The word euthanasia, originated in Greece means a good death1. Euthanasia encompasses various dimensions, from active (introducing something to cause death) to passive (withholding treatment or supportive measures); voluntary (consent) to involuntary (consent from guardian) and physician assisted (where physician's prescribe the medicine and patient or the third party administers the medication to cause death)2,3. Request for premature ending of life has contributed to the debate about the role of such practices in contemporary health care. This debate cuts across complex and dynamic aspects such as, legal, ethical, human rights, health, religious, economic, spiritual, social and cultural aspects of the civilised society. Here we argue this complex issue from both the supporters and opponents’ perspectives, and also attempts to present the plight of the sufferers and their caregivers. The objective is to discuss the subject of euthanasia from the medical and human rights perspective given the background of the recent Supreme Court judgement3 in this context.
In India abetment of suicide and attempt to suicide are both criminal offences. In 1994, constitutional validity of Indian Penal Code Section (IPC Sec) 309 was challenged in the Supreme Court4. The Supreme Court declared that IPC Sec 309 is unconstitutional, under Article 21 (Right to Life) of the constitution in a landmark judgement4. In 1996, an interesting case of abetment of commission of suicide (IPC Sec 306) came to Supreme Court5. The accused were convicted in the trial court and later the conviction was upheld by the High Court. They appealed to the Supreme Court and contended that ‘right to die’ be included in Article 21 of the Constitution and any person abetting the commission of suicide by anyone is merely assisting in the enforcement of the fundamental right under Article 21; hence their punishment is violation of Article 21. This made the Supreme Court to rethink and to reconsider the decision of right to die. Immediately the matter was referred to a Constitution Bench of the Indian Supreme Court. The Court held that the right to life under Article 21 of the Constitution does not include the right to die5.
Regarding suicide, the Supreme Court reconsidered its decision on suicide. Abetment of suicide (IPC Sec 306) and attempt to suicide (IPC Sec 309) are two distinct offences, hence Section 306 can survive independent of Section 309. It has also clearly stated that a person attempts suicide in a depression, and hence he needs help, rather than punishment. Therefore, the Supreme Court has recommended to Parliament to consider the feasibility of deleting Section 309 from the Indian Penal Code3.
Arguments against euthanasia
Eliminating the invalid: Euthanasia opposers argue that if we embrace ‘the right to death with dignity’, people with incurable and debilitating illnesses will be disposed from our civilised society. The practice of palliative care counters this view, as palliative care would provide relief from distressing symptoms and pain, and support to the patient as well as the care giver. Palliative care is an active, compassionate and creative care for the dying6.
Constitution of India: ‘Right to life’ is a natural right embodied in Article 21 but suicide is an unnatural termination or extinction of life and, therefore, incompatible and inconsistent with the concept of ‘right to life’. It is the duty of the State to protect life and the physician's duty to provide care and not to harm patients. If euthanasia is legalised, then there is a grave apprehension that the State may refuse to invest in health (working towards Right to life). Legalised euthanasia has led to a severe decline in the quality of care for terminally-ill patients in Holland7. Hence, in a welfare state there should not be any role of euthanasia in any form.
Symptom of mental illness: Attempts to suicide or completed suicide are commonly seen in patients suffering from depression8, schizophrenia9 and substance users10. It is also documented in patients suffering from obsessive compulsive disorder11. Hence, it is essential to assess the mental status of the individual seeking for euthanasia. In classical teaching, attempt to suicide is a psychiatric emergency and it is considered as a desperate call for help or assistance. Several guidelines have been formulated for management of suicidal patients in psychiatry12. Hence, attempted suicide is considered as a sign of mental illness13.
Malafide intention: In the era of declining morality and justice, there is a possibility of misusing euthanasia by family members or relatives for inheriting the property of the patient. The Supreme Court has also raised this issue in the recent judgement3. ‘Mercy killing’ should not lead to ‘killing mercy’ in the hands of the noble medical professionals. Hence, to keep control over the medical professionals, the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 discusses euthanasia briefly in Chapter 6, Section 6.7 and it is in accordance with the provisions of the Transplantation of Human Organ Act, 199414. There is an urgent need to protect patients and also medical practitioners caring the terminally ill patients from unnecessary lawsuit. Law commission had submitted a report (no-196) to the government on this issue15.
