“To End or Not to End”: The Slippery Slope of Euthanasia
Understanding the shades and dilemmas of euthanasia.
The average life span of an individual has increased by nearly 20 years over the last century, thanks to modern medicine, infection control, ecological and lifestyle changes.
However, it has also led to increased chronic non-communicable illnesses such as cancer, acquired immunodeficiency syndrome (AIDS), psychiatric disorders and dementia.
These disorders are often difficult to treat in their severe forms, leading to a significant number of years spent in suffering, distress and impaired quality of life.
Often, individuals get affected with terminal stage of these disorders where palliative care is the treatment of choice rather than a curative approach.
Over the decades with an increasing burden of such diseases, palliative care has received renewed importance based on the principles of human rights, freedom of choice, autonomy and dignity in the last days of life.
Understanding the Many Shades of “Assisted Death”
The English philosopher Sir Francis Bacon coined the phrase “euthanasia” early in the 17th Century.
Literally meaning “good death” in Greek, it is the practice of intentionally ending life to relieve pain and suffering.
Only voluntary euthanasia is practically accepted and most cases decided by physicians in discussion with the patient and family “in good faith” to shorten their incurable sufferings when there is no hope for further betterment in clinical symptoms.
The concepts of euthanasia and PAD however have some subtle lines of difference, which assume importance in legal discourse.
The British House of Lords select committee on medical ethics defines euthanasia as "a deliberate intervention undertaken with the express intention of ending a life, to relieve intractable suffering."
In the Netherlands and Belgium where euthanasia is legal, it is understood as “termination of life by a doctor at the request of a patient or his/her family.”
However, the Dutch law does not use the term ‘euthanasia’, though the concept is subsumed under the broader rubric of “assisted suicide and termination of life on request”. Exactly how much onus for “ending the life” is on the physicians brings in important medico-legal implications.
Traditionally, the practice of medicine under the Hippocratic Oath has been to “heal, protect and cure” rather than to take away life.
These issues have compelled us to re-evaluate our concepts of societal and medical ethics as well as value systems.
Concerns related to death, dying and the process of preparing for ‘death’ have traditionally been marked with controversy, ethical dilemmas and medical debate.
Perhaps the most compelling, intriguing yet clinically relevant issue of medical and legal significance today is that of physician-assisted death (PAD) or euthanasia.
Globally there are schools of thought both advocating for and against the idea of PAD, each having their own social, anthropological and ethical justifications.
Advocacy for promoting such an act in palliative care with freedom of choice in how and when terminally ill patients can decide on their death has increased during the recent years, with various nations like Canada, Switzerland, Germany, etc. passing legislations to that effect.
Though in India, euthanasia has been caught between political and legal debates for centuries, the importance of medical, social, psychological and environmental factors are often overlooked. Since 2006, euthanasia is the most active and debated area of research in bioethics.
Proponents of PAD however argue that as an integral part of a doctor’s attempt to “heal suffering and improve wellbeing” in an individual, the distressing and debilitating life-span can be shortened once a terminal condition is diagnosed.
Euthanasia can either be active (an act of commission such as administering a lethal drug) versus passive (an act of omission such as removing the ventilator plug or the feeding pipe in an irreversible coma).
While the passive form is more widely accepted, active euthanasia is fraught with much more controversies and is de facto legal in a handful of countries (Belgium, Canada, Switzerland, State of Oregon) under strict terms and conditions.
There are three essential elements to euthanasia. First and most importantly, the death should be intended or wished for and not accidental or not due to a condition which results in loss of judgement and reality check in an individual (for example: when a person suffering from severe depression is suicidal, this is a symptom of depression and can be treated).
Second, it should be painless, and finally, it is done in the context of “an incurable illness to relieve the unbearable suffering.”
The first premise of “self-determination” is often difficult to ascertain and that leads to the risk of death resulting from manipulation, undue influence, vested interests of the physician or the family or even the depressed mind set of the patient when he/she may misconstrue “death” as the only mode of relief.
To deal with these challenges, most legislations include an independent assessment of the mental state and capacity of the concerned individual, consider autonomy and informed decision-making separately with the patient and family, and finally, the decision for euthanasia is usually taken by a multi-disciplinary team which includes neutral physicians and legal experts who have not been involved in the patient’s care before.
Notwithstanding these controversies, the medical fraternity themselves are widely divided in the ethical question of whether “death should be induced”.
Large surveys from the United States and United Kingdom have reported broad public support for assisted dying though less than half of the physicians supported it. An alternative called “hospice approach” has been proposed in palliative care for dying patients.
This involves using spiritual practices, pain-relieving medications, dignified holistic medical and psychological care to improve the quality of life in the last days. This “intends neither to hasten or postpone death” but is kind of a middle path compromise in this never-ending controversy.
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Euthanasia in India
After a long-haul legal debate, on March 9th, 2018 the Supreme Court of India legalised passive euthanasia by means of withdrawal of life support to patients in a permanent vegetative state.
This decision was made as a part of the verdict in the landmark case involving Ms. Aruna Shanbaug, who had been in such a condition since 1973 till her death in 2015. What is considered as “destiny” by medical or religious connotations was challenged as a “violation of right to live with dignity”.
The Supreme Court specified two irreversible conditions to permit Passive Euthanasia Law in its 2011 Law: (I) The brain-dead for whom the ventilator can be switched off (II) Those in a Persistent Vegetative State (PVS) for whom the feed can be tapered out and pain-managing palliatives be added, according to laid-down international specifications.
Also advance directives or “living wills” made by an individual regarding passive euthanasia before he/she entered into a terminally ill state need to be honoured.
Way Beyond the Debate
To deny terminally ill patients the right to euthanasia is to condemn them to a miserable existence, against their wishes and best interests.
It is difficult to establish any difference in moral character between someone, who denies a legitimate request for voluntary euthanasia, and who subsequently watches that person die a slow and a painful death like someone watching a cancer –ridden pet writhe in agony without putting it down.
At the same time it is essential to remember that not all deaths are miserable or painful, cessation of an active treatment (pain-relievers) should not be done, the consent of the concerned individual should never be compromised, and all stakeholders should be involved.
Ultimately, the decision for euthanasia in “good faith” is a process and not a binary momentary decision. In medical science, the prevention of suffering and dignity of the individual should be the uppermost on the minds of those caring for the terminally ill.
When quality of life is more important than quantity, voluntary euthanasia is a preferred option.
The age-old debate about medical, legal, ethical and social dilemmas surrounding euthanasia will remain however this “slippery slope” needs to be treaded on a case-by-case basis with a rights and dignity-based approach and dialogue rather than an “one-size fits all” solution.
More legal clarity and medical guidelines by national professional bodies may help resolve some of these dilemmas for the physicians and general public alike.
*Views expressed are personal and have no bearing on FIT or any institute/organization/employer associated with the author.
(Dr Debanjan Banerjee is a psychiatrist at National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru)
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