 The emphasis on compassion in PAD prompts a need to appraise the physician’s moral role in the therapeutic relationship in the case of unbearable pain and suffering. The American Medical Association (AMA) considers compassion a necessary component of medical practice through the principle that “[a] physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.”^Footnote5 Similarly, the World Medical Association International Code of Medical Ethics describes the physician’s primary duty as being “to promote the health and well-being of individual patients by providing competent, timely, and compassionate care in accordance with good medical practice and professionalism.”^Footnote6. Therefore, it is possible to draw a direct connection between compassion and the physician’s moral duty and responsibility, including in the request for PAD. However, understanding or interpreting compassion plays a fundamental role in deciding its function in PAD. For this reason, the paper aims to compare Mahatma Gandhi’s view regarding compassion with Aristotle’s standpoint on virtues and vices to evaluate the possibility of using compassion to justify PAD.

Many scholars consider compassion a virtue that healthcare professionals should possess to understand patients’ needs and approach them appropriately.^Footnote7 Compassion is also a robust moral ground for legitimizing PAD.^Footnote8 Nevertheless, as William E. Stempsey emphasizes, religious views significantly influence people’s stances on PAD.^Footnote9 For instance, Abrahamic religions’ belief that God possesses ultimate power over birth and death precludes the practice of any form of euthanasia or physician-assisted death.^Footnote10 However, regarding religious approaches to PAD, Gandhi, whose political, social, and philosophical thoughts are strongly impacted by his religious views, is an extraordinary figure who submits the utilization of compassion in favor of assisted dying.^Footnote11 In this context, studying compassion through Aristotle’s opinion on virtues and vices and Gandhi’s religion-oriented standpoint can provide a useful insight into the role of compassion in the justification of PAD.

The significance of compassion in medicine is an overwhelmingly accepted phenomenon, but its definitions vary slightly.^Footnote12 Charles J. Dougherty and Ruth Purtilo consider compassion an essential component of the relationship between the physician and patient.^Footnote13 Ramy Sedhom defines compassion as “a deep response to the suffering of another.”^Footnote14 Gyatso Tenzin, the 14th Dalai Lama, deems compassion “not just an emotional response but a firm commitment founded on reason.”^Footnote15 Harvey Max Chochinov describes compassion as “a deep awareness of the suffering of another coupled with the wish to relieve it.”^Footnote16 Constance E. George describes compassion as “an indicator of quality for patients and … an indicator of good character and collegiality among clinicians.”^Footnote17 Additionally, according to Andre Comte-Sponville, compassion is a universal virtue due to its intention that aims to mitigate suffering regardless of the cause of the suffering and because of its scope, which not only covers human beings’ suffering but all beings’ suffering.^Footnote18 David C. Thomasma also considers compassion to be a virtue that generates feelings urging us to help the sufferer.^Footnote19

Based on these different descriptions and approaches, it is possible to highlight three aspects of compassion. First, compassion refers to emotions. The sufferer’s unfortunate circumstances touch others’ feelings and create sympathy for the person. Second, compassion incorporates the wish to help someone in pain or suffering. This point differentiates compassion from sympathy. Third, compassion may be accepted as a moral value, virtue, or characteristic of healthcare professionals in the therapeutic relationship. Even though compassion is a subjective concept, it indicates a desirable characteristic of people practicing healthcare services.^Footnote20

In general, compassion in medicine is deemed a virtue for or a personal characteristic of healthcare professionals without any religious references. Thus, compassion can be acknowledged as a moral value rather than a religious term. However, Mahatma Gandhi completely appraises compassion from a religious standpoint, takes compassion to be “at the very root of religion,” and says, “[r]eligion without compassion is a fraud.”^Footnote21 Ahimsa (non-killing) is an essential component of Hinduism, Jainism, and Buddhism.^Footnote22 Gandhi assesses the broad meaning of compassion via ahimsa and claims that “[t]he very essence of ahimsa lies in burning our anger and in cleansing the soul.”^Footnote23 In other words, Gandhi converts the concept of non-killing into the principle of non-violence and defines the state of non-violence as “an ocean of compassion.”^Footnote24 From this perspective, according to Gandhi, compassion is the most important component of the person’s dharma and a necessary part of non-violence.^Footnote25

Gandhi’s broad framework of compassion can be examined through two sub-categories: Compassion as relieving suffering and compassion as doing good or performing our duty. Gandhi says, “I feel pain when I see others suffer. It is the nature of compassion that whenever one is unable to relieve the suffering of others one suffers unbearably.”^Footnote26 He also expresses that “[t]rue compassion lies in doing what is good or performing our duty even at the cost of inflicting pain on others through our action.”^Footnote27 The former quotation deems compassion to be a strong wish to help the sufferer, and the latter one indicates compassion as acting according to our duties even in the case of causing pain, such as not giving money to your alcohol-addicted child or allowing her/him to drink alcohol. From this perspective, Gandhi’s compassion can be defined in light of these two approaches.

