The word euthanasia, originated in Greece means a good death1. Euthanasia encompasses various dimensions, from active (introducing something to cause death) to passive (withholding treatment or supportive measures); voluntary (consent) to involuntary (consent from guardian) and physician assisted (where physician's prescribe the medicine and patient or the third party administers the medication to cause death)2,3. Request for premature ending of life has contributed to the debate about the role of such practices in contemporary health care. This debate cuts across complex and dynamic aspects such as, legal, ethical, human rights, health, religious, economic, spiritual, social and cultural aspects of the civilised society. Here we argue this complex issue from both the supporters and opponents’ perspectives, and also attempts to present the plight of the sufferers and their caregivers. The objective is to discuss the subject of euthanasia from the medical and human rights perspective given the background of the recent Supreme Court judgement3 in this context.
In India abetment of suicide and attempt to suicide are both criminal offences. In 1994, constitutional validity of Indian Penal Code Section (IPC Sec) 309 was challenged in the Supreme Court4. The Supreme Court declared that IPC Sec 309 is unconstitutional, under Article 21 (Right to Life) of the constitution in a landmark judgement4. In 1996, an interesting case of abetment of commission of suicide (IPC Sec 306) came to Supreme Court5. The accused were convicted in the trial court and later the conviction was upheld by the High Court. They appealed to the Supreme Court and contended that ‘right to die’ be included in Article 21 of the Constitution and any person abetting the commission of suicide by anyone is merely assisting in the enforcement of the fundamental right under Article 21; hence their punishment is violation of Article 21. This made the Supreme Court to rethink and to reconsider the decision of right to die. Immediately the matter was referred to a Constitution Bench of the Indian Supreme Court. The Court held that the right to life under Article 21 of the Constitution does not include the right to die5.
Regarding suicide, the Supreme Court reconsidered its decision on suicide. Abetment of suicide (IPC Sec 306) and attempt to suicide (IPC Sec 309) are two distinct offences, hence Section 306 can survive independent of Section 309. It has also clearly stated that a person attempts suicide in a depression, and hence he needs help, rather than punishment. Therefore, the Supreme Court has recommended to Parliament to consider the feasibility of deleting Section 309 from the Indian Penal Code3.
Arguments against euthanasia
Eliminating the invalid: Euthanasia opposers argue that if we embrace ‘the right to death with dignity’, people with incurable and debilitating illnesses will be disposed from our civilised society. The practice of palliative care counters this view, as palliative care would provide relief from distressing symptoms and pain, and support to the patient as well as the care giver. Palliative care is an active, compassionate and creative care for the dying6.
Constitution of India: ‘Right to life’ is a natural right embodied in Article 21 but suicide is an unnatural termination or extinction of life and, therefore, incompatible and inconsistent with the concept of ‘right to life’. It is the duty of the State to protect life and the physician's duty to provide care and not to harm patients. If euthanasia is legalised, then there is a grave apprehension that the State may refuse to invest in health (working towards Right to life). Legalised euthanasia has led to a severe decline in the quality of care for terminally-ill patients in Holland7. Hence, in a welfare state there should not be any role of euthanasia in any form.
Symptom of mental illness: Attempts to suicide or completed suicide are commonly seen in patients suffering from depression8, schizophrenia9 and substance users10. It is also documented in patients suffering from obsessive compulsive disorder11. Hence, it is essential to assess the mental status of the individual seeking for euthanasia. In classical teaching, attempt to suicide is a psychiatric emergency and it is considered as a desperate call for help or assistance. Several guidelines have been formulated for management of suicidal patients in psychiatry12. Hence, attempted suicide is considered as a sign of mental illness13.
Malafide intention: In the era of declining morality and justice, there is a possibility of misusing euthanasia by family members or relatives for inheriting the property of the patient. The Supreme Court has also raised this issue in the recent judgement3. ‘Mercy killing’ should not lead to ‘killing mercy’ in the hands of the noble medical professionals. Hence, to keep control over the medical professionals, the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 discusses euthanasia briefly in Chapter 6, Section 6.7 and it is in accordance with the provisions of the Transplantation of Human Organ Act, 199414. There is an urgent need to protect patients and also medical practitioners caring the terminally ill patients from unnecessary lawsuit. Law commission had submitted a report (no-196) to the government on this issue15.