Emphasis on care: Earlier majority of them died before they reached the hospital but now it is converse. Now sciences had advanced to the extent, life can be prolonged but not to that extent of bringing back the dead one. This phenomenon has raised a complex situation. Earlier diseases outcome was discussed in terms of ‘CURE’ but in the contemporary world of diseases such as cancer, Aids, diabetes, hypertension and mental illness are debated in terms best ‘CARE’, since cure is distant. The principle is to add life to years rather than years to life with a good quality palliative care. The intention is to provide care when cure is not possible by low cost methods. The expectation of society is, ‘cure’ from the health professionals, but the role of medical professionals is to provide ‘care’. Hence, euthanasia for no cure illness does not have a logical argument. Whenever, there is no cure, the society and medical professionals become frustrated and the fellow citizen take extreme measures such as suicide, euthanasia or substance use. In such situations, palliative and rehabilitative care comes to the rescue of the patient and the family. At times, doctors do suggest to the family members to have the patient discharged from the hospital wait for death to come, if the family or patient so desires. Various reasons are quoted for such decisions, such as poverty, non-availability of bed, futile intervention, resources can be utilised for other patients where cure is possible and unfortunately majority of our patient's family do accordingly. Many of the terminally ill patients prefer to die at home, with or without any proper terminal health care. The societal perception needs to be altered and also the medical professionals need to focus on care rather in addition to just cure. The motive for many euthanasia requests is unawareness of alternatives. Patients hear from their doctors that ‘nothing can be done anymore’. However, when patients hear that a lot can be done through palliative care, that the symptoms can be controlled, now and in the future, many do not want euthanasia anymore16.
Commercialisation of health care: Passive euthanasia occurs in majority of the hospitals across the county, where poor patients and their family members refuse or withdraw treatment because of the huge cost involved in keeping them alive. If euthanasia is legalised, then commercial health sector will serve death sentence to many disabled and elderly citizens of India for meagre amount of money. This has been highlighted in the Supreme Court Judgement3,17.
Research has revealed that many terminally ill patients requesting euthanasia, have major depression, and that the desire for death in terminal patients is correlated with the depression18. In Indian setting also, strong desire for death was reported by 3 of the 191 advanced cancer patients, and these had severe depression19. They need palliative and rehabilitative care. They want to be looked after by enthusiastic, compassionate and humanistic team of health professionals and the complete expenses need to be borne by the State so that ‘Right to life’ becomes a reality and succeeds before ‘Right to death with dignity’. Palliative care actually provides death with dignity and a death considered good by the patient and the care givers.
Counterargument of euthanasia supporters
Caregivers burden: ‘Right-to-die’ supporters argue that people who have an incurable, degenerative, disabling or debilitating condition should be allowed to die in dignity. This argument is further defended for those, who have chronic debilitating illness even though it is not terminal such as severe mental illness. Majority of such petitions are filed by the sufferers or family members or their caretakers. The caregiver's burden is huge and cuts across various domains such as financial, emotional, time, physical, mental and social. Hence, it is uncommon to hear requests from the family members of the person with psychiatric illness to give some poison either to patient or else to them. Coupled with the States inefficiency, apathy and no investment on health is mockery of the ‘Right to life’.
Refusing care: Right to refuse medical treatment is well recognised in law, including medical treatment that sustains or prolongs life. For example, a patient suffering from blood cancer can refuse treatment or deny feeds through nasogastric tube. Recognition of right to refuse treatment gives a way for passive euthanasia. Many do argue that allowing medical termination of pregnancy before 16 wk is also a form of active involuntary euthanasia. This issue of mercy killing of deformed babies has already been in discussion in Holland20.
Right to die: Many patients in a persistent vegetative state or else in chronic illness, do not want to be a burden on their family members. Euthanasia can be considered as a way to upheld the ‘Right to life’ by honouring ‘Right to die’ with dignity.
Encouraging the organ transplantation: Euthanasia in terminally ill patients provides an opportunity to advocate for organ donation. This in turn will help many patients with organ failure waiting for transplantation. Not only euthanasia gives ‘Right to die’ for the terminally ill, but also ‘Right to life’ for the organ needy patients.
Constitution of India reads ‘right to life’ is in positive direction of protecting life. Hence, there is an urgent need to fulfil this obligation of ‘Right to life’ by providing ‘food, safe drinking water and health care’. On the contrary, the state does not own the responsibility of promoting, protecting and fulfilling the socio-economic rights such as right to food, right to water, right to education and right to health care, which are basic essential ingredients of right to life. Till date, most of the States has not done anything to support the terminally ill people by providing for hospice care.
