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.
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To be forced to continue living a life that one deems intolerable when there are doctors who are willing either to end one’s life or to assist one in ending one’s own life, is an unspeakable violation of an individual’s freedom to live—and to die—as he or she sees fit. Those who would deny patients a legal right to euthanasia or assisted suicide typically appeal to two arguments: a “slippery slope” argument, and an argument about the dangers of abuse. Both are scare tactics, the rhetorical force of which exceeds their logical strength.
Slippery slope arguments, which are regularly invoked in a variety of practical ethics contexts, make the claim that if some specific kind of action (such as euthanasia) is permitted, then society will be inexorably led (“down the slippery slope”) to permitting other actions that are morally wrong.
It is, of course, easier to assert the existence of a slippery slope than to prove that it exists. Opponents of a legal right to die thus point to the Netherlands, for example, and note how the law permitting euthanasia and doctor-assisted suicide in that country has become steadily more permissive. At first, euthanasia was permitted only for the terminally ill who requested it, but then it was permitted for the chronically ill, for those whose suffering was psychological, and for incompetent patients, including children.
It is indisputable that the Dutch laws regarding euthanasia and doctor-assisted suicide have become more permissive, but those who invoke the slippery slope argument fail to realize that those changes are insufficient to demonstrate the existence of a (noxious) slippery slope. To understand why this is the case, imagine, for example, that you are an opponent of apartheid in South Africa in the 1950s. If you are seeking to bring about legal change, through legal channels, you might realize that you have little hope of convincing the white electorate of abandoning apartheid. Thus, you might decide to begin by chipping away at the edges of the apartheid structure. You might recommend, for example, abolishing separate entrances to the post office for blacks and whites. A defender of apartheid might resist that move by pointing to the possibility of a slippery slope: “If we abolish separate entrances,” that defender might say, “we shall soon find that people of different races are permitted to marry one another, and before we know it, there will be no more apartheid.” It should be readily apparent that, even if the defender of apartheid is correct that the stated trajectory is a likely consequence of abolishing the separate entrances, that consequence would not be a noxious slippery slope.
With that scenario in mind, we can see the hidden assumption in the slippery slope argument against legalizing euthanasia: It is the assumption that the instances of euthanasia that the Netherlands now permits are morally wrong. But the problem is that very many defenders of a legal right to die would deny that those instances of euthanasia are wrong. Some of us think that the suffering that a person endures need not be the product of a terminal disease in order for it to be intolerable. We also recognize that some mental suffering is intractable and as unbearable as physical suffering. And we recognize that it is not only competent patients, but also incompetent ones who can suffer from conditions that make their lives not worth living. Accordingly, we would like to see euthanasia and assisted suicide permitted in such a wider range of cases. If, however, we cannot effect that legal change in one step, we recommend, in the first instance, a more limited liberalization of the law. Once that change has been made, people might realize that the next step and then the next are also acceptable, even if they cannot see it now.
The second argument invoked by opponents of a legal right to die is the argument that such a right will be abused and that no legal safeguards can prevent that abuse. Thus, for example, it has been said that where written voluntary consent to euthanasia is a legal requirement, that consent has not always been obtained. Similarly, it has been said that euthanasia or assisted suicide are often not reported, even in jurisdictions in which reporting is obligatory.
The problem with that argument is that citing many examples of abuse of a legal right is not sufficient to justify withholding that right. If the likelihood of abuse were thought to be grounds for withholding a right, then much more than euthanasia would have to be banned. Driving, for example, would have to be prohibited on the grounds that this right is abused and that none of the safeguards we have against such abuse are completely effective. People drive faster than they should. They drive through red traffic lights and weave through traffic, and they drive cars that are not roadworthy. Some even drive without a license or while under the influence of alcohol. Moreover, the abuse of a legal right to drive often has fatal consequences, and thus, it is not unlike euthanasia in the severity of the outcome of the abuse. (And unlike the case of euthanasia, fatalities from car accidents often involve people who were in excellent health, which makes abuse of driving worse than abuse of euthanasia.) Few opponents of a legal right to die are prepared to accept the implication that driving should be banned. Nor is it a conclusion that should be accepted. There is no reason to withhold from some people a legal right to reasonable activity merely because other people will abuse that right. The appropriate response is regulation, imperfect though that may be.
The opponents of euthanasia and assisted suicide who cite the dangers of abuse in support of their view also fail to notice that abuse is possible even when euthanasia and assisted suicide are legally prohibited. It is naïve to think that covert forms of euthanasia and assisted suicide are not occurring in places where those practices are illegal. At least some of those instances would constitute abuse if a legal right to die existed. It is hard to say how much abuse occurs in such jurisdictions, but that is partly because where euthanasia and assisted suicide are prohibited, doctors will be even less likely to admit to participating in such practicesa.
Banning alcohol consumption, prostitution, gambling, and so forth, does not result in the elimination of those practices, in either abusive or non-abusive forms. Similarly, the choice is not between euthanasia and no euthanasia, with abuse occurring only in the former. Instead the choice is between euthanasia with or without regulation. Abuse will occur in any event, and thus, on the assumption that there is nothing wrong with euthanasia in itself, we may as well legalize and regulate it.
The slippery slope and the abuse argument are both compatible with the view that there is nothing intrinsically wrong with the practices at issue. Any person could hold the view that euthanasia and assisted suicide are morally permissible, but then deny that they should be made legal on account of the slippery slope and the danger of abuse. As it happens, however, many if not most of those who advance the slippery slope and dangers of abuse arguments do think that euthanasia is immoral.
Those who think that euthanasia and assisted suicide are immoral often suggest that there are always alternatives to death for those whose lives have become intolerable. Thus, it is suggested that palliation is always a possibility, even if palliation requires sedating the patient to the point of minimal or no consciousness. What that suggestion fails to recognize, however, is that it is not always pain that renders a life not worth living. For some people, the prospect of continuing in a minimally conscious or unconscious state for the rest of their biological life is a fate worse than death. Opponents of a right to die sometimes reply that people with such views can be helped to realize that such a condition is not worse than death. However, this line of argument is dangerous precisely because it could as easily be argued that those who think that death is worse than sedation until natural death could be helped to realize that they are wrong and that they should therefore agree to euthanasia.
It is not at all unreasonable to view as undesirable continued biological life with only minimal (if any) consciousness. Nor is depression in response to such a prospect in any way irrational. To suggest that people who manifest such depression should rather be provided with psychiatric help is to pathologize an entirely reasonable response to an appalling situation.
The quality of life can fall to dismal levels. Not everyone agrees about just how bad life must be before it ceases to be worth living. However, the fact of that disagreement provides no more reason for prohibiting euthanasia than it does for requiring it. To force people to die when they think that their lives are still worth living would be an undue interference with people’s freedom. It is no less a violation of human freedom to force a continuation of life when people believe that their continued life is worse than death.
Opponents of a legal right to die are fond of saying that freedom has its limits. However, just because freedom has its limits does not mean that a right to die falls beyond those limits. When a person deems that life is no longer worth living, then taking action to prevent that person from gaining assistance to die imposes a very serious harm. Although society may restrict a person’s freedom to prevent the infliction of harm on others, it is very difficult to justify restricting a person’s freedom when that restriction will result in an immense personal harm.
aSome of the arguments in the preceding few paragraphs are developed at greater length in Benatar D. Assisted suicide, voluntary euthanasia, and the right to life. In: Jon Yorke, ed. The Right to Life and the Value of Life: Orientations in Law, Politics and Ethics. Aldershot, U.K.: Ashgate; 2010: 291–310.