Emphasis on care: Earlier majority of them died before they reached the hospital but now it is converse. Now sciences had advanced to the extent, life can be prolonged but not to that extent of bringing back the dead one. This phenomenon has raised a complex situation. Earlier diseases outcome was discussed in terms of ‘CURE’ but in the contemporary world of diseases such as cancer, Aids, diabetes, hypertension and mental illness are debated in terms best ‘CARE’, since cure is distant. The principle is to add life to years rather than years to life with a good quality palliative care. The intention is to provide care when cure is not possible by low cost methods. The expectation of society is, ‘cure’ from the health professionals, but the role of medical professionals is to provide ‘care’. Hence, euthanasia for no cure illness does not have a logical argument. Whenever, there is no cure, the society and medical professionals become frustrated and the fellow citizen take extreme measures such as suicide, euthanasia or substance use. In such situations, palliative and rehabilitative care comes to the rescue of the patient and the family. At times, doctors do suggest to the family members to have the patient discharged from the hospital wait for death to come, if the family or patient so desires. Various reasons are quoted for such decisions, such as poverty, non-availability of bed, futile intervention, resources can be utilised for other patients where cure is possible and unfortunately majority of our patient's family do accordingly. Many of the terminally ill patients prefer to die at home, with or without any proper terminal health care. The societal perception needs to be altered and also the medical professionals need to focus on care rather in addition to just cure. The motive for many euthanasia requests is unawareness of alternatives. Patients hear from their doctors that ‘nothing can be done anymore’. However, when patients hear that a lot can be done through palliative care, that the symptoms can be controlled, now and in the future, many do not want euthanasia anymore16.
Commercialisation of health care: Passive euthanasia occurs in majority of the hospitals across the county, where poor patients and their family members refuse or withdraw treatment because of the huge cost involved in keeping them alive. If euthanasia is legalised, then commercial health sector will serve death sentence to many disabled and elderly citizens of India for meagre amount of money. This has been highlighted in the Supreme Court Judgement3,17.
Research has revealed that many terminally ill patients requesting euthanasia, have major depression, and that the desire for death in terminal patients is correlated with the depression18. In Indian setting also, strong desire for death was reported by 3 of the 191 advanced cancer patients, and these had severe depression19. They need palliative and rehabilitative care. They want to be looked after by enthusiastic, compassionate and humanistic team of health professionals and the complete expenses need to be borne by the State so that ‘Right to life’ becomes a reality and succeeds before ‘Right to death with dignity’. Palliative care actually provides death with dignity and a death considered good by the patient and the care givers.
Counterargument of euthanasia supporters
Caregivers burden: ‘Right-to-die’ supporters argue that people who have an incurable, degenerative, disabling or debilitating condition should be allowed to die in dignity. This argument is further defended for those, who have chronic debilitating illness even though it is not terminal such as severe mental illness. Majority of such petitions are filed by the sufferers or family members or their caretakers. The caregiver's burden is huge and cuts across various domains such as financial, emotional, time, physical, mental and social. Hence, it is uncommon to hear requests from the family members of the person with psychiatric illness to give some poison either to patient or else to them. Coupled with the States inefficiency, apathy and no investment on health is mockery of the ‘Right to life’.
Refusing care: Right to refuse medical treatment is well recognised in law, including medical treatment that sustains or prolongs life. For example, a patient suffering from blood cancer can refuse treatment or deny feeds through nasogastric tube. Recognition of right to refuse treatment gives a way for passive euthanasia. Many do argue that allowing medical termination of pregnancy before 16 wk is also a form of active involuntary euthanasia. This issue of mercy killing of deformed babies has already been in discussion in Holland20.
Right to die: Many patients in a persistent vegetative state or else in chronic illness, do not want to be a burden on their family members. Euthanasia can be considered as a way to upheld the ‘Right to life’ by honouring ‘Right to die’ with dignity.
