Background
Aruna Shanbaug breathed her last on May 18, 2015 in Mumbai, after being in a permanent vegetative state (PVS) for 42 long years. She was the reason why India embraced the Passive Euthanasia by publishing the guidelines for the same in March 2011 (though the petition filed by the author Pinky Virani to let Aruna die with dignity was not accepted by the court). But her death probably has stirred up the yearlong debate once again on whether Active Euthanasia can be acceptable in India.
42 years!!! I was truly fascinated by this number. This is something really beyond my wildest imagination. Can someone really still long for life despite being in PVS for so long?? Can people daily attending to someone in such state for so long still desire for the patient’s prolonged life?? I don’t really know. Perhaps the answers vary on case to case basis; or perhaps there is no real simple answer to this.
Definition of Euthanasia and PAS
Before going on to the argument and justifications let us first ponder over the fundamental differences between the Passive and Active Euthanasia.
The word Euthanasia was coined by Sir Francis Bacon in the 17th Century. The origin of the word is derived from the Greek word ‘EU’ which means good or happy and ‘THANATOS’ meaning ‘death’. So in a nutshell, Euthanasia literally signifies a good or happy death to end someone’s prolonged and incurable suffering or pain.
Passive Euthanasia is the deliberate withdrawal of life-support systems (food, medicine, palliative care etc.) from someone who has no chance to recover.
Active Euthanasia, on the other hand, is actually achieved by administering lethal drugs by the physician to someone who will always be in a vegetative state for the rest of his/her life to ease the incurable suffering. There are three broad categories of Active Euthanasia: voluntary, involuntary and non-voluntary. Voluntary Euthanasia is carried out at the informed consent of the patient. Involuntary Euthanasia or “mercy killing,” involves taking the life of a patient who has not provided any consent but is capable of requesting for one, with the intent of relieving his pain and suffering. In case of non-voluntary Euthanasia, the process is carried out even though the patient is not in a position to give consent on the moral grounds.
As per Supreme Court of India, “the difference between Active and Passive Euthanasia is that in Active Euthanasia something is done to end the patient’s life while in Passive Euthanasia, something is not done that would have preserved the patient’s life”
There is also a fine line between Active Euthanasia and physician assisted suicide (PAS). PAS involves a physician providing medications or advice to enable the patient to end his or her own life.
Euthanasia and PAS in India
Some countries in the world like Netherlands, Belgium and US (only Oregon, Washington and Montana states) have actually legalized both forms of Euthanasia. In Switzerland PAS is permitted.
In India though, Euthanasia and PAS are legal offenses. Sections 309 and 306 of the Indian Penal Code (IPC) deal with the attempt to commit suicide and abetment of suicide respectively. Both these actions can be prosecuted under the law. But on 7th March 2011, Supreme Court of India, in a historic judgment, allowed Passive Euthanasia, but there is still no legislation around the same. Refusing the mercy killing of Aruna Shaunbag based on a petition filed by her ‘next friend’ Pinky Virani, a two-judge bench laid down a set of tough guidelines under which Passive Euthanasia can be legalized through a high-court monitored mechanism. These guidelines were put in place to prevent any plausible misuse of the provision and these guidelines must have to be followed in every such case till a final legislation is made by the Government. The following guidelines set by the Supreme Court of India are considered as the law as of now:
· Any petition for Passive Euthanasia has to be filed with the relevant High Court. The Chief Justice of the High Court should constitute a Bench of at least two Judges who should decide to grant the approval or not.
· Before taking any decision, the bench should seek the opinion of a committee of three reputed doctors to be nominated by the bench. Preferably, one of the three doctors should be a neurologist; one should be a psychiatrist, and the third a physician.
· The High Court Bench should issue notice to the State and close relatives e.g. parents, spouse, brothers/sisters etc. of the patient, and in their absence, the next friend.
· The Court should supply a copy of the report of the doctor’s committee to them as soon as it is available.
· After hearing all the parties, the High Court bench should give its verdict at the earliest.
Arguments Supporting PAS and Euthanasia
There are quite a few strong arguments that can be shown in the favor of legalizing Euthanasia and PAS.
The first and the foremost reason that is cited by the proponents is the humanitarian ground on the basis of which a patient can choose to end his/her life if he/she is considered to be terminally ill, or even the physician can choose to enact on the patient’s behalf. The relatives and the patient him/herself should not be forced to suffer the pain in the course of a prolonged death. Even if the only way to eradicate his/her pain is by ending his/her life, the process can be ethical and justifiable in case the quality of sustaining the life for the terminally ill has degraded to such lowliness that it calls for ending it.
The law in India separates out passive and active euthanasia based on the process and who carries out the necessary steps. But even the passive version of the process involves and active step where the life-supports has to be withdrawn. So if passive euthanasia is accepted why not the active one as well if both are based on the patient’s – who is terminally ill - consent?
