Few issues in medical ethics have interested the layperson as much as the topic of euthanasia. Not only do medical journals frequently contain articles on it, but even the general public has access to material on the subject. The Karen Ann Quinlan case introduced the topic to the Western world about 20 years ago. The extremely successful play by Ron Clark Whose life is it anyway? its screenplay and the movie of the same name, starring Richard Dreyfuss are well known examples of euthanasia in the arts. More recently, the publication of the book The Final Exit by Derek Humphrey as well as the acts of Jack Kevorkian, the pathologist in California have put euthanasia and its proponents in the news. Statistics from America are informative and a Gallup poll in 1990 showed that 84% of the people interviewed felt that they would desire withdrawal of treatment if they were to be put on life-support systems with no hope of recovery. As many as 66 % felt it was their moral right to do so (1). Significantly, of 200 doctors interviewed by the Society for the Right to Die with Dignity, in Mumbai, 78% believed that patients should have the right to choose in cases of terminal illness while 74% believed that artificial life supports should not be extended when death is imminent (2).

What is all this fuss about anyway? Euthanasia literally means “good death” (from the Greek, eu = good, thanatos = death), something its proponents always stress on. It may come as a surprise to many people to learn that euthanasia is not a new subject – in fact, there are references to it even in ancient Greece and Rome! Indeed, the Hippocratics were among those who challenged the practice of euthanasia. This is the reason for the clause in the Hippocratic Oath which refers to the doctors refusal to give deadly drugs to patients. Possibly the first reference to euthanasia in the English literature was in Sir Thomas More’s Utopia in 1516. The arguments for and against euthanasia increased after the invention of anaesthesia and the discovery of morphine in the mid-nineteenth century – agents which dramatically opened new possibilities for the euthanasia enthusiasts. These arguments have largely remained the same, a century later (3).

Those in favour of euthanasia believe that it is a human right born of self-determination and is the ultimate act of democracy. They also state that the act of relieving a painful or a distressful death would promote a patient’s well-being, hence, one which will lead to more good than harm. It is an act of compassion and is humanitarian. Importantly, they suggest that there is no real difference between active euthanasia and withdrawal of life-sustaining interventions, except one of semantics (3).To those who equate euthanasia with killing or murder, the argument given is that the difference between these two concepts is as different as that between love-making and rape. The crucial difference is that one of the acts takes place by consent (4). Finally, legalisation is unlikely to lead to harmful consequences.

Those against euthanasia cannot accept most of these statements. They suggest that most deaths are not painful, thus obviating the need for such a procedure. The great worry – and indeed everybody’s worry – was possible misuse of a law. They claimed it could give opportunities to the unscrupulous to eliminate unwanted people. Indeed, old people might feel pressurised to ask for euthanasia so as to relieve their families of distress and financial burden. Moreover, it could lead to undermining the patient’s trust in his doctor. Finally, the legalisation of euthanasia would only be the thin end of a very big wedge. This would only be the first stage and would ultimately lead to the introduction of terminal procedures for mentally retarded people, convicts and other such socially unwanted or unpopular people (3).

Janet Radcliffe Richards takes issue on these aspects of euthanasia and states most emphatically that voluntary euthanasia has nothing to do with doctors deciding whom to kill. It only refers to whether people trapped by incurable disease have the freedom to commit suicide – an act which most of us have the freedom to commit. Since the act is entirely voluntary on both sides, it need not be considered to be contrary to conventional medical practice. The so called slippery slope is more likely to be a theoretical fear than a real issue (5).

A practical suggestion has been put forward by Mason and Mulligan (6). They state that although there are a lot of grey areas in euthanasia, there are two areas that satisfy all criteria – medical, moral as well as legal – for initiating euthanasia, the good death. The first is the persistent or permanent vegetative state where it is clear beyond reasonable doubt to qualified people that continued treatment of the patient would be meaningless and futile. They suggest that a bill called the Medical Futility Bill be introduced for this purpose. The second condition in which it would apply is in progressive neurological disease such as amyotropic lateral sclerosis. Physician aided suicide is justified-and ethical – in such conditions.

The Living will or advance health directive that has been suggested by many authorities is a document that establishes the individual’s legal rights to refuse any form of treatment offered to him. It is to be made when the individual is compos mentis and is applicable even later, when the patient may not be in a position to make a decision. The advance health directive, by definition, needs to be approved of by a physician and is hence binding.

Indeed, a health care professional who refuses to honour such an advance directive is ethically and probably even legally guilty. In Mumbai, the Society for the Right to Die with Dignity has been working on a format for such a living will or an Icchamaran . Forty-one per cent of the doctors interviewed by the society felt that the living will should be respected. It must be added, though, that a number as large as 31% had their reservations (2).

What is appropriate for India? It is interesting that the Father of the nation, Mahatma Gandhi, wrote that a person suffering from an incurable disease had the right to commit suicide if he could not perform any service whatsoever and lived only as a result of the ministration of others (7). At least two famous people ended their lives with euthanasia – the poet, Dylan Thomas, who ironically implored his father to ‘not go into that good night – rage, rage against the dying of the light’ as well Sigmund Freud, the father of psychoanalysis, who after being operated numerous times for a buccal mucosa carcinoma decided to opt for a peaceful death with intravenous morphine. I would personally like to believe that in principle, euthanasia is a sensible thing. However, there are practical difficulties of introducing it in a country where large parts of the population live beneath the poverty line, physicians – especially specialists – are mainly based in the cities, and corruption is a way of life. Our archaic laws are only too well known and implementing a law that exists on paper raises new difficulties. In the same interview in Mumbai, mentioned above, over 70 % were apprehensive of the abuse of the law if voluntary euthanasia were legalised (2).

It would perhaps be too much to expect our courts to take a legal stand on these esoteric subjects – either those of euthanasia or on living wills – when there are so many more pressing-and unsolved – matters at hand. Indeed, as a columnist in Blitz said sometime in the 1970s, there is a society for the right to die with dignity in India – but nothing at all for the right to live with dignity. The Supreme Court’s decision to legalise suicide in 1994, followed by a reversal of its stand in 1996, only served to confuse the issue further. But this much is clear – it’s time to start thinking seriously about these issues so that a decision that is effective, medically, legally and morally can be taken soon.

In conclusion, to quote Janet Radcliffe Richards, “I hope that I shall never need to ask for it. But I also hope that if I do, no kind friends or doctors will have to risk their own liberty to give me mine.” (4)

Acknowledgement

I am grateful to Dr Anita M. Borges for her comments and suggestions on the text.)