Poke Me: Supreme Court wants India to have a clear stand on euthanasia. Here are two views

This week's " Poke Me" invites your comments on "All Deserve a Good Death". The feature will be reproduced on the edit page of the Saturday edition of the newspaper with a pick of readers' best comments. So be poked and fire in your comments to us right away. Comments reproduced in the paper will be the ones that support or oppose the views expressed here intelligently. Feel free to add reference links etc, in support of your comments.

All Deserve a Good Death

Allow Refusal of Treatment

Minakshi Biswas


On January 16, the Supreme Court asked the government to provide its opinion on the plight of brain dead patients who are kept on life support systems. This was after the court had heard a petition filed in 2005 by the non-profit advocacy group Common Cause for allowing euthanasia. Prashant Bhusan appearing for Common Cause has also proposed the idea of providing legal sanctity to the concept of ‘living will’ – the right to execute a will in a sound mind stating that if one ever slipped into a vegetative state with a terminal disease with no chance of recovery, doctors shouldn't keep one alive with the help of life support.

The Supreme Court has scheduled a further hearing on the matter on February 1. The onus of protecting the rights and interests of the individual, particularly of those vulnerable, lies in the hands of the state. Taking into account the fact that the Indian state adheres to a liberal democratic framework, one of its basic responsibilities is to protect the rights and interest of its citizens. Within this context, an individual who is competent should be allowed to refuse invasive treatment if he so wishes. The case, however, becomes convoluted if the patient is incompetent, brain dead or does not have sound mental faculties to make a choice about his treatment.

It is imperative for India to have a law on euthanasia so that there is a clear understanding about whether a brain dead patient can be put off the ventilator. It is also pertinent to have a law on the subject which comprehensively demarcates active and passive euthanasia and identifies which of the two is suitable for India. Active euthanasia involves injecting lethal drugs into the patient’s body, while passive euthanasia involves withdrawing the life support system, food and drugs which are used to keep the patient alive when the patient is terminally ill or is in a permanent vegetative state. The government needs to take cognisance of the difference between the two and put forward guidelines applicable and appropriate for general Indian society.

This further leads to a discussion about living wills. The need for an informed consent by the patient regarding his treatment, or refusal of treatment, plays a pivotal role in the euthanasia debate. Issues of autonomy and best interests are major in any discussion. However, the question that needs to be asked is: What about the autonomy and best interests of those who are not in a conscious state? Or those inflicted with diseases like Alzheimer’s who undergo rapid change? Are such individuals competent enough to make a decision based on their best interests? Should such individuals be treated as autonomous beings?

This is where the concept of ‘living will’ merits attention. A living will is a document where an individual mentions the kind of healthcare he should be subjected to in a future when he is no longer capable of making his life-defining decisions. In many countries where euthanasia has already been legalised, such advanced directives help reach solutions keeping the wishes of the patient intact in case he is no longer capable of making decisions. It helps the physician to act in accordance with the wishes of the patient, whereby the latter’s autonomy and best interests are not violated.

Modern states are entities that engage in fostering and administering lives. Therefore, in such cases that involve the issue of mercy-killing, they may not rule in favour of active euthanasia, which essentially amounts to killing a person by means of the oral administration of lethal drugs. The moral distinction between passive and active euthanasia becomes significant as the former implies letting one die, while the latter amounts to killing.

This also proves why a modern state may, in some cases under rare circumstances, still make room for passive euthanasia. By providing legal sanctity to living wills, the state may also cater to the best interests of the patients who are brain dead or lack the mental faculties to make life-defining decisions at a given point of time.

(The writer is a researcher in the politics of euthanasia, Jawaharlal Nehru University, New Delhi)

First, Create a Care Culture

Harmala Gupta


It was hoped that the verdict given by the Supreme Court in 2011 in the Aruna Shanbaug case would make it easier to take people with irreversible medical conditions off ventilators and stop further futile life-prolonging interventions. The fact is, little has changed.

This was brought home to me while participating in a TV panel discussion last year when one of the judges who had handed down the judgement candidly admitted that when her husband was dying, she could not bring herself to follow her own guidelines.
Letting go of a loved one is extremely difficult. It is complicated by the limited access most of us have to skilled, compassionate and trustworthy care. Unless trained to do so, doctors and nurses are loath to discuss approaching death with their patients. And yet, evidence shows that these conversations help patients and members of the family to cope with what lies ahead. The treating team, too, is able to take steps that are life-affirming and appropriate so as to ensure a good death.
It is not just a question of getting patients to sign a ‘Do Not Resuscitate’ (DNA) declaration. It is about creating a culture within hospitals and nursing homes where those who are grievously sick or have a life-limiting condition are encouraged to make their views known, including how they would like to die.

While the ‘living will’ is a step in this direction, it has limited utility as experience has shown that people are prone to change their mind when they actually fall sick. Next of kin, too, find it difficult to follow instructions. Neither can we assume that they necessarily know what the patient would have wanted.
Besides amending the law, so that doctors who practise humane and ethical medicine are not treated as criminals, a number of confidence-building measures are needed.

Our care-providers must learn to listen to us. They should be trained to tease out and understand what quality of life means to the patient as well as empathise with the anguish of the family. Patients and family members in turn must be open to learning more in order to take informed decisions.

As Atul Gawande states in his book, Being Mortal, if being a doctor is an art so is being a patient. The doctor must know when to push and when to withdraw, equally so must the patient and the family. An attitude of ‘I know best’ or ‘I would rather not know’ on either side is ruinous to this relationship.

Further, there should be adequate safeguards built into this process so that every decision taken can be defended if challenged on medical, ethical and legal grounds. Building a wide consensus and bringing in more experienced colleagues to weigh in is always advisable. The palliative care team is often in the best position to advise both sides and serve as a bridge.

Their understanding of the dying process along with their skills in symptom control, nursing, communication and counseling have much to contribute. With their back-up, families and treating teams are able to do what is in the best interest of their patients.

It is unfortunate that at present access to palliative care is limited in our country due to the failure to integrate it into mainstream medical practice. Consequently, patients continue to receive expensive critical care in hospitals and nursing homes and die in ICUs. For a poor family, or one without adequate insurance cover, it is a cruel blow as they not only lose some one dear to them but also see all means of sustenance slowly slipping away.

Medical professionals swear by an oath that enjoins them to do what is in the best interest of their patients. Families, too, by and large, are committed to do the same for their loved ones. There comes a time when both parties must consult with the patient and/or with each other and let go of unreal expectations so as to ensure a humane death.

The law, too, must play its part by upholding the right of doctors to remove unnecessary life-prolonging interventions that prevent dying with dignity and not call it murder.



(The writer is President, CanSupport, which delivers palliative care to cancer survivors)