Euthanasia – All You Need to Know

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In January 2020, the Supreme Court sought response from the health ministry and environment ministry to the Public Interest Litigation seeking the right to euthanasia for persons suffering from rabies. This petition points out the limitations of SC’s 2018 judgement that provided for guidelines for passive euthanasia.

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What is Euthanasia?

  • The word Euthanasia originates from Greek terms ‘Eu’ (good) and ‘Thanatos’ (death), meaning “good death” or “gentle and easy death”.
  • The term euthanasia was first used in a medical context by Francis Bacon in the 17th century to refer to an easy and painless death during which it is a physician’s duty to alleviate the ‘physical sufferings’ of the body.
  • It is also known as Mercy Killing.
  • According to the World Medical Association, it is a deliberate and intentional action with a clear intention to cease another individual’s life when:
  1. The subject is a competent, informed person with an incurable illness
  2. The subject voluntarily asked to end his/her life
  3. The individual who is acting knows about the state of the subject and about his/her wish to die and is doing with an intention to end the life of this person based on compassion and not profit.
  • To put it simply, euthanasia is the act of intentionally ending the life of an extremely sick person who is bedridden, terminally ill and shows no signs of health improvement to relieve his/her sufferings.

 

What are the types of euthanasia?

Passive Euthanasia:

  • It involves the omission of treatment or daily care that is required for survival of the patient.
  • It includes withdrawing current treatment (like turning off the ventilator) and withholding treatment (like not performing the required surgeries).
  • This is to ensure that the death is brought about voluntarily.
  • Passive euthanasia is made legal in India.

Active Euthanasia:

  • Active euthanasia involves ending life with the help of a physician who gives a lethal dose of a toxic drug to end the sufferings of a terminally-ill patient.
  • Active euthanasia is illegal in India.

Voluntary Euthanasia:

  • Sometimes known as ‘assisted suicide’, it is the euthanasia practised with the expressed desire and the consent of the sufferer.

Involuntary Euthanasia:

  • It is conducted without the consent of the patient.
  • It involves another person making the decision for the sufferer who is incapable of doing the same.
  • It is used in cases of a prolonged comma, old age, extreme dementia etc.

What is the debate regarding euthanasia?

Arguments for euthanasia:

  • A permanent end to the suffering of an individual is a benevolent action, almost a charitable one.
  • Ends physical, mental and psychological misery for the patient and the family
  • Enables more facilities and funds for other patients needing medical treatment and attention
  • An example of freedom of choice
  • Organs can be transplanted to save numerous other lives

Arguments against euthanasia:

  • Exploitation of ‘living will’
  • Against religious sentiments
  • Possibility of the lack of awareness about additional treatment options
  • Euthanasia demeans and devalues the sanctity of human life
  • Possibility of becoming a means to reduce healthcare cost
  • Possibility of becoming involuntary
  • Possibility of being used for those not terminally ill
  • Destroys potential of life, which is unknown to the patient, doctor or family
  • Irreversible

What is the legal history of euthanasia in India?

  • The constitutionality of a suicide attempt was discussed by the Supreme Court in Rathinam v. Union of India (1994) under IPC Section 309.
  • The IPC Section 309 was struck down. Thus, for the first time, the right to die was included within the right to live with dignity.
  • This judgement was overruled in Gain Kaur v. State of Punjab (1996), in which it was held that the right to life did not include the right to die.
  • In the 2011 Aruna Shanbaug case, the SC had recognised passive euthanasia and provided for a set of guidelines to be used for it.
  • It had held passive euthanasia to be the withdrawal of life-sustaining treatment from patients who are not in a position to make an informed decision.

What is 2018 SC verdict on passive euthanasia?

  • In March 2018, a five-judge constitution bench of the Supreme Court recognised ‘living will’ made by terminally ill patients for passive euthanasia and laid guidelines on procedures to be adopted for it.
  • The living will or Advance Directive is a written document through which a patient can give explicit instructions in advance about the medical treatment to be administered when he/she is terminally ill or can no longer express informed consent.
  • Directions and guidelines provided by the SC in this regard will remain in force until legislation is brought on this issue.
  • It should be noted that the Centre opposed the recognition of ‘living will’ because of the possibilities of the patient’s consent to remove the life-supporting system being ill-informed and without awareness of medical advancements.

