A controversial issue

One of the most controversial issues in the recent past has been the question of legalising the right to a dignified death, or euthanasia (a good death). Like the question of capital punishment or suicide, euthanasia is controversial since it involves the deliberate taking of human life.

This issue has fascinated and troubled sensitive and concerned persons through the centuries. Plato, in The Republic, condemned physicians who allowed patients to suffer from lingering death and suggested euthanasia. So did Seneca when he raised the query of whether man is lengthening his life or death. Well-known philosophers and writers who have justified or supported the cause of individuals voluntarily opting for a dignified death include Epicurus, Thomas More, Francis Bacon, Schopenhauer, Koestler and Nietsche.

Indian philosophical tradition has justified the idea of willing one’s death (ichacha maran). Sane Guruji, Veer Savarkar and Vinobha Bhave are some well-known examples of persons choosing to end their lives by refusing the intake of all nutrition. Even a person like Gandhi, whose name is synonymous with non-violence, supported this idea.

On the other hand a number of scholars and religious heads have opposed euthanasia on the plea that life is sacred.

Doctors can now sustain life without purpose

Recent developments in medical technology, though pregnant with blessings, threaten to keep human beings alive as comatose lumps of flesh. This has focussed interest on euthanasia. Doctors can prolong life but they can also cause unmitigated pain and agony to the patient, friends and relatives. As a result, a search is on to find a more humane solution.

Concerned individuals and groups are addressing questions like: What is the right to life – does it mean merely staying alive or does it include a meaningful life? Is it justified in the name of sanctity of life, to deprive an individual his sense of autonomy and dignity and debase him to the state of a mere vegetative organism? A debate is also on about the constantly changing meaning of ‘natural death’. Medicine has advanced to such an extant that it can sustain human life artificially. In such cases, when life support systems such as heart-lung machine and respirator are removed, life ceases. So what can one actually define as natural death?

Active and passive euthanasia

Medical ethicists have tried to draw a fine distinction between positive or active euthanasia (mercy killing) and passive euthanasia. In the former the doctors or other medical personnel consciously give the patient an overdose of sleeping pills, other medication or an intravenous injection of potassium chloride to hasten death.

In passive euthanasia the doctor merely withholds from a terminally ill person treatment without which the patient would die, rather slowly but die nonetheless. One example is switching off the artificial respirator in use for a person who cannot breathe without it. Other examples include not giving any treatment to an ill patient or starving an infant to death. A doctor might leave instructions that if a hopelessly comatose patient suffers cardiac arrest nothing be done to start his heart beat again. This practice is termed ‘No Coding’. Here the doctor is not inducing death. It is the disease that is a natural cause terminating the life of the patient. The consent of the patient and/or the immediate family is not always sought. This is thought to be a medical decision and hence the province of doctors. In truth, it is a moral ruling.

While most legal systems would punish any person who actively participated in euthanasia, the rules are nebulous on the passive variety. Courts have been lenient in cases where doctors or others have withdrawn medication. The right of a competent patient to refuse can also cause treatment is generally recognised in western legal tradition, the idea being that letting a person die is different from actually killing a person.

Of late this distinction has lost its relevance. The question remains whether or not there is any difference, from the moral point of view, between the omission and the performance of an act. What is the difference between the doctor who starves his patient to death and one who prescribes a dose of seconal with the warning that imbibing a gramme will result in death? Many doctors and philosophers do not really consider this distinction relevant. As Dr. D C S Cameron of the American Cancer Society points out, the difference between active euthansia (i.e. killing) and letting the patient die by omitting life-saving treatment is a moral quibble (1). As far as the patient is concerned, it does not matter whether euthansia is active or passive; in either case the result is death.

A number of arguments have been put forth in favour of and against euthanasia. It is important to analyse some of them in order to initiate a meaningful dialogue on this issue.

Arguments against euthanasia

Most religious persons, especially those espousing the Judaeo-Christain faith, believe that life is sacred because it is created by God. They regard killing to be a dreadful sin as it amounts to destruction or rejection of a divine gift. It is believed that man is not the independent master of his life but a steward, subject to the sovereignty of God. They argue that one has not only a right to life but an obligation to go on living and that human dignity involves the heroic acceptance or bowing to a higher purpose of existence. The objection to euthanasia is also the basis on which the church finds suicide and abortion unacceptable.

