The right to die is a tough act to follow

M Udaya Kumar Maiya History was made when the Supreme Court recently upheld that the fundamental right to a “meaningful existence” includes a person’s choice to die without suffering. It has permitted a ‘living will’ by patients, authorising the withdrawal of medical support if they slip into medically irretrievable conditions such as irreversible coma.

Passive euthanasia is now legal. Patients are happy with the verdict and we, the medical fraternity, in principle, welcome the move.

The implications

The judgment is favourable to patients who will now be able to avoid needless medical interventions. The decision will also save a lot of money and agony for patients and their families, and prevent unnecessary treatments for the terminally ill. The fact that there are strict and elaborate guidelines to govern the implementation of passive euthanasia is reassuring. As doctors, we may be able to avoid becoming part of inheritance struggles and family feuds because the decision to end the sufferer’s life will be made earlier. Sometimes, we are forced to keep the patient alive, apprehending court cases. This problem too will be removed.

We must consider and understand the difference between passive and active euthanasia. In active euthanasia, medical professionals, or a relevant authority, deliberately act upon a patient’s desire (such as giving an injection or medication) to cause the patient to die. In passive euthanasia, the patient dies because the mechanism that keeps the patient alive is removed (life-support machines, feeding tube, a life-extending operation, drugs).

This is where doctors face a dilemma. Morally and ethically, both processes are difficult for us. Prolonging and maintaining life comes naturally to us; no doctor likes to have a patient die under his/her care. Instinctively, we are pro-natural death. The idea of deciding to end a life goes against the grain. Even in the presence of a living will, and when one is honour-bound to respect the patient’s wishes, there are many questions and doubts.

For instance, the patient may have been coerced to write the will. Sometimes a living will written at a certain juncture of a person’s life may not be applicable after a period of time when circumstances may have changed. Without a foolproof system, we cannot give up on a patient, however desperate the circumstances.

Also,to decide that there is no hope in continuing the treatment and that there is zero possibility of recovery precludes the astonishing ability of the human body to recuperate. As long as there is life, there is hope. Even with the legalisation of euthanasia, the “choice” to die may sometimes not be the final prerogative of the patient. The patient could be too ill to decide. Here, the decision-makers possibly will be the medical team and the patients’ relatives, not the patient.

Palliative care in India

Another question that comes up is whether withdrawing treatment, even on compassionate grounds, is a form of medical care. India needs improved access to high-quality healthcare for the terminally ill so that they go in peace, whenever they do. This is referred to as palliative care — right from the time an illness is diagnosed till the end of life. Control over the manner and timing of a person’s death has not been and should not be a goal of medicine.

Palliative care came to India only during the mid-1980s. Since then, committed individuals, including health professionals and volunteers, in collaboration with international organisations and individuals from other countries, have worked towards building this system of care in the country. However, the situation is still abysmal — there are six million people who need palliative care, while there are only 1,400 centres, making it one centre for every 4,300 patients.

The WHO defines palliative care as a multi-disciplinary approach that improves the quality of life of patients with life-threatening illnesses, and their families, by relieving suffering and pain — physical, psycho-social and spiritual. However, there is still a long way to go. Apart from the existing shortage in terms of funds, infrastructure, and medical professionals, what stalls progress in this area is that we are too busy fighting diseases and not in offering palliative treatment and pain relief. In this context, how relevant is the move to allow a living will?

Perhaps, wisdom lies in the middle path, as the great healer Gautam Buddha advocated. The Supreme Court has said that a living will from a patient to stop medical treatment at a particular stage — “particularly when he is brain dead or clinically dead or not revivable” — quells misgivings from the family and the chances of criminal action against doctors. But is the individual really equipped to see the medical and situational conditions of the future?

In conclusion

Allow me to paint a scenario. An old man lies in the ICU, on a ventilator. He has left a living will authorising his death in just such a scenario. His family clings to the hope that he may revive. They beg you to wait another few days. What do I, as a good doctor, do under these circumstances? Here, the younger son protests. He suspects that the will has been written under duress. I am torn. The mechanisms of verifying and validating the medical condition of the patient for euthanasia will come into force and the medical board of the hospital, an independent medical team inspection, judicial approvals, etc., as laid out in the judgment will need to be executed.

While the decision to passively euthanise oneself can be left to the patient, the conditions on which this right may be invoked can be left to a medical board. A living will makes sense when coupled with a medical power of attorney and independent third party monitoring. This will allow for a middle way considering all the interests at play: the right of the patient, the state’s interest in human life, and the interest of the patient’s family.

The Supreme Court has taken a bold decision — only time will tell what course it will take. How easy it is for a family to put into action a patient’s desire to die depends on how quickly the process of medical/judicial reviews and verifications take place. If done tardily and with insensitivity (as is the case in such situations, experience tells us), the whole purpose can be self-defeating.

The writer is the medical director of Portea Medical

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