If the State takes the responsibility of providing reasonable degree of health care, then majority of the euthanasia supporters will definitely reconsider their argument. We do endorse the Supreme Court Judgement that our contemporary society and public health system is not matured enough to handle this sensitive issue, hence it needs to be withheld. However, this issue needs to be re-examined again after few years depending upon the evolution of the society with regard to providing health care to the disabled and public health sector with regard to providing health care to poor people.
The Supreme Court judgement to withhold decision on this sensitive issue is a first step towards a new era of health care in terminally ill patients. The Judgment laid down is to preserve harmony within a society, when faced with a complex medical, social and legal dilemma. There is a need to enact a legislation to protect terminally ill patients and also medical practitioners caring for them as per the recommendation of Law Commission Report-19615. There is also an urgent need to invest in our health care system, so that poor people suffering from ill health can access free health care. Investment in health care is not a charity; ‘Right to Health’ is bestowed under ‘Right to Life’ of our constitution.
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2. Dowbiggin I. A merciful end: The euthanasia movement in modern America. New York: Oxford University Press, Inc; 2003.
3. Aruna Ramchandra Shanbaug vs. Union of India & Ors. Writ Petition (Criminal) no. 115 of 2009, Decided on 7 March, 2011. [accessed on August 16, 2011]. Available from: http://www.supremecourtofindia.nic.in/outtoday/wr1152009.pdf .
4. P. Rathinam vs. Union of India, 1994(3) SCC 394
5. Gian Kaur vs. State of Punjab, 1996(2) SCC 648
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20. Sheldon T. Dutch legal protection scheme for doctors involved in mercy killing of babies receives first report. BMJ. 2009:339.
Against the will of God
Religious people don't argue that we can't kill ourselves, or get others to do it. They know that we can do it because God has given us free will. Their argument is that it would be wrong for us to do so.
They believe that every human being is the creation of God, and that this imposes certain limits on us. Our lives are not only our lives for us to do with as we see fit.
To kill oneself, or to get someone else to do it for us, is to deny God, and to deny God's rights over our lives and his right to choose the length of our lives and the way our lives end.
The value of suffering
Religious people sometimes argue against euthanasia because they see positive value in suffering.
The religious attitude to suffering
Most religions would say something like this:
The nature of suffering
Christianity teaches that suffering can have a place in God's plan, in that it allows the sufferer to share in Christ's agony and his redeeming sacrifice. They believe that Christ will be present to share in the suffering of the believer.
Pope John Paul II wrote that "It is suffering, more than anything else, which clears the way for the grace which transforms human souls."
However while the churches acknowledge that some Christians will want to accept some suffering for this reason, most Christians are not so heroic.
So there is nothing wrong in trying to relieve someone's suffering. In fact, Christians believe that it is a good to do so, as long as one does not intentionally cause death.
Dying is good for us
Some people think that dying is just one of the tests that God sets for human beings, and that the way we react to it shows the sort of person we are, and how deep our faith and trust in God is.
Others, while acknowledging that a loving God doesn't set his creations such a horrible test, say that the process of dying is the ultimate opportunity for human beings to develop their souls.
When people are dying they may be able, more than at any time in their life, to concentrate on the important things in life, and to set aside the present-day 'consumer culture', and their own ego and desire to control the world. Curtailing the process of dying would deny them this opportunity.
Several Eastern religions believe that we live many lives and the quality of each life is set by the way we lived our previous lives.
Those who believe this think that suffering is part of the moral force of the universe, and that by cutting it short a person interferes with their progress towards ultimate liberation.
A non-religious view
Some non-religious people also believe that suffering has value. They think it provides an opportunity to grow in wisdom, character, and compassion.
Suffering is something which draws upon all the resources of a human being and enables them to reach the highest and noblest points of what they really are.
Suffering allows a person to be a good example to others by showing how to behave when things are bad.
M Scott Peck, author of The Road Less Travelled, has written that in a few weeks at the end of life, with pain properly controlled a person might learn
The nature of suffering
It isn't easy to define suffering - most of us can decide when we are suffering but what is suffering for one person may not be suffering for another.
It's also impossible to measure suffering in any useful way, and it's particularly hard to come up with any objective idea of what constitutes unbearable suffering, since each individual will react to the same physical and mental conditions in a different way.
The slippery slope
Many people worry that if voluntary euthanasia were to become legal, it would not be long before involuntary euthanasia would start to happen.
This is called the slippery slope argument. In general form it says that if we allow something relatively harmless today, we may start a trend that results in something currently unthinkable becoming accepted.
