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.
1. Lewy G. Assisted suicide in US and Europe. New York: Oxford University Press, Inc; 2011.
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
6. Saunders C. Terminal care in medical oncology. In: Begshawe KD, editor. Medical oncology. Oxford: Blackwell; 1975. pp. 563–76.
7. Caldwell S. Now the Dutch turn against legalised mercy killing. [accessed on August 15, 2011]. Available from: http://www.hospicevolunteerassociation.org/HVANewsletter/0120_Vol6No1_2009Dec9_Now The DutchTurn Against Legalised MercyKilling.pdf .
8. Brådvik L, Mattisson C, Bogren M, Nettelbladt P. Long term suicide risk of depression in the Lundby cohort 1947-1997-severity and gender. Acta Psychiatr Scand. 2008;117:185–91.[PubMed]
9. Campbell C, Fahy T. Suicide and schizophrenia. Psychiatry. 2005;4:65–7.
10. Griffin BA, Harris KM, McCaffrey DF, Morral AR. A prospective investigation of suicide ideation, attempts, and use of mental health service among adolescents in substance abuse treatment. Psychol Addict Behav. 2008;22:524–32.[PMC free article][PubMed]
11. Alonso P. Suicide in patients treated for obsessive-compulsive disorder: A prospective follow-up study. J Affect Disorders. 2010;124:300–8.[PubMed]
12. Bongar BME. Suicide: Guidelines for assessment, management, and treatment. USA: Oxford University Press; 1992.
13. Lonnqvist J. The Oxford textbook of suicidology and suicide prevention. Oxford: Oxford University Press; 2009. Major psychiatric disorders in suicide and suicide attempters; pp. 275–86.
14. The Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations. 2002. [accessed on August 19, 2011]. Available from: http://www.mciindia.org/RulesandRegulations/CodeofMedicalEthicsRegulations2002.aspx . [PubMed]
15. Law Commission report no.196 on medical treatment to terminally ill patients. [accessed on August 19, 2011]. Available from: http://lawcommissionofindia.nie.in/reports/rep196.pdf .
16. Zylicz Z, Finlay IG. Euthanasia and palliative care: reflections from The Netherlands and the UK. J R Soc Med. 1999;92:370–3.[PMC free article][PubMed]
17. Gursahani R. Life and death after Aruna Shanbaug. Indian J Med Ethics. 2011;8:68–9.[PubMed]
18. Chochinov HM, Wilson KG, Enns M. Desire for death in the terminally ill. Am J Psychiatry. 1995;152:1185–91.[PubMed]
19. Gandhi A, Chaturvedi SK, Chandra P. Desire for death in cancer patients - an Indian Study. Presented at the International Congress of the International Psycho OncologySociety, Copenhagen 2004
20. Sheldon T. Dutch legal protection scheme for doctors involved in mercy killing of babies receives first report. BMJ. 2009:339.
It is commonplace to pit the length of life against the quality of life. This happens in the sort of clinical discussion where the patient is nearly dead and seems to have little residual human functioning left. The typical situation GPs may face is the decision whether to send the patient to hospital for vigorous intravenous treatment of pneumonia or urinary infection, or leave them at home to survive or succumb under oral antibiotics alone. The resolution of the quandary generally depends more on the personalities involved than on rational debate. One of the more unfortunate consequences is where the family is called on to decide how energetically the doctors should strive to maintain the waning life. I say this is unfortunate because family members, albeit more familiar with the preferences of the patient, are also more liable to be in a state of conflict of interest, especially where they are the immediate caregivers bearing the personal cost and the day-today burden of the terminal stage of life, and even more so where they are the prospective inheritors of the patient's property.
I should like to unpick some of the terms we sometimes use only half-thinking. Underlying the discussion is a concept of a life not worth living, for it is only such a life that may be scrutinised as a candidate for termination, whether by benign neglect, passive euthanasia or assisted suicide. One may distinguish between early, middle and late lives that are not worth living. The early ones, severely damaged neonates, are clearly different from the late ones, the old person with advanced dementia in deep coma who has had what is often called a good and long innings. But it is the ones in the middle that are the most difficult to grasp. They have had their chances in life, but may have expected more. As well as terminally ill and suffering patients, this group could include others whose lives are not worth living, such as victims of prolonged violence —imprisonment in some regimes, domestic violence, sex slavery, and military occupation. Extreme poverty is often enough to make life not worth living. The key seems to be hope; where there is hope of a better tomorrow even the most unhappy life might be worth living. It is the absence of any hope that makes people give up.
The idea of a better tomorrow begs the question of the meaning of the quality of life. Whereas the existence of life may be observed objectively, and its days may be counted, its quality can only be judged subjectively. There can be no universally agreed criteria for the quality of life, for each person attaches different value to the various aspects of life, and this changes too with changing circumstances. Pain without hope of recovery may be judged differently from pain with the hope of recovery. The idea of averaging out different peoples' judgments to produce a conglomerate metric of the quality of life, ignores its essentially contextual nature and its intrinsic subjectivity. Life, with its joys and its suffering, its hope and its desperation, has a purely individual meaning for each person. Nobody can be a proxy for this sort of judgment, neither the family, nor social consensus, and certainly not the doctor.