There are some, like Sir Immanuael Jakobvit, who believe that even voluntary euthanasia should be resisted since it could result in the general lowering of values of human life. Once we compromise on the infinite worth of every human life and make it finite in value, turning it from absolute into relative – either relative to his state of health or his usefulness to society – we automatically bring about a situation in which some human beings will be worth more and others worth less. This could ultimately recrcjte the kind of holocaust perpetuated by the Nazis (2).

Another argument put forth against euthanasia is that it can be extended to an indefinite number of cases. There is no clear and unambiguous way of restructuring the categories. The last resort, when legalised, has a habit of becoming the first option, not necessarily because killing is contagious but because the concept of life-not-worth-living is open to numerous interpretations. It is this perspective that is highlighted by those who oppose this slippery slope. New boundaries can – and will – be exploited by those with dubious intentions.

The objection is not to euthanasia per se but against the projected consequences – such as the sick, elderly and disabled being pushed into death just to spare their families energies, emotion and money. Not only will euthanasia become legal, it could be made to appear desirable.

There are many who believe that euthanasia might brutalise those carrying it out. Once doctors get accustomed to sending certain categories of people to death, they may be indifferent to suffering inflicted on others. Such a possibility should be prevented at all costs. As Cardinal Roger Mohony, Archbishop of Los Angeles points out, all that it serves is the attitude that we can solve the problems of people by getting rid of people (3).

It is believed that sometimes patients in a vegetative state due to head injury or a variety of brain diseases are not sure-fire cases for euthanasia. There have been cases where comatose patients maintained on life support systems for months have miraculously swung back to recovery and resumed life. Euthanasia is therefore totally unjustified.

Arguments for euthanasia

A common argument in support of euthanasia is that rather than degenerate helplessly, the ill person can choose to make an honourable exit. Coma deprives an individual of his sense of autonomy and dignity and debases him into a mere organism with a beating heart but sans all other purpose or feeling. To preserve such a biological but insensate existence, or to preserve life in a terminally ill individual, suffering from unmitigated pain and agony, against his expressed wishes, is the very negation of respect for life. Prolongation of useless suffering is a greater evil than expediting death that is inevitable.

It is argued that this is a fundamental right since the right to die is the final and ultimate affirmation of the right to life. Since the constitution provides an individual the right to life, the right to choose the time to die with dignity should also be his/her prerogative. Further, freedom to act should not be restricted unless there are convincing arguments that this conflicts with the rights of others. Since no such conflict can be shown however in the case of a terminally ill person, a person has the right to die as he chooses.

In this sense it is different from suicide because when a healthy person takes his life he might be finding a way out of his responsibilities. A person suffering from a terminal illness however does not have any duties to fulfil because he is simply incapable of doing anything hirnself or for others.

It is also argued that euthanasia is an act of compassion and concern. This is why Gandhi, who believed that even an evil thought or unnecessary accumulation of wealth was an act of hinsa( violence), considered euthanasia to be an act of non-violence. He insisted that the critics of euthanasia were wrong in assuming that death was always worse than life. When life is painful and unbearable, he pointed out, not to kill was an act of hinsa. There is far more violence in the slow torture of individuals, wanton humiliation and oppression of the weak and the killing of their self-respect than in benevolent taking of life (4). Similarly, Engelhard believes that there is a duty not to prolong life which has a negative value for the person. By negative value, he just means that it is unpleasant.

Those in favour of euthanasia believe that this will regularise practices which are going on surreptitiously. As Dr. Colabawala points out, many doctors have done it but nobody will say it openly because of the law of the land. As of now since the act is done in utmost secrecy no one knows how often, or for which motives it is committed. There is no accountability because it is simply not admitted. Legalising the practice could help spell out the conditions and thus enable closer monitoring.

Resources of the national exchequer are not limitless and prolongation of the life of one aged patient may in fact entail the deprivation of aid to others and even shorten their lives. A difficult but necessary choice has to be made. This acquires important dimensions in Third World countries.