What are the SC guidelines on euthanasia?

Execution of living will:

  • Only an adult with a sound and healthy state of mind can execute the living will.
  • It must be voluntarily executed without any coercion or compulsion.

The living will should contain:

  • Circumstances under which the medical treatment is to be withdrawn/withheld.
  • The name of the executor who will act on the patient’s behalf.
  • The executor has understood the consequences of withdrawing the treatment
  • If the executor is unable to take the decision, the consent of the guardian has to be obtained for withdrawal of treatment.

Revocation of living will:

  • The maker can revoke such instruction at any given point of time.
  • Such revocation has to be clear, unambiguous and in writing.
  • It there is more than one advance directive, the one that is latest is valid.

Signatories:

  • The living will is to be signed by the executor, two attesting witnesses and countersigned by relevant judicial magistrate of the first class (JMFC) in charge.

Implementation:

In the presence of advance directive:

  • It can be valid only when the maker is terminally ill and is undergoing prolonged medical treatment with no hope of recovery.
  • First, the preliminary opinion regarding the validity of the execution of passive euthanasia is to be provided by a medical board that is constituted after the treating physician believes that the withholding of medical treatment is the appropriate course of action.
  • If the medical board opines that the directive should be carried out, it should inform the jurisdictional collector, who shall constitute a collector medical board.
  • If the collector medical board concurs with the hospital medical board’s opinion, it may endorse the certificate to carry out the instruction contained in the directive.
  • If the collector medical board refuses to give effect to the directive, the family members or treating doctor or the hospital staff can file a writ petition before the relevant high court.
  • The judiciary that is hearing the case can constitute an independent committee consisting of doctors to help with its decision.

In the absence of the advance directive:

  • The hospital medical board shall discuss options with the family physician and family members, record such discussion in writing, and have the course of action and consent of the family members certified by it.
  • This is to be treated by the preliminary opinion of the hospital medical board.
  • If the collector medical board concurs with this opinion and if the magistrate signs off, the decision must be intimated to the HC before the implementation.
  • If there are differences in opinions between the two medical boards, the nominee of the patient or the family member can seek permission from the HC to withdraw life support.

Why is passive euthanasia permitted in India while the active euthanasia is not?

  • In a legal viewpoint, the distinction between committing a positive act (administering a drug) versus withdrawing of treatment (taking patient off the ventilator) is one that has significance.
  • In passive euthanasia, the death is caused by a pre-existing medical condition of the patient, which enables life to chart a natural course of its inevitable end.
  • On the other hand, in active euthanasia, the act of doctor causes the death.
  • Though the judiciary recognised the criticism of the act/omission distinction, it held that the judicial restraint demands that only Parliament and not the courts can take the final call on legalising active euthanasia.

Why has euthanasia debate come again?

  • Recently, a Public Interest Litigation was filed questioning the 2018 judgement that legalised passive euthanasia.
  • As per this PIL, the judgement excluded those suffering from rabies.
  • It pointed out that rabies has a nearly 100% fatality rate despite the medical assistances, unlike cancer where all forms carry a certain amount of survival rate.
  • It was asserted that due to the violent nature of rabies and the absence of a cure for it, the victims are deprived of personal freedom, movement, dignity and integrity.
  • Therefore, suffering must not be prolonged until death.
  • Rabies patients do not have the option of medical intervention to prolong lives.
  • Hence, they cannot be put through passive euthanasia and have the only option of active euthanasia, which is not included under the 2018 judgement.
  • This petition has once again brought in the debate on whether or not a person has the right to die with dignity.
  • The aim of this petition is to carve out an exception for rabies patients within the 2018 SC judgement.

Is rabies incurable?

