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Topic Guide EUTHANASIA: “India should legalise voluntary active euthanasia” The rights and wrongs of Euthanasia have been hotly debated across India over the last few months. The Supreme Court’s ruling on the case of Aruna Shanbaug, a former nurse who was violently attacked in 1973 and has been in a ‘vegetative’ state ever since, has made the question of mercy killing the subject heated national debate. Whilst the Supreme Court ruled that Aruna should live, supported as she is now by the doctors and nurses who care for her at the King Edward Memorial hospital, the court also ruled that it will allow ‘passive euthanasia’ – the withdrawal of medical treatment to allow patients to die - in certain circumstances. The ruling was an important one in the development of the law in this area. In a country that has been avowedly ‘pro-life’, the acceptance of Euthanasia, albeit ‘passive’, has been deemed a watershed moment. But while some have celebrated the ruling, a number of campaigners and commentators suggest that it doesn’t go far enough. They argue that if the government is serious about giving Indian’s both choice and dignity in end of life care, then it is time also to support ‘voluntary active euthanasia, where doctors administer lethal medication’. Others warn that the road to hell is paved with good intentions, and question in particular whether a country such as India, which lacks universal health care provision, should be endorsing euthanasia. The euthanasia debate has been ethically and politically controversial in many countries in recent years. Some argue the growing pressure for a ‘dignified death’ is the sign of a progressive and compassionate movement for change, but others worry that our obsession with the right to die is both morbid and threatens to involve government and the law in an area of life that should be a private affair. Is it time India recognised the right of individual patients to decide on the time and manner of their own death? Or should we always be morally wary of endorsing suicide, whatever the circumstances? The Euthanasia debate in context: What is euthanasia? Debates over assisted suicide and euthanasia involve a complex array of distinctions. In India the discussion around euthanasia has often been confused by the varied terms at play in the debate. Passive euthanasia refers to the withdrawal of treatment, mainly intensive care support, when it is considered medically futile for the patient; something that is routinely practised in the West and backed by law, but until the Shanbaug ruling there was no equivalent in India. In contrast, when a doctor directly ends a patient’s life by administering lethal medication at a patient’s request (based on informed consent) this is known as ‘voluntary active euthanasia’. When a doctor indirectly helps a patient to die by prescribing medication that will enable him to end his own life, this is known as patient assisted dying, also commonly described as physician assisted suicide. This debate focuses on the question of whether the time has come to allow voluntary active euthanasia, the most controversial kind. A dignified death? Proponents of voluntary euthanasia argue that legalising the practice would allow terminally ill patients the control and choice over their lives that they are currently denied. They argue that the right to a dignified life, enshrined in the Constitution of India, should also incorporate the right of terminally ill individuals to die with dignity at a time of their own choosing, rather than having to suffer needlessly. Activists such as Flavia Agnes warn that we should be wary of ‘moral pontification from the pulpit about the divinity enshrined in the right to life’. Others agree and underline that there must be limits to suffering we endure; indeed, quality of life in cases of terminal illness is as important as life itself, and it is callous of both doctors and society to suggest otherwise. Allowing patients who are enduring unimaginable suffering to die on their own terms demonstrates both the autonomy of the patient and the mercy of the society in which they live. But others argue that ‘dignity’ should not be reduced to ‘bodily integrity’, such that life is seen as no longer worth living once someone is no longer able-bodied. Healthy people often say that they would not want to go on living Topic Guide with debilitating illness, but both patients and doctors testify that such feelings are subject to change, and the very ill often decide that life is worth living after all. It is also important to recognise that dying takes place within a social context. There is a danger that in allowing voluntary euthanasia, says Olivia Timms, we abrogate our