Those who oppose this argument say that properly drafted legislation can draw a firm barrier across the slippery slope.
Various forms of the slippery slope argument
If we change the law and accept voluntary euthanasia, we will not be able to keep it under control.
- Proponents of euthanasia say: Euthanasia would never be legalised without proper regulation and control mechanisms in place
Doctors may soon start killing people without bothering with their permission.
- Proponents say: There is a huge difference between killing people who ask for death under appropriate circumstances, and killing people without their permission
- Very few people are so lacking in moral understanding that they would ignore this distinction
- Very few people are so lacking in intellect that they can't make the distinction above
- Any doctor who would ignore this distinction probably wouldn't worry about the law anyway
Health care costs will lead to doctors killing patients to save money or free up beds:
- Proponents say: The main reason some doctors support voluntary euthanasia is because they believe that they should respect their patients' right to be treated as autonomous human beings
- That is, when doctors are in favour of euthanasia it's because they want to respect the wishes of their patients
- So doctors are unlikely to kill people without their permission because that contradicts the whole motivation for allowing voluntary euthanasia
- But cost-conscious doctors are more likely to honour their patients' requests for death
- A 1998 study found that doctors who are cost-conscious and 'practice resource-conserving medicine' are significantly more likely to write a lethal prescription for terminally-ill patients [Arch. Intern. Med., 5/11/98, p. 974]
- This suggests that medical costs do influence doctors' opinions in this area of medical ethics
The Nazis engaged in massive programmes of involuntary euthanasia, so we shouldn't place our trust in the good moral sense of doctors.
- Proponents say: The Nazis are not a useful moral example, because their actions are almost universally regarded as both criminal and morally wrong
- The Nazis embarked on invountary euthanasia as a deliberate political act - they didn't slip into it from voluntary euthanasia (although at first they did pretend it was for the benefit of the patient)
- What the Nazis did wasn't euthanasia by even the widest definition, it was the use of murder to get rid of people they disapproved of
- The universal horror at Nazi euthanasia demonstrates that almost everyone can make the distinction between voluntary and involuntary euthanasia
- The example of the Nazis has made people more sensitive to the dangers of involuntary euthanasia
Allowing voluntary euthanasia makes it easier to commit murder, since the perpetrators can disguise it as active voluntary euthanasia.
- Proponents say: The law is able to deal with the possibility of self-defence or suicide being used as disguises for murder. It will thus be able to deal with this case equally well
- To dress murder up as euthanasia will involve medical co-operation. The need for a conspiracy will make it an unattractive option
Patient's best interests
A serious problem for supporters of euthanasia are the number of cases in which a patient may ask for euthanasia, or feel obliged to ask for it, when it isn't in their best interest. Some examples are listed below:
- the diagnosis is wrong and the patient is not terminally ill
- the prognosis (the doctor's prediction as to how the disease will progress) is wrong and the patient is not going to die soon
- the patient is getting bad medical care and their suffering could be relieved by other means
- the doctor is unaware of all the non-fatal options that could be offered to the patient
- the patient's request for euthanasia is actually a 'cry for help', implying that life is not worth living now but could be worth living if various symptoms or fears were managed
- the patient is depressed and so believes things are much worse than they are
- the patient is confused and unable to make sensible judgements
- the patient has an unrealistic fear of the pain and suffering that lies ahead
- the patient is feeling vulnerable
- the patient feels that they are a worthless burden on others
- the patient feels that their sickness is causing unbearable anguish to their family
- the patient is under pressure from other people to feel that they are a burden
- the patient is under pressure because of a shortage of resources to care for them
- the patient requests euthanasia because of a passing phase of their disease, but is likely to feel much better in a while
Supporters of euthanasia say these are good reasons to make sure the euthanasia process will not be rushed, and agree that a well-designed system for euthanasia will have to take all these points into account. They say that most of these problems can be identified by assessing the patient properly, and, if necessary, the system should discriminate against the opinions of people who are particularly vulnerable.
Chochinov and colleagues found that fleeting or occasional thoughts of a desire for death were common in a study of people who were terminally ill, but few patients expressed a genuine desire for death. (Chochinov HM, Tataryn D, Clinch JJ, Dudgeon D. Will to live in the terminally ill. Lancet 1999; 354: 816-819)
They also found that the will to live fluctuates substantially in dying patients, particularly in relation to depression, anxiety, shortness of breath, and their sense of wellbeing.