  • Rabies is an infectious viral disease that is usually transmitted from a dog bite.
  • When symptoms start to appear, there is no cure and the fatality rate is 95%.
  • The initial symptoms include a fever with pain and abnormal tingling or burning sensation of the wound.
  • If not treated, the virus spreads to the central nervous system, which in turn causes inflammation of the brain and spinal cord.
  • Patient with full-blown rabies would present hyperactivity, excitability, aerophobia and hydrophobia.
  • Death usually occurs either due to painful cardiorespiratory arrest (simultaneous shutting down of lungs and heart) or after slow paralysis followed by a comatose state.

What are the challenges?

  • Euthanasia is a highly contentious issue.
  • There is a limited difference between murder and an act of charity in this regard.
  • There is also the question of the distinction between a person who has lost the will to live and one who cannot live.
  • These issues are fraught with emotions and complexities at legal, psychological and ethical perspectives.
  • Passive euthanasia is the maximum that one may tread on this contentious path.
  • The judiciary has provided with the right to choose death in dignity. This line has to be trodden carefully.
  • Another step in this direction could result in “killing” as opposed to “mercy killing”.
  • Religious beliefs in India are against premature death. Therefore, the right to life may outweigh the right to die with dignity.
  • Hurdles from these religious communities are inevitable despite SC judgement supporting passive euthanasia.
  • There is also the contention with regards to the difference between passive and active euthanasia.
  • Many judges and commentators recognised that in the context of euthanasia, there is no legally intelligible difference between deliberately “doing” (active) and “not doing or stopping to do” (passive) that leads to death.
  • They also question why “withdrawal” (as opposed to “withholding”) of current treatment is not an illegal “active” decision that hastens death from an underlying cause, much like a lethal injection that also accelerates imminent death.
  • Thus, they contend that it is unjust to deny a recognised fundamental right to die with dignity to those in need of it.

What can be the way forward?

  • The SC guidelines address the overarching policy concerns like potential abuse of unscrupulous individuals, criminal persecution of benign doctors and families and exercise of judicial restraint on a sensitive issue that warrants legislation involving a democratic will.
  • Yet, it is fragmented and flawed because these fall within the purview of the Parliament. Thus, the issue of the need for active euthanasia, like in the case of rabies patients, cannot be addressed without a strong legal and policy framework.
  • Within this legal and policy framework, the mandatory mental health assessment of the individual seeking euthanasia must be put in place.
  • Some of the main reasons behind opting for euthanasia are depression, hopelessness, pain and the lack of care or awareness about modern pain management techniques.
  • Patients can overcome their need for euthanasia when they are provided with the necessary care.
  • Studies reveal that when patients receive adequate palliative care, request for euthanasia decrease.
  • The government is already promoting palliative care policies for elderly, poor and terminally ill, who are most likely to opt for euthanasia. These policies must be strengthened.
  • The National Health Protection Scheme provides quality healthcare for poor suffering from a serious terminal illness.
  • Though many call for the regulation of euthanasia, it is highly difficult.
  • Even those in favour of euthanasia fear that regulations would not deal with people who have ulterior motives.
  • It is also argued that the regulations will not stop patients from being pressured to choose death when they would rather live a few more weeks.
  • Yet, some rules are better than none.
  • Though illegal euthanasia will continue to take place, legalising and regulating it would ensure minimal abuse and greater accountability.
  • Well-defined procedures and rules will ensure better protection of vulnerable patients.
  • Decriminalisation of suicide is a precondition to permitting active euthanasia.
  • Section 115 of the Mental Healthcare Act creates a presumption that anyone attempting to commit suicide is under severe stress and should not be tried or punished
  • This is a positive step towards decriminalising suicide.

Conclusion:

Judiciary has ensured the rights to autonomy, dignity, liberty and privacy, while also recognising the right to a dignified death. If these rights are to be given in their full effect, it would be hard to justify the permission for passive euthanasia not for active euthanasia. For the active euthanasia to be permitted, a solid legal framework is to be ensured by the Parliament so as to prevent misuse and ensure the protection of terminally ill vulnerable people.

Practice question for mains:

Highlight the limitations of SC guidelines with regards to passive euthanasia. How can be they be addressed? (250 words)

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thomas
thomas
1 year ago

please add more ethics related articles

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