Encouraging the organ transplantation: Euthanasia in terminally ill patients provides an opportunity to advocate for organ donation. This in turn will help many patients with organ failure waiting for transplantation. Not only euthanasia gives ‘Right to die’ for the terminally ill, but also ‘Right to life’ for the organ needy patients.
Constitution of India reads ‘right to life’ is in positive direction of protecting life. Hence, there is an urgent need to fulfil this obligation of ‘Right to life’ by providing ‘food, safe drinking water and health care’. On the contrary, the state does not own the responsibility of promoting, protecting and fulfilling the socio-economic rights such as right to food, right to water, right to education and right to health care, which are basic essential ingredients of right to life. Till date, most of the States has not done anything to support the terminally ill people by providing for hospice care.
If the State takes the responsibility of providing reasonable degree of health care, then majority of the euthanasia supporters will definitely reconsider their argument. We do endorse the Supreme Court Judgement that our contemporary society and public health system is not matured enough to handle this sensitive issue, hence it needs to be withheld. However, this issue needs to be re-examined again after few years depending upon the evolution of the society with regard to providing health care to the disabled and public health sector with regard to providing health care to poor people.
The Supreme Court judgement to withhold decision on this sensitive issue is a first step towards a new era of health care in terminally ill patients. The Judgment laid down is to preserve harmony within a society, when faced with a complex medical, social and legal dilemma. There is a need to enact a legislation to protect terminally ill patients and also medical practitioners caring for them as per the recommendation of Law Commission Report-19615. There is also an urgent need to invest in our health care system, so that poor people suffering from ill health can access free health care. Investment in health care is not a charity; ‘Right to Health’ is bestowed under ‘Right to Life’ of our constitution.
1. Lewy G. Assisted suicide in US and Europe. New York: Oxford University Press, Inc; 2011.
2. Dowbiggin I. A merciful end: The euthanasia movement in modern America. New York: Oxford University Press, Inc; 2003.
3. Aruna Ramchandra Shanbaug vs. Union of India & Ors. Writ Petition (Criminal) no. 115 of 2009, Decided on 7 March, 2011. [accessed on August 16, 2011]. Available from: http://www.supremecourtofindia.nic.in/outtoday/wr1152009.pdf .
4. P. Rathinam vs. Union of India, 1994(3) SCC 394
5. Gian Kaur vs. State of Punjab, 1996(2) SCC 648
6. Saunders C. Terminal care in medical oncology. In: Begshawe KD, editor. Medical oncology. Oxford: Blackwell; 1975. pp. 563–76.
7. Caldwell S. Now the Dutch turn against legalised mercy killing. [accessed on August 15, 2011]. Available from: http://www.hospicevolunteerassociation.org/HVANewsletter/0120_Vol6No1_2009Dec9_Now The DutchTurn Against Legalised MercyKilling.pdf .
8. Brådvik L, Mattisson C, Bogren M, Nettelbladt P. Long term suicide risk of depression in the Lundby cohort 1947-1997-severity and gender. Acta Psychiatr Scand. 2008;117:185–91.[PubMed]
9. Campbell C, Fahy T. Suicide and schizophrenia. Psychiatry. 2005;4:65–7.
10. Griffin BA, Harris KM, McCaffrey DF, Morral AR. A prospective investigation of suicide ideation, attempts, and use of mental health service among adolescents in substance abuse treatment. Psychol Addict Behav. 2008;22:524–32.[PMC free article][PubMed]
11. Alonso P. Suicide in patients treated for obsessive-compulsive disorder: A prospective follow-up study. J Affect Disorders. 2010;124:300–8.[PubMed]
12. Bongar BME. Suicide: Guidelines for assessment, management, and treatment. USA: Oxford University Press; 1992.
13. Lonnqvist J. The Oxford textbook of suicidology and suicide prevention. Oxford: Oxford University Press; 2009. Major psychiatric disorders in suicide and suicide attempters; pp. 275–86.
14. The Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations. 2002. [accessed on August 19, 2011]. Available from: http://www.mciindia.org/RulesandRegulations/CodeofMedicalEthicsRegulations2002.aspx . [PubMed]
15. Law Commission report no.196 on medical treatment to terminally ill patients. [accessed on August 19, 2011]. Available from: http://lawcommissionofindia.nie.in/reports/rep196.pdf .