responsibility as a society to affirm the life of a dying or terminally ill person when they need it most. What does this mean for doctors and healthcare? The medical profession in India appears to be split on the question of euthanasia. Some suggest that helping others to die by administering lethal medication goes against the idea stated in the Hippocratic Oath that doctors should not cause harm. Some doctors feel that a change in the law would turn them into ‘executioners’ and so undermine and corrupt doctor-patient relations. Advocates counter that the role of medicine has changed, and oaths of old are outdated, no longer reflecting the reality of medical practice, where patients can be artificially kept alive against their best interests. In such cases, a doctor can act humanely in helping a patient to die. Nevertheless, some query whether it even makes sense to be having a debate about voluntary euthanasia in a country such as India. There is growing evidence, says medical activist Padma Praskash, that access to healthcare is shrinking. Simple and effective healthcare is not only limited, but where available is extortionately expensive. In such a situation, talk of the autonomy and choice associated with voluntary euthanasia make little sense, especially when ‘passive euthanasia’ is being inadvertently practised across the country because of the lack of resources. Medical practitioners also draw attention to the lack of palliative care – offering relief from suffering - available to dying people in India, arguing that were this available there would be very little need or demand for voluntary euthanasia. There is also a danger that support for voluntary euthanasia could drown out calls for the provision of proper palliative care. Who should decide? “Euthanasia is an expression of the individual right to decide how and when he or she should die, rather than allow the State to decide” says Dr Nagraj G. Huilgol, secretary of the Mumbai-based Society for the Right to Die with Dignity. Over the years campaigners have drawn attention to the fact that decisions regarding their lives and deaths are ultimately in the hands of the state. In a famous Canadian court case, Sue Rodriguez, a woman who was terminally ill and sought to end her life by euthanasia asked “Whose body is this? Who owns my life?” In India proponents such as a Times of India columnist and editor Jug Suraiya argue that by denying terminally ill people the right to help in ending their own lives, the state is effectively saying that it will be the final arbiter of our lives and conscience. But others argue that permitting assisted suicide in fact does the very opposite and actually deepens the state’s involvement in our lives. Rather than freeing the decision to die from the mechanisms of the state, legalised voluntary euthanasia would subject a terminally ill person’s final choices to external arbitration and judgement. In the call for task forces, review boards and medical and legal councils who will decide those who should be allowed to die, and those who should not, argues British journalist Brendan O’Neill, we are in danger of replacing an intensely private and intimate situation and decision, with a bureaucratic and legalistic process overlooked by the state. Topic Guide Essential Readings: Is Euthanasia ethical? Times of India 27 March 2011 http://articles.timesofindia.indiatimes.com/2011-03-27/people/29170841_1_passive-euthanasia-medical- care-rare-cases The fight for dignity in death Sudha Umashanker The Hindu 13 February 2011 http://www.thehindu.com/arts/magazine/article105948.ece Who has the last word? The Hindu 21 March 2011 http://www.thehindu.com/arts/magazine/article1553065.ece?css=print Euthanasia: death with dignity? Medicare 8 February 2011 http://modernmedicare.co.in/2011/02/18/euthanasia-death-with-dignity/ For: To die, to sleep no more Meena Menon The Hindu 13 February 2011 http://www.thehindu.com/arts/magazine/article1553065.ece?css=print To die on one’s own terms can be a boon, but.... Prashant Aiyar The Hindu 13 March 2011 http://www.thehindu.com/opinion/open-page/article1532410.ece?css=print The right to a dignified death Editorial Livemint.com 3 March 2011 http://www.livemint.com/2011/03/03213448/The-right-to-dignified-death.html The origins of ending life mercifully V R Narayanaswami Livemint.com 18 October 2010 http://www.livemint.com/2010/10/18220800/The-origins-of-ending-life-mer.html The right to death Sauravpran Goswami The Hindu 20 March 2011 http://www.thehindu.com/opinion/open-page/article1553986.ece?css=print The right to live and let die Editorial Livemint.com 20 December 2009 http://www.livemint.com/2009/12/20220509/The-right-to-live-and-let-die.html The triumph in the case of Aruna Shanbaug Juggle-Badhi