Saturday, December 13, 2008

Euthanasia, the death-shot

Life and death are no longer in the realm of only god’s activity. Or, at least, so it seems. Medical science, through In virto fertilization (IVF procedures) brings to reality certain aspects of human procreation hitherto not known to be possible. Again, when a person shall die may even be decided by a suave physician; he may deliver a death shot at a chosen time, without being charged with the offence of murder. Euthanasia is its name. But euthanasia is not legal yet in India. It may soon be, if global trends are any indication. Indian Medical Council (Professional Conduct, and Ethics) Regulations with regard to professional conduct, etiquette and ethics notified in 2002 also declares expressly euthanasia to be unethical conduct. However, the Regulation allows withdrawing life-supporting devices to a patient which shall be decided only by a team of doctors and not merely by the treating physician. A team of doctors shall declare withdrawal of support system. Such team shall consist of the doctor in charge of the patient, Chief Medical Officer / Medical Officer in charge of the hospital and a doctor nominated by the in-charge of the hospital from the hospital staff or in accordance with the provisions of the Transplantation of Human Organ Act, 1994.

Assisted suicide in its diverse forms - General
Suicide is an act of criminal self-destruction. While it is not possible to punish a dead person for what he did, if he survived the attempt, he could be proceeded with legally under regimes that make an attempt at suicide an offence. The Indian Penal Code contains detailed provisions about when attempt to suicide is punishable, when abetment to suicide constitutes culpable homicide (a lesser form than murder) and when even the husband or certain classes of relatives could be said to committed acts of cruelty, when a woman after marriage commits suicide. We are however concerned to issues of assisted suicide in the context of medical intervention. Euthanasia is assisted suicide and something more. The mild variations are treated along the following lines:
(i) Passive Assistance, occurs when a health care provider does nothing to prevent a patient's choice not to seek medical intervention during terminally ill state.
(ii) Facilitation of Suicide is a second circumstance in the health care context, which occurs when the health care provider renders peripheral aid to the victim. Facilitation of suicide can be distinguished from other types of assistance, in that the health care provider's aid only amounts to minimal supportive behavior. Encouraging an individual to commit suicide, for example, is illegal.
(iii) Another type of assisted suicide occurs when the health care provider supplies the means for committing suicide. Most cases do not involve malicious acts but involve ailing victims who have determined that their existence is meaningless and intolerable. Some physicians assist patients who request [suicide assistance], either by prescribing sleeping pills with knowledge of their intended use or by discussing the required doses and methods of administration with the patient.
(iv) The last type of assisted suicide occurs when the health care provider actively participates in the act of suicide.

Euthanasia, active and passive
Assisting patients with suicide comes close to performing an act of euthanasia. Active euthanasia generally involves the administration of some agent or procedure which the physician believes is warranted to end the patient's life.
Passive euthanasia consists of permitting a patient to die by withholding life-sustaining treatment. Passive euthanasia may take many forms. McKay v. Bergsted (1990) was a case in Nevada, U.S.A, where the patient, who had been dependent on a respirator for twenty-one years but who could read, watch television and occasionally enjoy wheel chair ambulation, despaired at the prospect of his father’s natural death due to old age (His father was nursing the ailing son all along). The court allowed him to discontinue treatment. The court distinguished the plaintiff's case from that of a suicidal adult by stating, "Unlike a person bent on suicide, the plaintiff sought no affirmative measures to terminate his life; he desired only to eliminate the artificial barriers standing between him and the natural processes of life and death that would otherwise ensue with someone in his physical condition."
In the Netherlands, nearly 10,000 people die by euthanasia every year at the hands of cooperative physicians. The Netherlands has developed criteria that must be met for an act of euthanasia to be considered medically and ethically acceptable. First, the patient's medical situation must be intolerable, with no prospect for improvement. Second, the patient must be rational and must voluntarily and repeatedly request euthanasia of the physician. Third, the patient must be fully informed of the procedures and consequences. Lastly, there must be no other means of relieving the suffering, and two physicians must concur with the request. Although most physicians do not openly embrace the Dutch position, the silent practice of passive and active euthanasia will continue in the health care delivery system. Whatever attitudes society may develop toward assisted suicide or euthanasia, individual physicians will decide for themselves whether to provide suicide assistance or practice euthanasia.

The old justifications
There are again no universally accepted norms to justify it. On the contrary, the opinion that euthanasia is morally permissible is traceable to Socrates, Plato, and the Stoics. It is rejected in traditional Christian belief, chiefly because it is thought to contravene the prohibition of murder in the Ten Commandments. The organized movement for legalization of euthanasia commenced in England in 1935, when C. Killick Millard founded the Voluntary Euthanasia Legalisation Society (later called the
Euthanasia Society). The society's bill was defeated in the House of Lords in 1936, as was a motion on the same subject in the House of Lords in 1950. In the United States the Euthanasia Society of America was founded in 1938. The first countries to legalize euthanasia were the Netherlands in 2001 and Belgium in 2002. In 1997 Oregon became the first state in the United States to decriminalize physician-assisted suicide through the Death with Dignity Act. Opponents of the controversial law had it overturned by court process. State of Washington's ban on assisted suicide(1994), was challenged as violative of the U.S. Constitution Amendment XIV on assisted suicide. The US Supreme Court however held in Washington v Harold Glucksberg (1997) that the Act was prima facie rationally related to a legitimate government interest and did not violate the Due Process Clause of the Fourteenth Amendment. The court reasoned that State legislation sought to preserve human life and also uphold the integrity and ethics of the medical profession. Additionally, Washington's statute sought to protect vulnerable groups, such as the poor, elderly, and disabled from abuse, neglect, and mistakes. Finally, the Court held that Washington's ban on assisted-suicide effectively prevented a broader license to voluntary or involuntary euthanasia.