Any patient has the autonomous right to accept or refuse the level and quality of treatment. Active euthanasia and PAS could be a natural extension to this autonomy to the patients. The patients, many a times, out of the terminal illness and disability and fear of being (or continuing to be) a burden to families and society – even with the extreme palliative care – can take a rational decision to end his/her life.
Each and every patient completely relies on their physician to carry out the necessary treatment to ensure they do not become more disabled and burdensome. So if a patient who has absolutely no chance of being cured can depend on the physician to assist him/her to be relieved from the extended suffering.
For a terminally ill patient it sometimes works as a psychological advantage in case he/she is aware that he/she can actually control the time and manner of the death. Being aware of the fact that there can indeed be an escape from the pain and suffering of illness or disability or the mental trauma may alleviate some of the stress associated with the dying processes, even if the escape process does actually mean to end his/her life.
Arguments Opposing PAS and Euthanasia
The opponents provide some sound counter arguments too.
The medical profession is all about saving, healing and extending the lives and not taking or shortening it or even assisting to it. So it is completely unethical and immoral for a physician to be involved in hastening the death of anyone. And needless to say, this is completely contradictory to the Hippocratic Oath which is the first stepping stone for any physician to get into the medical profession.
As per the medical studies, suicidal tendencies and interest in PAS are actually a distorted form of a mental disorder. And this goes to the extreme in case of terminally ill patients as they knew that there is no cure. But sometimes the request for PAS is actually because of the absence or inadequacy of the palliative care. So the physicians must have to be careful in answering to the patient’s request for PAS. If PAS is legalized, physicians might unknowingly commit PAS to alleviate the pain of someone, which could have been done – to some extent – by proper palliative care.
There is another possibility that terminally ill patients from a particular social background can be actually driven towards PAS, if it is legalized. This is a really valid point, given the financial aspect attached to a patient from the perspective of the hospitals. Hence incurable patients with poor health insurance or limited financial resources may be forced into requesting PAS in order to actually reduce the burden from the hospital to provide the palliative care and other facilities for someone who eventually will die but will not be able to afford the services.
In case of the patients are not in a position to provide a consent, the guidelines currently state that the relatives or a next friend can provide an informed consent. If PAS or Euthanasia is really legalized it will be hard to determine the vested interest of the person providing the consents for each and every cases. The court, even if it is involved, cannot be accurate in its verdicts for each and every case. Thus, the providing security to those who are under threat because the law is being misused by a few would also perhaps need to be thought of.
My Two Cents
Theoretically there is an essential difference between the processes of active and passive euthanasia and PAS but effectively all of these are the same. They are to expedite the unavoidable.
While Passive Euthanasia is acceptable in India to many as perhaps this is considered to the right to die willingly, there is a worldwide debate on the moral grounds and ethical complications attached to Active Euthanasia as this is also considered as a planned homicide. In India attempting suicide and assisting in the same are all punishable crimes under the law. Ideally can a person claim for Passive Euthanasia if he wants to commit suicide? No. There is a broad demarcation. Passive Euthanasia is only applicable to someone who has no chance of surviving medically.
There are actually a few lingering questions which India must answer, if we are really rooting for Euthanasia and PAS to be legalized.
The patient should provide informed consent to law that he/she should be administered with lethal drugs and of course with valid and justified reasons. In case the patient is not able to provide the consent due to his medical condition, the close relatives or a next friend can provide the consent. How to identify that the relatives do not have any hidden motives?
The intention to use Active Euthanasia must be established on solid grounds and sound logic. This is really a big ask. The manipulation of the law is really common across worldwide; even the strongest of the laws are breached and exploited. The court can (and must) intervene to finally decide whether to go ahead with the euthanasia for a particular patient or not, but I am not convinced that the verdict of the court will be truly accurate in all the cases.
There has to be a core committee of neutral and unbiased – and government recognized – medical professionals who must evaluate the criticality of the patient. Obviously not all the patients can be allowed to have Active Euthanasia or PAS. It must be based on the medical evaluation only. Now the question here is to where to draw the boundary. How do you confirm that a patient is to be permitted for Active Euthanasia? How do you determine to whom you can inject a fatal drug? Where is the cut-off? What is the limit? Or can we really define any parameters?
Personally I believe firmly that Active Euthanasia and PAS are certainly needed in some cases (perhaps like in the case of Aruna Shanbaug), but I do not know how to draw the line.
The moral and ethical perspectives pose the biggest of all hindrances in my belief. Can we really kill a cancer or an AIDS patient who is certain of death within the next few months? Or can we kill a patient who is supposed to spend the rest of his life on a wheelchair and curse his fate everyday for becoming a burden to his family but will not die naturally anytime soon? Do we really have the right to kill someone or even expedite someone’s death?
I don’t know the answers to all these. Does anyone really know???
I think only the time will tell, but as of now, in my opinion, India is not really in a position to embrace Euthanasia if we are not able to answer these fundamental questions.
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