Following this argument, doctors are led to conclude that quality of life is too fickle to use in making clinical decisions, and that all we can reasonably do is to concentrate on the countable and the measurable — to keep the physiological homeostasis going as long as we can, until entropy takes its inevitable toll and life ends. This gives us a usable endpoint whereby to assess the success or otherwise of our medical interventions, for the constant improvement of our science and our skills. This reductionist scientific attitude is also wholly consistent with the expressed and traditional commitment of our profession to save lives wherever possible.
The formulation I have given of the quality of life is essentially grounded in the western hedonistic tradition, where special value is ascribed to happiness and joy. Religious traditions promote other values. Religion attributes the quality of sanctity to human life, where life is not the property of man to use for his own entertainment, but rather a gift from God to use for higher purposes. This holy gift from God must be respected and maintained at all costs, say the religious fundamentalists. Since it does not belong to us, it is not for us to destroy — ever. In Helga Kuhse's definition — ‘it is absolutely prohibited intentionally to terminate life because all human life irrespective of its quality or kind is equally valuable and inviolable.’1 We arrive then, at a convergence of interest between reductionist medical science and fundamentalist religious doctrine. Both devote themselves to the maintenance of life — its salvage and its salvation.
However, many or most doctors, and many or most religious people, may find it difficult to identify with what I have just written. For there are other chords both in the secular2 and the religious3 worlds. It is not right to describe western society in purely hedonistic terms. Even using the simplest form of the ‘golden rule’ — behave towards others as you would have them behave to yourself — life has special value in itself. The ultimate thing that you do not want is to be killed, so do not kill others. From this special value of life derives a special duty to maintain and protect life, irrespective of what you think its value may be. This personal duty becomes subsumed as a social consensus and is enshrined in law. It also generates a right to life that each living person may demand of his fellows. It is this right to life that a person may chose of his own free will to forfeit, and in so doing relieve his fellows of their duty towards him. In this way a terminal and suffering patient, or any other person leading an intolerable life, may opt out of the efforts others make to save them. The doctor confronted with a patient who declines his best efforts to prolong life may, indeed should, withdraw and with no pangs of conscience. If the duty to treat derives from the right to life, then it evaporates when those rights are not exercised. Where the person himself cannot express a wish, in practice it is extremely difficult to generate any valid proxy, and the dangers loom of the slippery slope of xenophobic euthanasia. It would seem wise to err on the side of caution.
In the religious world, too, there are other voices. Although life is indeed the gift of God, it is not merely a biological gift, and morally neutral. Its holiness is to be defined not by its origins but by its dedication to the ends it was intended for — the service of man and God. If a life cannot be used for its intended purpose, it is not a sanctified life. This is the basis for the death penalty in religious legal systems, for otherwise the penalty would be sacrilegious. The life of a deliberate murderer, whose actions negate the very nature of God's purpose in the world, loses its protected status. Judaism, a religion that delights in encapsulating everything possible in codes and laws, specifies two more categories of sin where the duty to maintain life is suspended —incest and adopting pagan rituals and beliefs.4 A life essentially contradictory to God's wishes is not a holy life. There is no intrinsic sanctity of life, rather life is given by God to man in order to sanctify it.
So here we arrive at another convergence of the secular and the religious. In both systems there are circumstances where the duty to save life is not absolute, but contingent on the value of that life. In secular terms, where the sane and competent patient ceases to value his own life, the doctor is relieved of the duty to maintain it. In religious terms, where it is not possible to use the life for its God-given purpose, it loses its status of holiness. This convergence is in marked contrast to the sanctity-of-life/right-to-life coalition which typifies the fundamentalist periphery of religious thinking, as well as the more conservative and narrowly scientific sections of secular society.
I suggest that the term ‘sanctity of life’ confuses rather than clarifies the debate. It should be replaced by ‘value of life’, which exposes the individual case to critical scrutiny. Medicine can better cope with its current and future ethical dilemmas by a case-by-case approach5 rather than by adopting a series of dogmas, such as the sanctity of life.
1. Kuhse H. The sanctity of life doctrine: a critique. Oxford: Clarendon; 1987.
2. McMahan J. The ethics of killing: problems at the margin of life. Oxford: Oxford University Press; 2002.
3. Weingarten MA. Sanctity of life: a critical reassessment of Jewish medical ethics. In: Twohig P, Kalitzkus V, editors. Interdisciplinary perspectives on health, illness and disease. Amsterdam and New York: Rodopi; 2004. p. 1.
4. Dorff EN. Matters of life and death: a Jewish approach to modern medical ethics. Philadelphia and Jerusalem: The Jewish Publication Society; 1998.
5. Brody B. A historical introduction to Jewish casuistry on suicide and euthanasia. In: Brody B, editor. Suicide and euthanasia. Dordrecht: Kluwer; 1989. pp. 39–75.