The doctrine of non-violence rejects harming any beings and requires love and compassion toward them.^Footnote28 Therefore, compassion plays an indispensable role in the idea of non-violence. However, this does not mean that Gandhi refuses all forms of inflicting harm or pain. On the contrary, according to Gandhi, under the condition of the following situations, inflicting harm or pain is the requirement of compassion:

“1. We can do something which hurts someone only if it hurts us more than it hurts him.

2. Our motive must be absolutely pure. We should have no other thought in our mind than the welfare of the other person.”^Footnote29

Based on these conditions, harm or pain can be inflicted for the sake of the sufferer’s welfare. Gandhi even takes this permissibility to a level of moral obligation when there is no alternative to relieve suffering. He states,

“I cannot for a moment bear to see a dog, or for that matter any other living being, helplessly suffering the torture of a slow death. I do not kill a human being thus circumstanced because I have more hopeful remedies. I should kill a dog similarly situated, because in its case I am without a remedy. Should my child be attacked by rabies and there was no hopeful remedy to relieve his agony, I should consider it my duty to take his life.”^Footnote30

This quotation demonstrates both aspects of compassion: Helping the sufferer and performing our duty. The goal is to help alleviate suffering, but it is not only an act of kindness or benevolence but also a moral requirement resulting from our duty.

The example of rabies also shows that Gandhi does not have any limitations to the application of compassion. Thus, Gandhi says, “[t]here is religion only to the extent that there is compassion. There can be no limit to compassion.”^Footnote31 Gandhi’s religious view on compassion can be regarded as a supportive argument for the acceptability of PAD practices. Moreover, it is even possible to interpret his standpoint as a moral obligation to implement PAD under the conditions of intractable pain or suffering, pure motivation, and unavailability of alternatives.

In Nicomachean Ethics, Aristotle considers happiness “the best, noblest, and most pleasant thing in the world” as “an activity of soul in accordance with perfect virtue.”^Footnote32 According to Aristotle, virtue is “a state of character” aiming to find a mean between deficiency and excess “in passions and in actions.”^Footnote33 He claims that virtue can be acquired only by pinpointing the middle of two vices, deficiency and excess, but it is not an easy task everyone can achieve.^Footnote34 Additionally, a mean (intermediate) is only possible for good passions and actions, not intrinsically bad things, like murder, theft, or envy, or excesses and deficiencies.^Footnote35 Aristotle also gives many examples of means with relevant excesses and deficiencies, some of which are as follows^Footnote36:

Besides these specific examples of virtues and the possible vices of each, Aristotle draws a general framework about how to decide on virtues by asserting that feeling passions and actions “at the right times, with reference to the right objects, towards the right people, with the right motive, and in the right way” depends on “the quality of aiming at the intermediate.”^Footnote37 From this perspective, any passion or action, including compassion, can be appraised in accordance with this view to determine the pertinent state of virtue. However, it should be highlighted that Aristotle’s standpoint on virtues and vices indicates specific limitations to all passions and actions.

Compassion is a moral value and requires helping the sufferer. Gandhi deems compassion to be a duty to help and relieve the sufferer’s pain and suffering without any limitation. Even though compassion is a primary component of the principle of non-violence, which refuses to harm or kill any beings and requires showing love to them, under the condition of pure motivation, Gandhi justifies taking the life of a human being who suffers unbearably and has no possibility of remedy. In the light of compassion, Gandhi’s view can be interpreted such that PAD is morally justifiable if the goal is to relieve intractable pain or suffering, if there are no alternatives to relieve the intractable pain or suffering, and if practicing PAD hurts/saddens the practitioner.

