Home Profile Services Other Therapist Prevention FAQ Contact Us Feedback

Stay Thy Hand, Yet


The Statesman 26-11-2001

Reflective consciousness in ethical issues may have reached a level to validate euthanasia as a concept (“Dead Man Stalking”, by Saubhik Chakrabarti, 14-15 December), but active practice in a living community must, first, satisfactorily resolve three basic issues. Who initiates and benefits from the action, who performs the actual act and by what laws. Indian experience being limited so far, a debate in context requires a look at international experience.

 While ethical laws distinguish between voluntary and imposed euthanasia, medical practice recognises either passive euthanasia, done by withdrawal of treatment, or active euthanasia, where an actual killing drug is obtained  from a physician (physician assisted suicide or PAS) or the physician himself delivers the lethal dose. It is a misconception that euthanasia in all these forms have been legalised in some countries.

   The first legal sanction of euthanasia (the Northern Territory Rights of the Terminally Ill Act 1995, Australia) was repealed on 23 March 1997. Netherlands never had legal sanctions, but because of a “tolerant judiciary “the practice of euthanasia is common among Dutch physicians. A survey there, analysing 839 deaths of mental patients involving 79 doctors, detected as many as 350 ending-of-life decisions.
With supportive medical care becoming increasingly capable of prolonging  human live in its most reduced forms, for example in a  permanent vegetative states (PVS), the western primacy on the autonomy of the individual produced the notion that, as in life, dignity must accompany death. Humanity, in 1974 published a signed appeal, led by noble laureate Linus Pauling, which proclaimed the belief that society has no genuine interest or need to preserve the terminally ills against their wills and that the right to beneficent euthanasia, with proper procedural safeguards, was worth protecting.

Such thoughts ultimately culminated in the practice of writing a “living will” which specifically directs and ethically binds the physician to act as willed when the patient can no longer make his wish known and respect a DNR (do not resuscitate) choice if a person already terminally ill should develop; another life threatening emergency like a cardiac stroke (Patient Self-determination Act, 1991, U.S.A). A further concession to the demand for the right to die was made by the state of Oregon, U.S. It passed the Death with Dignity Act allowing PAS with the provision that the physician will only prescribe the lethal drug for self-administration at the patient’s request. This law has since been upheld by higher U.S. courts of laws and by other American states. 

Colombia was perhaps the first country to accept the right to die as one of the rights of the patients in October 1997. Almost all other countries consider euthanasia, including PAS, to be illegal and deliberate acts, which are charged as first degree murder; suicide in any form being a criminal offence in most countries, including India. Law-makers find it difficult to draft a comprehensive law due to complexities surrounding euthanasia or ending-of –life decisions which may be illustrated by these case reports.

In September 1991, Dr. Boudewijn Chabot in Netherlands was charged for assisting the suicide of Hilly Bosscher, a 50-year-old woman in good physical health but suffering from depression due to the loss of her two sons and the end of her marriage. The question here was whether psychological suffering can be equated to physical suffering. Rose Wend land wants to withdraw the feeding tube of her husband Robert; a 45-year-old “physically and cognitively” disabled man now awake after 16 months’ coma. But her husband’s kin has sued her to prevent his death by starvation and dehydration.

C A Thomas, an 80-year-old man in South India who is in good health, financially secure and content in family life, has challenged Indian laws against suicide saying he ‘should be able to choose when he shall die. Karen Ann Quinlan, a 21-year-old in New Jersey, U.S., deteriorated to a vegetative state from an overdose of pills and alcohol in 19975. Her parents moved several courts to take her off the respirator. But, ironically Karen remained alive minus the respirator for 10 more years.

Physician’s organisations the world over overwhelmingly oppose active euthanasia. Neither the Hippocratic Oath nor the Geneva Convention condones such proposals. In reality, though, doctors often participate in passive euthanasia by withdrawing or declining treatment in terminal cases.
The “double effect” of a palliating drug is used sometimes – morphine is given in gradually increasing dosage, knowing but not admitting that it may gradually depress respiration and shorten life. The situation becomes more controversial, however, when withdrawal of life-support means withdrawal of food and nutrition. At oxford house, Preston, Mrs. Mary Ormond lived for two months more after nutritive food was withdrawn from her on her daughter’s request and doctor’s instruction. One can justifiably argue that slow death by starvation is inhuman and can never be beneficent.

But the argument changes dramatically as soon as euthanasia is active. Here, the physician is the key figure. Therefore, his character and relationship with the patient must be well-defined. Who is he? The family practitioner, the treatment specialist, or the terminal care specialist? Is he sufficiently emotionally involved to feel the compassion of a family member or a person like Dr.Jack Kevorkian who is alleged to be just a vendor of death, having helped to “kill” 109 persons without even knowing them ?

Clinical detachment or emotional involvement, which shall be preferred? While the physician next door may not be immune to lot of subjective consideration, other physicians, even behind the anonymity of the closed doors of a multi-tiered institution, may not like the hassles involved. And what if the patient is a prospective organ donor or if death is convenient for covering medical misdeeds? Besides, no terminal care specialist will probably want to be known as the “death doctor”,

Ultimately whatever law empowers the physician, most will shy away leaving this field to a new band of professionals, failures in clinical life and outcasts from medical societies, who would derive sustenance and a macabre sense of achievement in the name of mercy killing. (iaetf accuses Dr. Kevorkian of just being that, an unsuccessful pathologist devoid of any clinical experience) and they will lay the ground for all kinds of abuse and malpractice.

In India, the concept of individual autonomy is still weak and even the right to live a dignified life is not a prime consideration for many. But for a culture which has lived with the prescription of renunciation of worldly motives after a certain age (Banaprastha) and the traditional practice of consecration of dying persons (Antarjali), the concept of euthanasia can not be alien.
However the Indian Constitution and laws presently hold an opposite view. By a reversal  of an earlier ruling ( Rathinam Vs Indian Union) the Supreme Court has declared  suicide as illegal though it has conceded that in case of a terminally ill patient in PVS , attempts to hasten death may  be viewed as acceleration of dying process already started.  Sale of morphine sulfate, the best friend for any palliative care, is illegal in most Indian states.
Possible abuse

Perhaps, the situation here in India, also does not merit a drastic change of law. True, our traditional holistic attitude to medicine is now weakened by the practice of a fragmented form of western medicine and the health care system itself is undergoing a transition directed more by “technological push rather than clinical pull”, but Indian hospitals are not exactly crowded with people waiting for their respirators or feeding tubes to be removed.

Good and simple palliative care for most terminal patients are now available  and many western concepts of palliative and terminal care are redundant in India because of our three-tier family system which, however splintered it may look now, provides an effective cushion against many inconvenient situations. The dependent octogenarian here is perhaps less embarrassed since no law expects him or her to make a choice.

 Thus, from almost any point of view, it is difficult to make a case for blanket permission for the right to die. Proponents of euthanasia argue that ultimately it will be applicable in a “narrow range of cases”. But it can be equally convincingly argued that opening the door for a narrow range of cases will soon lead to broader application, with proportionate abuse.

Gerontocide will be an unwelcome addition to an already ugly list of foeticide, Satidaha, bride killing, and surely some not so beneficent antarjali yatras.  Our own world is not ready for legalising assisted death.