16. Zylicz Z, Finlay IG. Euthanasia and palliative care: reflections from The Netherlands and the UK. J R Soc Med. 1999;92:370–3.[PMC free article][PubMed]
17. Gursahani R. Life and death after Aruna Shanbaug. Indian J Med Ethics. 2011;8:68–9.[PubMed]
18. Chochinov HM, Wilson KG, Enns M. Desire for death in the terminally ill. Am J Psychiatry. 1995;152:1185–91.[PubMed]
19. Gandhi A, Chaturvedi SK, Chandra P. Desire for death in cancer patients - an Indian Study. Presented at the International Congress of the International Psycho OncologySociety, Copenhagen 2004
20. Sheldon T. Dutch legal protection scheme for doctors involved in mercy killing of babies receives first report. BMJ. 2009:339.
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A Patients Right To Die - With A Free Essay Review
Imagine that you are lying in the hospital bed and the past months have brought nothing but agony and pain to you. Tears and sadness can be seen on the faces of your family and friends wishing there was something they could do for you. Then, your doctor informs you that what you have is incurable and will only get worse. Would you be able to live on with the pain and try to make the most of your lifes situation? For years, doctors have been prohibited from helping patients to take their own lives. I believe that a terminally ill patient should have the right to decide if they have had enough. By legalizing euthanasia, also referred to as physician assisted suicide, tremendous misery and anguish of patients can be saved. The right to die should be a fundamental freedom to each person (Gorsuch, 2008).
Patients should have to right to die with their dignity intact rather than have their illness leave them as merely a shell of their former selves. Some say assisted suicides will open a whirlwind response to non-critical patient suicides and other abuses. It is the pain and anguished experienced by the patients and their families that ultimately can be protected. When do we agree with the person going through this anguish first hand and allow them to determine their own destiny? Assisted suicide is done in order to put a stop to a patients agony and suffering. Working with the state government would help nurses and hospitals gain a clearer definition of what assisted suicide covers in order to prevent the abuse of this practice.
Physician assisted suicides, also referred to as euthanasia, have been in existence for hundreds of years. One name more known with this subject is Jack Kevorkian, but he was not the first practitioner of assisted suicides. If we look at Romeo and Juliet, we see how a reluctant sells a vial poison to Romeo, who uses the vial to kill himself after learning of Juliets death. These types of deaths have been seen as honorable in past events. New and often expensive medical technologies have been developed that prolong life. However, the technologies also prolong the dying processes, leading some people to question whether modern medicine is forcing patients to live in unnecessary pain when there is no chance they will be cured. Passive euthanasia when a feeding tube is removed or a respirator is disconnected has become accepted as one solution. However, someone who overdoses on pills remains controversial. Assisted suicide is known as a type of active euthanasia where a doctor provides a lethal prescription dose to a patient who is responsible for performing the final act. Even though changes in modern medicine are continuous, attitudes toward assisted suicide among the legal system are not as unceasing.
Another argument we see in opposition of assisted suicides is that it violates medical ethics. The American Nurses Association (ANA) position statement reads, "A nurse must not act deliberately to end a person's life" (Kjervik, 1996). The Hippocratic oath also states; "I will give no deadly medicine to anyone if asked, nor suggest any such counsel" (Pretzer, 2000). These are two of the most respected and acknowledged documents in the medical field. What both of these statements are doing is prohibiting any partaking of a patient's life or helping a patient in his or her death. Health care professionals work hard on developing a caring and trusting relationship with their patients, giving support while providing the medical care necessary for the patients well-being. We are working so hard on the relationship than we must also ask ourselves, when is it right to make the patient most comfortable with in incurable and painful disease?
Those against assisted suicide question and bring religious views into play arguing that life must be sanctioned by all means as life is most sacred. Another position seen from the opposition is that when a patient is undergoing medical treatment, they must be made to stay alive for as long as possible no matter what they may want because only God can decide when one may die. We can look at the Terri Schiavo as one example in relation (Quill, 2005). Terri was far beyond life based on an examined life and a medical basis; most philosophers would say she could be considered no longer a person. At what point do we take the best interest of the patient into hand and heart? We see how patients can have a say whether to live off of a machine or to have it unplug and this is justified legally. Because these people cannot speak up for themselves, but those that can and are suffering are unjust in their reasonings.