blog Times of India 14 March 2011 http://blogs.timesofindia.indiatimes.com/jugglebandhi/entry/the-triumph-in-the-tragedy-of-aruna-shanbaug A right to dignified death R N Bhaskar Livemint.com 8 September 2008 http://www.livemint.com/Articles/PrintArticle.aspx?artid=EE6FDA78-7DBF-11DD-B0A2-000B5DABF613 Against: Questions about the right to die Rajeev Dhavan India Today 14 March 2011 http://indiatoday.intoday.in/site/story/questions-about-the-right-to-die/1/132338.html Whose life is it anyway? Harmala Gupta Times of India 28 March 2011 http://articles.timesofindia.indiatimes.com/2011-03-28/edit-page/29353862_1_palliative-care-euthanasia- aruna-shanbaug Why talk of euthanasia is pointless in India Mahesh Vijapurkar Rediff.com 17 March 2011 http://www.rediff.com/news/column/why-talk-of-euthanasia-is-pointless-in-india/20110317.htm Topic Guide th It is outrageous and impracticable in India Abdul Subhan The Hindu 13 March 2011 http://www.hindu.com/op/2011/03/13/stories/2011031355811400.htm The sea inside Vijay Nagaswami Deccan Herald September 2009 http://www.deccanherald.com/content/24770/sea-inside.html Euthanasia: Where human life is concerned, one can’t be silent Olinda Timms Deccan Heald http://www.deccanherald.com/content/113101/euthanasia-human-life-concerned-one.html Euthanasia: where angels fear to tread Professor B.M Hegde The Hindu 13 March 2011 http://www.thehindu.com/opinion/open-page/article1532414.ece Euthanasia: cost factor is a worry Sanjay Nagral Times of India 13 March 2011 http://articles.timesofindia.indiatimes.com/2011-03-13/all-that-matters/28685344_1_passive-euthanasia- patient-legal-sanction Further Reading: Euthanasia: A Global Issue Gerald A Larue Humanism today Vol 113 http://www.humanismtoday.org/vol13/larue.html Constitutionality of the right to die - a brief analysis Legal Services India 26 March 2011 http://legalservicesindia.com/article/article/constitutionality-of-the-right-to-die-a-brief-analysis-608-1.html th Legalisation of Euthanasia in India – a critical analysis Amandeep Kaur Law Herald 29 July 2009 http://lawherald.in/articlefull.php?id=13 The fight for dignity in death Sudha Umashankar The Hindu 2 February 2011 http://www.thehindu.com/arts/magazine/article105948.ece?css=print Euthanasia [mercy killing] P.N.Murkey & Konsam Suken Singh Journal of Indian Academic Forensic Medicine Indian Acad Forensic, 30 (2) http://medind.nic.in/jal/t08/i2/jalt08i2p92.pdf http://www.issuesinmedicalethics.org/051ed001.html Death with dignity T.V. Jayan The Telegraph http://www.telegraphindia.com/1100822/jsp/7days/story_12839171.jsp# th For dignity in death Padma Prakash The Hindu 20 March 2011 http://www.hindu.com/mag/2011/03/20/stories/2011032050140100.htm The humanist case against euthanasia Brendan O’Neill Spiked 17 May 2010 http://www.spiked-online.com/index.php/site/article/8887/ Legalisation of Euthanasia in India – A Critical Analysis Law Herald 29 July 2009 http://lawherald.in/articlefull.php?id=13 Is India The World’s Worst Place to Die? World Policy Blog 6 August 2010 http://www.worldpolicy.org/blog/india-world%E2%80%99s-worst-place-die Whose Life is it Anyway? The Evolving Face if Euthanasia Shalaka R Joshi Journal of Associations of Physicians India http://www.japi.org/april2005/E-279.pdf Topic Guide Key Terms: Passive euthanasia http://www.bbc.co.uk/ethics/euthanasia/overview/activepassive_1.shtml Voluntary active euthanasia http://dying.about.com/od/glossary/g/euthanasia.htm Physician assisted suicide http://dying.about.com/od/glossary/g/PAS.htm In the news: ‘Willing’ for death over a life on support Mumbai Mirror 11 August 2011 http://www.mumbaimirror.com/article/15/2011080720110807052922351e456d64/%E2%80%98Willing%E2% 80%99-for-death-over-a-life-on-support.html Passive euthanasia: 'Practice has existed in India for years' Times of India 8 March 2011 http://articles.timesofindia.indiatimes.com/2011-03-08/india/28667713_1_passive-euthanasia-patient- doctors Aruna Shanbaug will live: Supreme Court Sify - ar http://www.sify.com/news/aruna-shanbaug-will-live-supreme-court-news-national-ldhsapegdgg.html Should the Supreme Court allow Aruna Shanbaug to die? DNA 17 December 2009 http://www.dnaindia.com/speakup/message-board_should-the-supreme-court-allow-aruna-shanbhag-to- die_1324731 Comma, period? Outlook 28 February 2011 http://www.outlookindia.com/printarticle.aspx?270537 Euthanasia is murder: rights activist The Hindu 14 January 2009 http://www.thehindu.com/todays-paper/tp-national/tp-kerala/article374650.ece Law on Euthanasia proposed in Kerala World News.com 9 March 2011 http://article.wn.com/view/2011/03/09/Law_on_euthanasia_proposed_in_Kerala/ 'Society must support palliative care' The Hindu 3 August 2011 http://www.thehindu.com/news/cities/Mangalore/article2321385.ece