Based on Aristotle’s idea of virtues and vice, compassion can be considered a virtue because it is a passion indicating the wish to help the sufferer. However, Aristotle does not acknowledge any passion in a limitless state but claims the necessity to find the intermediate for all passions and actions. Therefore, in the case of regarding compassion as a virtue, its excess and deficiency states should also be reckoned. In the translation of Nicomachean Ethics and The Art of Rhetoric, the term “pity” is used rather than compassion.^Footnote38 However, according to John Saunders, “pity” in modern translation of Aristotle’s works refers to compassion.^Footnote39 Aristotle defines pity as “a feeling of pain caused by the sight of some evil, destructive or painful, which befalls one who does not deserve it” and describes the person who feels pity as one who is between two extremes: The insolent person, who has no concern about any evil that happens to her/him and the panic-stricken person who is preoccupied with what happens to her/him.^Footnote40 In this view, it is possible to argue that Aristotle uses pity only as a feeling of pain, not a wish to do something to alleviate pain. Thus, in Nicomachean Ethics, Aristotle says, “with respect to weakness and infirmity; no one would reproach a man blind from birth or by disease or from a blow, but rather pity him, while everyone would blame a man who was blind from drunkenness.”^Footnote41 From this perspective, a conclusion may be drawn as Aristotle’s utilization of pity in Nicomachean Ethics and The Art of Rhetoric refers to sympathy rather than compassion because compassion not only indicates a sense of understanding the person’s suffering; it also requests to do or wish to do something to relieve the suffering.

Aristotle elaborates on the virtues and vices of several passions in Nicomachean Ethics, but compassion is not one of them. However, based on his general framework of virtues and vices, compassion can undoubtedly be accepted as a virtue. In such a case, the excess and deficiency of compassion should also be reckoned, and fixation might be recognized as the excess, whereas apathy may be contemplated as the deficiency. Fixation refers to the state of feeling responsible for everything and striving to have control over all circumstances. Gandhi’s example of responsibility for taking the life of a person attacked by rabies can signify such a situation because instead of admitting the person’s unfortunate condition/fate, showing patience, and acknowledging God’s decision, assuming the responsibility for ending the suffering at all costs, even by killing, may reveal such an extreme. On the other hand, apathy might show a deficiency of compassion because besides sympathy for the suffering, trying to mitigate it is an essential part of compassion. However, not demonstrating any wish to help the suffering person points out a deficiency.

Compassion, as a virtue that is the intermediate between fixation and apathy, cannot justify PAD practices. Providing a person suffering intolerably with palliative, social, emotional, and spiritual care may be consistent with compassion. However, taking this effort even further by terminating the person’s life might become a vice as an excess of compassion. As a result, since Aristotle defines virtues through certain limits, contrary to Gandhi’s standpoint, according to Aristotle’s view on virtues and vices, compassion cannot be considered a moral justification for PAD interventions.

Even though the need for compassion in the therapeutic relationship is acknowledged by consensus, its utilization in the justification of end-of-life interventions generates controversial arguments. In particular, the views legitimizing PAD deploy compassion as a primary ground to support assisting people who suffer intolerably to die. Considering compassion a virtue and defining it as a strong feeling of helping the sufferer may lead to a conclusion of alleviating the suffering at all costs. However, examining compassion from the perspective of Aristotle’s thoughts on virtues and vices demonstrates that compassion should indicate an intermediate level, such as an area between apathy and fixation, to be acknowledged as a virtue. In other words, according to a virtue-oriented evaluation, compassion should not be used to justify PAD interventions because it requires helping the person to relieve suffering, but the help should be limited to an intermediate approach (a mean); relieving suffering at all costs would represent an excess. Therefore, rather than describing compassion as a moral duty or responsibility for alleviating suffering at all costs, assessing compassion as an intermediate way to help patients with available medical, spiritual, emotional, and social support may be construed as a virtue ethics-based requirement.

On the other hand, despite the strong religious impact on his political, social, and philosophical views, Mahatma Gandhi accepts compassion as a moral duty and admits it as a basis, under certain conditions, for mitigating intractable suffering at all costs, including assisted dying practices. At that point, Gandhi’s approach is significant, not only because of his endorsement of PAD, but also because of his dissent to religious arguments on PAD.

Additionally, it is generally possible to presume Aristotle’s non-religion-driven thoughts in favor of assisted dying and to assume Gandhi’s religion-based standpoint against PAD practices. However, the paper reveals that based on a compassion-related comparison, both display opposite positions to that general expectation because Gandhi agrees on relieving intractable pain or suffering through all available means in the event of the lack of alternatives and self-interest motivations, whereas Aristotle’s approach to virtues asks us to interpret compassion through an intermediate stance, which demands helping sufferers without killing them or directly causing their death.