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A step forward, not a giant leap
For doctors, care of the living includes care of the dying as well, especially in intensive care units. Modern technology-driven intensive care is a marvel for many, but not all. For the terminally ill in whom for one reason or other it is reasonably clear that further aggressive treatment is futile, such care is no longer an imperative. Although the compassionate decision to withhold or withdraw care should be a very considered one, it does need to be taken when the situation demands it. Consider the case of a 45-year-old foreign national with terminal cancer who has been put on ventilator. His wife requests that the ventilator be removed so that her husband may have a peaceful end after an agonizingly prolonged battle with his disease. She has exhausted all her resources in sustaining him and cannot understand why her wishes should not be respected. The Indian physician is reluctant to take an ethical decision, as he is not sure whether his position would be understood by the law as it exists today. Law should facilitate, not obstruct humane care.
The Aruna Shanbaug case highlights a different and far less common scenario than the one recounted: a chronically vegetative patient who has no immediate threat to her life that would require highly invasive and mechanical supports to sustain life. For doctors the issue of the morality or legality of euthanasia is miniscule as compared to moral dilemmas of applying aggressive support to one who would not, in the real sense, benefit from it, or one who has clearly expressed that one does not want it.
The term 'passive euthanasia', as opposed to active killing (euthanasia), is misleading and therefore no longer used in contemporary medical terminology. An act intended only to allow a natural dying process already started can have nothing to do with mercy killing. In his landmark 196th report of the Indian Law Commission, Justice Jagannadha Rao has stated in his opening lines that withdrawal and withholding decisions are distinct from euthanasia and therefore do not violate suicide laws. In the developed world such confusion no longer exists and the term "passive euthanasia" is regarded as an oxymoron.
From an area of darkness with respect to compassionate care of the terminally ill, when awareness of ethical dilemmas was largely nonexistent in our society, we have at last come to sensitise ourselves to such issues. In this context, the Shanbaug case touches but does not delve deep. Partly this is because the point of reference was, most unfortunately euthanasia, and not death in dignity. The Gian Kaur case is misquoted to declare that the Supreme Court believes Article 21 confers the right to live but not to die. One must see that the point of reference here was abetment to suicide - as the validity of suicide laws was being challenged. Gian Kaur was accused of abetting the suicide of her daughter-in-law. The plea of the accused was that abetment is not unlawful if suicide itself was not. The Supreme Court disallowed such an interpretation and the judges in their wisdom pointed out that only taking of one's life in health is unlawful, not the pursuing of a natural end towards dignified death. The right to privacy sanctions choosing a dignified process of death which is indeed the basis of legislations for limiting life support throughout the developed world.
From a legal vacuum, the judgment has led to path breaking legal opinion. The honorable judges have for the first time pronounced that brain death (when brain activity has ceased while the patient's breathing is sustained artificially) is equivalent to death. This would allay physicians' apprehensions about removing life supports from such a patient and would improve organ retrieval opportunities for transplantation. By making the distinction of "passive" euthanasia, albeit with its confusing connotations, the judges may have opened the door a little to exploring the subject of limiting life support.
We must note carefully that the legal procedure of appealing to the high court is applicable only to an extraordinary case such as Aruna's. It would be a travesty if it is extended to include the usual dying patients in an ICU. Here doctors are called upon to make decisions of starting or stopping medically useless treatments or those based on respecting patients' right to self determination. Such decisions have to be made within hours or days, and in most countries are regarded as part of everyday medical practice. Developing a procedure covering such situations needs to be preceded by awareness of the issues and an open debate sans the use of emotive terminology. We have to shed the term "passive euthanasia" to move over to the less loaded "limitation of life support". A workable legal procedure much like that for organ transplantation should then be possible in the foreseeable future.
The writer is director, critical care, pulmonology & sleep medicine at Artemis Health Institute, Gurgaon
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