By shielding the patient’s family from economic catastrophe, euthanasia eases the psychological tension experienced by the patient.

Of late public opinion the world over seems to be in favour of legalising euthanasia. Dutch courts have allowed an extremely liberal interpretation of their already liberal laws. A Federal court ruling in the US in 1994 gave patients the right to end their life. US District Court Judge Barbara J. Rothstein struck down a Washington State law banning assisted suicide. The Court held that a dying person has a right to take his own life just as a woman has a right to an abortion and a person has a right to refuse medicines. The judge held that there is no more profoundly personal decision, nor one which is closer to the heart of personal liberty, than the choice which a terminally ill person makes to end his suffering and hasten an inevitable death.

She also suggested that the freedom to make such a choice without interference by the government or third parties is protected by the fourteenth amendment of the American Constitution which says that no state shall make or enforce any law abridging the privileges or immunities of the citizens of the US.

Similarly a Michigan jury acquitted Dr. Jack Kevorkian of charges that he had violated a state law against assisted suicide. This again is a significant judgement since Kevorkian has, over the last five years, helped over twenty patients to kill themselves. This decision reflects the change in the thinking process. of the judiciary. While in 1994 a man charged of assisting in twenty deaths was set free, in 1920, in People vs Campbell, the Michigan Supreme Court upheld the conviction for murder of a man who placed poison within reach of his wife who was dying of multiple sclerosis. Courts in the US and UK permit the removal of feeding tubes from brain dead patients.

Many terminally ill but conscious patients have fought for and won the right to be taken off life support systems. Constitutional. courts in Germany have ruled that doctors can withdraw treatment from terminally ill patients and thereby hasten their death.

The Supreme Court of India took a step forward in April 1994, when, in P. Rathinam/Nagabhusan Patnaik vs. Union of India it declared the penal clause imposing punishment on a person charged with attempting suicide as ultra vires. This should help in leading toward informed debate on voluntary euthanasia. The invalidity of Section 309 of the Indian Penal Code (1860) has raised the question whether the invalidity of the main crime affects the validity of the section criminalising the abetment of suicide.

Some vexing questions

This is an issue where ready-made solutions or clear answers are not possible. An incorrect decision could debase an entire country as in Nazi Germany, where under the name of euthanasia, a whole population was liquidated. Soul searching is called for and a debate at the national level is necessary.

A number of delicate issues have to be dealt with:

• Who should be allowed to ask for euthansaia? Should this right be given only to the terminally ill person or to his immediate kith looking after him to exercise it on his behalf?
• Should the right be extended to those who have already lost the mental capacity to choose for themselves?
• Should persons afflicted with a serious condition but who are not near death be allowed to end their lives? How close to death does one have to be to get the right to take one’s life?
• Should physicians, who according to their oath are expected to save life, be asked to kill or should this be the task of others who are paid for such a service?
• How would the doctor ensure that the patient’s request is real and valid and also ensure that the patient is really in a position to evaluate his own situation and make a request with a clear mind? On what criteria should a witness testify that the patient made the request for his own death with a sane and sound mind?
• Can all pressures be eliminated?

This list of questions of problems are mere1y illustrative of the kind of problems that might arise.

Need for a publicly accepted policy

Any publicly acceptable policy on euthanasia must refer to a wide range of related issues. These include an inadequate health care system co-existing with the use of advanced medical technology, an inequitable economic structure, the highly lucrative organ transplant racket; medical malpractice, marginalisation of weaker groups, and the role of the state.

Medical ethics is a much neglected subject. Medical students and many practising doctors clearly lack depth or dimension in the handling of these problems. obliged to witness prolonged suffering by a loved one. In such a situation, their views are purely personal and may even be idiosyncratic and erratic. This predisposes to loose interpretations of the law. If euthanasia is to be implemented, the state must provide unambiguous guidelines and help medical personnel in the management of their patients.

There is a need for immediate action since as of now the situation is completely muddled and patients are condemned to misery they would rather end. Doctors are torn between law and conscience and families are obliged to witness prolonged suffering by a loved one.