Introduction
The human brain is wired for survival. Over millennia, our instincts have driven us to preserve life, overcome threats, and seek comfort in adversity. Yet, despite this deeply ingrained drive, survival alone does not define a meaningful existence. At some point, we may confront questions that challenge the very core of this biological imperative: What happens when survival conflicts with autonomy? When suffering outweighs the will to live? Should autonomy include the right to die, even in the absence of terminal illness?
These questions are not new. Across cultures and throughout history, humans have grappled with the ethics and meaning of life and death. Practices such as Prayopavesa in Hinduism and Sallekhana in Jainism reflect long-standing traditions of voluntary fasting to death as acts of spiritual detachment and self-determination. In modern contexts, similar intentional acts, such as Voluntary Stopping of Eating and Drinking (VSED), emerge from medical and ethical discussions about autonomy and the alleviation of suffering.
This essay examines the intersection of survival, suffering, and autonomy. By reframing our understanding of these concepts, we can challenge societal norms about what it means to live—and die—with dignity and intention.
The Biology of Survival
The human brain has evolved mechanisms that prioritize survival by responding to environmental challenges. Central to this process is the limbic system, which regulates emotional responses. The amygdala, a key structure within this system, plays a role in processing fear and initiating physiological responses, such as the release of stress hormones like adrenaline and cortisol, that prepare the body for immediate action1.
Complementing this system is the brain’s reward pathway, centered on the mesolimbic dopamine system. Dopamine, a neurotransmitter associated with pleasure and motivation, reinforces behaviors essential for survival, such as eating, bonding, and achieving goals2. Together, these systems create a powerful biological bias toward survival, shaping how we respond to challenges and opportunities.
Yet, survival is not always aligned with well-being. When chronic suffering—whether physical, emotional, or existential—disrupts the brain’s balance, it can challenge the instinct to live.
Suffering and the Challenge to Survival Instincts
Suffering has profound neurological and psychological effects that are measurable changes in brain activity. For example, in states of chronic pain or depression, activity in the prefrontal cortex (PFC)—which supports planning, reasoning, and decision-making—may decrease, influencing cognitive processes3. Concurrently, increased activity in the anterior cingulate cortex (ACC), which is involved in processing both physical and emotional pain, can amplify the salience of distressing experiences4. These neurobiological adaptations may contribute to shifts in an individual’s perspectives on survival, quality of life, and decision-making.
For some, this reassessment leads to a desire for autonomy—not merely in living but also in dying. This desire has found expression in diverse cultural practices and modern medical frameworks, each grappling with the tension between survival and dignity.
Autonomy Beyond the Will to Survive
Autonomy is the ability to make self-directed choices, free from external coercion. It is central to human dignity, enabling individuals to shape their lives according to their values. Yet, autonomy often faces resistance when it comes to decisions about death. Modern societies increasingly recognize euthanasia or assisted suicide as options for individuals with terminal illnesses, framed within ethical and legal parameters. However, decisions influenced by chronic, non-terminal suffering remain a complex and often debated aspect of public and ethical discourse.
One medically recognized practice that expands autonomy is Voluntary Stopping of Eating and Drinking (VSED). This practice involves an individual’s intentional choice to cease food and fluid intake, leading to physiological changes that result in death. In medical contexts, VSED is characterized by a deliberate and controlled approach and is often supported by palliative care to manage symptoms and maintain comfort throughout the process5. In this framework, autonomy is expressed not as an escape from life but as a deliberate act of self-determination when life’s quality becomes intolerable.
Historically, similar practices have existed in spiritual traditions. In Hinduism, Prayopavesa (Sanskrit: प्रायोपवेशनम्, prāyopaveśanam, lit. “resolving to die through fasting”) is framed within the context of spiritual liberation (Devnagari: मोक्ष, moksha) and is traditionally undertaken by individuals who perceive their worldly responsibilities as complete6. Similarly, Sallekhana (Devnagari: सल्लेखना, lit. “thinning out” or “emaciating”), in Jainism is a vow of fasting to death that signifies the ultimate renunciation of material attachments. It is viewed as a disciplined, spiritual purification aligned with the principle of non-violence (Devnagari: अहिंसा, ahimsa)7.
While Prayopavesa and Sallekhana are motivated by spiritual ideals, VSED reflects a more secular and medicalized approach. What unites these practices is their affirmation of autonomy: the ability to choose how and when to die, often with clarity, dignity, and intention.
Toward a New Framework for Autonomy
Rethinking the relationship between survival and autonomy requires us to confront deeply held beliefs about the sanctity of life. Survival, while biologically imperative, is not always the highest good. For some, the ability to determine when and how to die is an extension of dignity and agency, particularly when suffering erodes the quality of life.
By recognizing practices like VSED, Prayopavesa, and Sallekhana, we broaden our understanding of autonomy. These choices challenge us to move beyond the fear of death and the instinct to survive at all costs, opening space for a more compassionate framework that honors individual self-determination.
Conclusion
Humanity’s engagement with mortality has always been complex, shaped by the tension between survival instincts and the philosophical questions that arise from self-awareness. Practices like VSED, Prayopavesa, and Sallekhana remind us that autonomy is not only about living well but also about dying well.
This essay has laid the groundwork for exploring how autonomy, suffering, and detachment intersect with mortality. In the next essay, we will delve deeper into the neuroscience of survival and suffering, examining how the brain’s biology shapes our relationship with life and death.
References
- Kozlowska, Kasia et al. “Fear and the Defense Cascade: Clinical Implications and Management.” Harvard review of psychiatry vol. 23,4 (2015): 263-87. doi:10.1097/HRP.0000000000000065
- Schultz, W. “Predictive reward signal of dopamine neurons.” Journal of neurophysiology vol. 80,1 (1998): 1-27. doi:10.1152/jn.1998.80.1.1
- Drevets, Wayne C et al. “Brain structural and functional abnormalities in mood disorders: implications for neurocircuitry models of depression.” Brain structure & function vol. 213,1-2 (2008): 93-118. doi:10.1007/s00429-008-0189-x
- Shackman, Alexander J et al. “The integration of negative affect, pain and cognitive control in the cingulate cortex.” Nature reviews. Neuroscience vol. 12,3 (2011): 154-67. doi:10.1038/nrn2994
- Quill, T. E., & Byock, I. R. (2000). “Responding to intractable terminal suffering: The role of terminal sedation and voluntary refusal of food and fluids.” Annals of Internal Medicine, 132(5), 408–414. doi:10.7326/0003-4819-132-5-200003070-00012
- Setta, S.M., Shemie, S.D. “An explanation and analysis of how world religions formulate their ethical decisions on withdrawing treatment and determining death.” Philos Ethics Humanit Med 10, 6 (2015). doi.org/10.1186/s13010-015-0025-x
- Olson, C. “The conflicting themes of nonviolence and violence in ancient Indian asceticism as evident in the practice of fasting.” Int. J. Dharma Studies 2, 1 (2014). doi.org/10.1186/2196-8802-2-1
