Today's Editorial

23 April 2017

The right of choice


Source: By Manish Nandy: The Telegraph


It is intriguing that an aroused judiciary in India, spurred by the provocative case of Aruna Shanbaug, has prodded indifferent legislators and a recalcitrant Union government to face the issue of euthanasia. The immediate issue is whether law should permit passive euthanasia, the ending of medical (meaning artificial) prolonging of life when a person is in a persistent vegetative state ( meaning he or she is technically alive but can do nothing a person does on his or her own — move, eat, talk or think).

The first point to note is that we are still shrinking from the discussion we need to have: on euthanasia itself. The word, coined by Suetonius in 14 CE to describe Emperor Augustus dying calmly in the arms of charming Livia, means dying well or, in modern terms, 'dying with dignity.' People overlook that there is no dignity in the way many people now die routinely after what are known as 'heroic measures' to keep a person alive. These are often brutal, invasive procedures intended to force the collapsing body to breathe, feed and hydrate and keep it alive at any cost. If patients were in a condition to protest, they might, but they are not. Few execute in advance ' living wills' or detailed formal instructions about what would be allowed, and hospitals have been known to disregard these in case of the slightest ambiguity.

Their family members are too overwhelmed or ignorant and too eager for an extension of life to resist whatever doctors recommend. The doctors' recommendation is invariably to prolong life at whatever cost; by training, that is their instinctive response. It is also good for business: they make more money and nobody can sue them for not doing enough for a dying patient. Few would question the importance of saving lives. Fewer still would deny credit to doctors who try dutifully to save lives in critical cases. But prolonging lives routinely by a few days by extraordinary means, such as ventilators and feeding tubes, simply because the technology is accessible defies reason.

A car mechanic can listen to the current problems of a client and simply offer a quick fix. A doctor, ostensibly belonging to the ' noble profession,' must do more: find a remedy for the current pain, suggest action for the long run and make sure the best interest of the patient is consistently served. That is rarely the situation today, especially for the people who need such assistance the most, the poor and the vulnerable — and perhaps the gullible too.

The Supreme Court has rightly provided grist for new thinking by forcing the law- makers to recognize the legitimacy of passive euthanasia, the withdrawal of medical sustenance if a patient is in an irreversible vegetative condition. It is saying in effect that it is not enough for doctors to provide textbook treatment to a patient; they must serve the patient's best overall interest, sometimes by not continuing life- extending treatment mindlessly. Sceptical of mercenary doctors and predatory relatives, the court has gone to great lengths to suggest numerous precautions, including multiple doctors from different disciplines and exacting review by judicial eyes. It has in advance taken care of traditional objections, such as fraud and inhumanity, and laid the groundwork for a rational legal framework.

Yet, while the court's directive is a good first step in starting a discussion on euthanasia, it should be called for what it is: a very cautious and limited step. The court has not evaluated the larger aspects of euthanasia or explored why several countries continue to debate its role and some have found a place for it. In fact, it has cavalierly rejected active euthanasia out of hand without seriously considering its relevance for India.

India not only has a large population but also a high incidence of traffic accidents, industrial accidents and medical accidents. A significant percentage of the victims are the paraplegics and the bedridden, many of whom feel imprisoned in their broken bodies and agonize daily in the iron cages their bodies have become. Many cannot afford professional help and must depend on reluctant or indifferent relatives for every step. There are also hundreds of others, victims of painful terminal diseases, for whom every living moment is a cry of pain, with scant or intermittent relief, and no hope of durable remission.

For such people, there is no escape from a living hell, and the constitutional promise of the right to live is a cruel joke. The court recognizes that the right to live includes the right to die with dignity and says in the Shanbaug case, " This category of cases may fall within the ambit of the 'right to die' with dignity as a part of right to live with dignity, when death due to termination of natural life is certain and imminent and the process of natural death has commenced. These are not cases of extinguishing life but only of accelerating conclusion of the process of natural death which has already commenced." But the court ends with the tawdry comment, “The debate even in such cases to permit physician assisted termination of life is inconclusive." It is inconclusive because the court lets it be so.

It shrinks unaccountably from providing a sliver of hope or an option to the understandably miserable victims who wish to end their dark days early rather than leave it to the ravage of slow- moving time. To ask the person whose remaining days mean only ache and agony to endure that fate stoically is a callous invitation to pointless penance. It is both socially and morally repugnant. A society owes it to its citizens, who have already suffered grievously, to leave open an option to end their suffering by ending their life early, should they choose to do so.

This is precisely the reason why countries like the Netherlands, Belgium and Switzerland and certain states of the US permit active euthanasia or physician- assisted dying. It is secondary whether the procedure is administered by a physician or a patient under the guidance of a physician — given the steady emergence of more potent medicines the distinction is virtually disappearing — and the real import is that the suffering citizens have a recourse, even if they prefer not to use it for reason of religion or conviction.

Behind the reluctance to consider active euthanasia there appears to be the implicit assumption that what advanced countries can safely do a less advanced country like, India cannot afford to experiment with. The assumption has become anachronistic as literacy, health, education and technology standards have risen dramatically in India in recent decades. If special circumstances obtain in India, special precautions can be taken to adapt to them. For instance, the Netherlands prescribe that the initiative has to be from the patient, the patient's full awareness must be ascertained, the doctor's opinion should be buttressed by a second opinion and the patient must be at least 16 ( a person 12- 16 needs parental approval). The state of Oregon in the US requires the patient to be terminally ill, receive counselling and allow a waiting period of 15 days.

We should be grateful to the Supreme Court for setting in motion a badly- needed debate on euthanasia, for a modern society ought to grapple with the central issue underlying the debate, which is nothing less than a person's right to choose his own life, including its end. The manner in which the debate has originated may, however, preclude the range of discussion that is necessary. It is critical that we evaluate both active and passive euthanasia, and adopt procedures that make them both safe and compassionate.