Limitation to the sanctity of life principle
A competent patient cannot be compelled to undergo life saving treatment. In Airedale NHS Trust v Bland [1993], a case decided in U.K, Tony Bland's awful predicament had been widely reported. He was a young supporter of Liverpool Football Club who was caught in the Hillsborough crush which reduced him to a persistent vegetative state. The hospital applied for a declaration that it might lawfully discontinue all life-sustaining treatment and medical support measures designed to keep him alive in that state, including the termination of ventilation, nutrition and hydration by artificial means. That declaration was granted. Under the double effect principle, medical treatment may be administered to a terminally ill person to alleviate pain although it may hasten death. This principle entails a distinction between foreseeing an outcome and intending it. The case of Bland involved a further step of the House of Lords holding that under judicial control it was permissible to cease to take active steps to keep a person in a permanent vegetative state alive. It involved the notion of a distinction between doctors killing a patient and letting him die. These are at present the only inroads on the sanctity of life principle in English law. The Dutch courts, relying on the principle of "noodtoestand" (necessity), relaxed the prohibition on euthanasia and assisted suicide. The perceived necessity was the conflict between a doctor's respect for life and his duty to assist a patient suffering unbearably. The Dutch courts reasoned that it is necessary to be guided by responsible medical opinion. It is important to note that this line of decisions is not based on the European Convention. The Parliament of the Netherlands has enacted a statute, viz the Termination of Life for Request and Assisted Suicide (Review Procedures) Act 2001, which formalises a relaxation of the law prohibiting euthanasia and assisted suicide previously by judicial decision. Both the case law and the 2001 statute only permit euthanasia and doctor assisted suicide under a regime of ascertaining the wishes of the patient and with considerable medical supervision. However, the UN Human Rights Committee in a report dated 27 August 2001 expressed serious concerns about the operation of the system.

The unending, inconclusive debate
The subject of euthanasia and assisted suicide have been deeply controversial long before the adoption of the Universal Declaration of Human Rights in 1948, which was followed two years later by the European Convention on Human Rights and Freedoms (1950). The arguments and counter arguments have ranged widely. There is a conviction that human life is sacred and that the corollary is that euthanasia and assisted suicide are always wrong. This view is supported by the Roman Catholic Church, Islam and other religions. There is also a secular view, shared sometimes by atheists and agnostics, that human life is sacred. On the other side, there are many millions who do not hold these beliefs. For many the personal autonomy of individuals is predominant. They would argue that it is the moral right of individuals to have a say over the time and manner of their death. On the other hand, there are utilitarian arguments to the contrary effect. The terminally ill and those suffering great pain from incurable illnesses are often vulnerable. And not all families, whose interests are at stake, are wholly unselfish and loving. There is a risk that assisted suicide may be abused in the sense that such people may be persuaded that they want to die or that they ought to want to die. Another strand is that, when one knows the genuine wish of a terminally ill patient to die, they should not be forced against their will to endure a life they no longer wish to endure. Such views are countered by those who say it is a slippery slope or the thin end of the wedge. It is also argued that euthanasia and assisted suicide, under medical supervision, will undermine the trust between doctors and patients. It is said that protective safeguards are unworkable. The opposing views within the disability community on the issue of assisted suicide share a common ground—a recognition of the danger of discrimination to the interests and fair treatment of people with disabilities. The countervailing contentions of moral philosophers, medical experts and ordinary people are endless.
We are prepared to wink at medical interventions such as that which assists birth to take place to a woman in Haryana well past her 70, after menopause (TOI, 8th Dec 2008). A transsexual, Beatie at Los Angeles who underwent a sex change surgery from female to male retained his/her ovaries, lived like a man outwardly and begot a child (TOI, 5th Jul 208). If you say that in birth lies happiness and hence such medical interventions against nature is possible, there are some who suggest that in death dies freedom from suffering. Hear Donne say: Death be not proud, though some have called thee/ Mighty and dreadful, for, thou art not so/…/One short sleepe past, wee wake eternally/ And death shall be no more; death, thou shalt die.


gaurav said...

sir, i read ur article on euthanasia. what i feel is that it may be allowed as when the person cant bear pain , intolerable suffering or what i call is the pleasures of pain then he/she should be allowed to take his own decision. but at the same time, i also feel that is act of euthanasia is extremely cruel, should be banned, cant we take care of ill persons.

sir, but what about those peoples/doctors who r wearing white coats who r sucking the bloood of stupid comman man's.

what about those parmasutical industries which sell their medicines 10 times more than normal market price.

thnxs sir, 4 such a wonderful article.

S. Subramaniam Balaji said...

Euthanasia should be allowed as a right in personam, but only under extreme conditions of illness which should be prescribed by statute itself. Upon pain and suffering from such diseases or physical conditions an application could be made to a commission/ tribunal for Euthanasia, on a case by case basis could allow it. The tribunal or commission could be headed by a High Court Judge.

Actually it was followed in olden days Tamil civilization and could be ascertained from researchers.

I think Euthanasia is a concept whose time is yet to come.