Other people have rights too
Euthanasia is usually viewed from the viewpoint of the person who wants to die, but it affects other people too, and their rights should be considered.
- family and friends
- medical and other carers
- other people in a similar situation who may feel pressured by the decision of this patient
- society in general
Proper palliative care
Palliative care is physical, emotional and spiritual care for a dying person when cure is not possible. It includes compassion and support for family and friends.
Competent palliative care may well be enough to prevent a person feeling any need to contemplate euthanasia.
The key to successful palliative care is to treat the patient as a person, not as a set of symptoms, or medical problems.
The World Health Organisation states that palliative care affirms life and regards dying as a normal process; it neither hastens nor postpones death; it provides relief from pain and suffering; it integrates the psychological and spiritual aspects of the patient.
Making things better for patient, family and friends
The patient's family and friends will need care too. Palliative care aims to enhance the quality of life for the family as well as the patient.
Effective palliative care gives the patient and their loved ones a chance to spend quality time together, with as much distress removed as possible. They can (if they want to) use this time to bring any unfinished business in their lives to a proper closure and to say their last goodbyes.
Palliative care should aim to make it easier and more attractive for family and friends to visit the dying person. A survey (USA 2001) showed that terminally ill patients actually spent the vast majority of their time on their own, with few visits from medical personnel or family members.
Spiritual care may be important even for non-religious people. Spiritual care should be interpreted in a very wide sense, since patients and families facing death often want to search for the meaning of their lives in their own way.
Palliative care and euthanasia
Good palliative care is the alternative to euthanasia. If it was available to every patient, it would certainly reduce the desire for death to be brought about sooner.
But providing palliative care can be very hard work, both physically and psychologically. Ending a patient's life by injection is quicker and easier and cheaper. This may tempt people away from palliative care.
Legalising euthanasia may reduce the availability of palliative care
Some fear that the introduction of euthanasia will reduce the availability of palliative care in the community, because health systems will want to choose the most cost effective ways of dealing with dying patients.
Medical decision-makers already face difficult moral dilemmas in choosing between competing demands for their limited funds. So making euthanasia easier could exacerbate the slippery slope, pushing people towards euthanasia who may not otherwise choose it.
When palliative care is not enough
Palliative care will not always be an adequate solution:
- Pain: Some doctors estimate that about 5% of patients don't have their pain properly relieved during the terminal phase of their illness, despite good palliative and hospice care
- Dependency: Some patients may prefer death to dependency, because they hate relying on other people for all their bodily functions, and the consequent loss of privacy and dignity
- Lack of home care: Other patients will not wish to have palliative care if that means that they have to die in a hospital and not at home
- Loss of alertness: Some people would prefer to die while they are fully alert and and able to say goodbye to their family; they fear that palliative care would involve a level of pain-killing drugs that would leave them semi-anaesthetised
- Not in the final stages: Other people are grateful for palliative care to a certain point in their disease, but after that would prefer to die rather than live in a state of helplessness and distress, regardless of what is available in terms of pain-killing and comfort.
Pressure on the vulnerable
This is another of those arguments that says that euthanasia should not be allowed because it will be abused.
The fear is that if euthanasia is allowed, vulnerable people will be put under pressure to end their lives. It would be difficult, and possibly impossible, to stop people using persuasion or coercion to get people to request euthanasia when they don't really want it.
The pressure of feeling a burden
People who are ill and dependent can often feel worthless and an undue burden on those who love and care for them. They may actually be a burden, but those who love them may be happy to bear that burden.
Nonetheless, if euthanasia is available, the sick person may pressure themselves into asking for euthanasia.
Pressure from family and others
Family or others involved with the sick person may regard them as a burden that they don't wish to carry, and may put pressure (which may be very subtle) on the sick person to ask for euthanasia.
Increasing numbers of examples of the abuse or neglect of elderly people by their families makes this an important issue to consider.
The last few months of a patient's life are often the most expensive in terms of medical and other care. Shortening this period through euthanasia could be seen as a way of relieving pressure on scarce medical resources, or family finances.
It's worth noting that cost of the lethal medication required for euthanasia is less than £50, which is much cheaper than continuing treatment for many medical conditions.
Some people argue that refusing patients drugs because they are too expensive is a form of euthanasia, and that while this produces public anger at present, legal euthanasia provides a less obvious solution to drug costs.
If there was 'ageism' in health services, and certain types of care were denied to those over a certain age, euthanasia could be seen as a logical extension of this practice.