In summary, everyone is going to have an opinion in this matter just as each case is unique in nature. We can see how one case of someone who is suffering from stage four pancreatic cancer can be sympathized with verses reaching out and trying alternative ways to help a patient with extreme depression wanting to end their life because of what their depression is telling them to do. We have seen changes in the form of more and more hospice and homes in communities and this high need of hospice nurses nationwide. This is a struggle that will be within the medical field for years to come as there is no legal end in sight. The power to protect our civil liberty which is the right to die should lie within us.
I'll begin with your second paragraph, since I've little to say about your first paragraph (but note that some readers prefer a more elaborate thesis statement than the one you offer; i.e., some teachers may want your thesis statement not only to state your view but also to summarize your reasons for holding that view). The second paragraph deals with the topic of patient dignity and with the slippery-slope argument against legalizing euthanasia. Generally, try to keep to one topic per paragraph. I think it would be a good idea, in any case, to devote a paragraph to the question of "patient dignity." It's a fairly vague concept on its own, but it shouldn't be too difficult to make it more concrete. You try to do that by referring to the fact that patients become "merely a shell of their former selves," but really that's just a cliche. Don't be afraid to talk about the actual conditions under which terminally ill patients sometimes must live. For instance, some patients need help eating, washing, and going to the toilet. Some patients wear diapers and need others to change their diapers. Others throw up on themselves, or wet their beds. And so on. That kind of stuff is perhaps unpleasant to write about, but writing about it will allow you to clarify what you mean about dignity.
The third paragraph also deals with more than one topic: the history of euthanasia; the impact of life-prolonging technology; passive euthanasia; assisted suicide properly speaking. One of the problems with having a bunch of different topics in one paragraph is that it is difficult to keep track of your argument; you move very quickly from one assertion to another without pausing to clarify how each assertion contributes to the demonstration of the truth of your thesis. What do we learn from the history of euthanasia, for instance, that might help us rethink our resistance to euthanasia today? (I especially don't understand, by the way, the relevance of the reference to Romeo and Juliet, since its subject is a matter of fiction, not history, although you could argue that it reflects the values of its time). With your reference to modern medical technology, you seem to want to argue that we, in modern times, have all the more reason to be receptive to the idea of euthanasia, but you don't actually, explicitly, make that argument, but instead rush headlong towards your next topic.
So slow down. Divide the topics you actually want to discuss, and want to draw conclusions from, into separate paragraphs. Note that you could devote one paragraph to the difference between historical attitudes and modern attitudes to euthanasia, thus making one topic, that difference and its implications, out of what was originally two topics (the history of euthanasia; modern medical technology). What you want to aim for, in other words, is a paragraph that is argumentatively coherent. To achieve that aim, you will need to know in advance what you want the paragraph to argue. So ask yourself that question every time you go to write a paragraph: what exactly do I want to argue here?
Your next paragraph does deal with one topic: medical ethics. So as a paragraph it is better, more coherent, than the previous paragraph. Note, however, that the paragraph does not culminate in an argument related to your thesis, but rather in a question. It is almost always better to make your claims explicit, instead of relying on your reader to come to the conclusion of you would want the reader to reach. Readers are unreliable!
I don't quite understand what you are trying to say in the last two sentences of your paragraph on the religious opposition to euthanasia. They are worded very awkwardly (the last sentence is not, grammatically speaking, a sentence at all). Revise those sentences with a view to making a compelling case why the religious view is less ethical than the view that favors giving patients the right to physician assisted suicide.
The first sentence of your conclusion is a bit banal, but the second sentence makes a good point, although again not explicitly enough. It may be crucial to the success of your argument that we believe it is possible to tell the difference between cases where euthanasia is justified and cases where it is not. It's not a bad idea to emphasize in your conclusion the point that you make in that respect.
Submitted by: Jinkers02