Life and death as concepts have invited
many a thinker, philosopher, writer and physician to define or describe
them. Swami Vivekananda expects one to understand that life is the lamp
that is constantly burning out and further suggests that if one wants to
have life, one has to die every moment for it. One may like to compare
life with constant restless moment spent in fear of extinction of a
valued vapour; and another may sincerely believe that it is beyond any
conceivable metaphor. Death is complicated and life is a phenomenon
which possibly intends to keep away from negatives that try to attack
the virtue and vigour of life from any arena. In spite of all the
statements, references and utterances, be it mystical, philosophical or
psychological, the fact remains, at least on the basis of conceptual
majority, that people love to live – whether at eighty or eighteen – and
do not, in actuality, intend to treat life like an ―autumn leaf.
The
perception is not always the same at every stage. There comes a phase
in life when the spring of life is frozen, the rain of circulation
becomes dry, the movement of body becomes motionless, the rainbow of
life becomes colourless and the word life, which one calls a dance in
space and time becomes still and blurred and the inevitable death comes
near to hold it as an octopus gripping firmly with its tentacles so that
the person shall rise up never.
The ancient Greet philosopher, Epicurus, has said, although in a different context:-
Why should I fear death?
If I am, then death is not.
If death is, then I am not.
Why should I fear that which can only exist when I do not?
But there is a fallacy in the said proposition. It is because mere existence does not amount to presence. And sometimes there is a feebleness of feeling of presence in semi-reality state when the idea of conceptual identity is lost, quality of life is sunk and the sanctity of life is destroyed and such destruction is denial of real living.
The society at large feels that a patient should be treated till he breathes his last breath.
Every
doctor is supposed to take a specific oath that he will make every
attempt to save the life of the patient whom he/she is treating and who
is under his/her treatment. This oath, thus, puts a moral and
professional duty upon a doctor to do everything possible, till the last
attempt, to save the life of a patient.
The
Medical Council of India (MCI) Code of Ethics Regulations
rejects Euthanasia (deliberately ending a patient’s life at his or her
own request or at the request of close relatives). “6.7 Euthanasia: Practicing euthanasia shall constitute unethical conduct.
However, on specific occasion, the question of withdrawing supporting
devices to sustain cardio-pulmonary function even after brain death,
shall be decided only by a team of doctors and not merely by the
treating physician alone. A team of doctors shall declare withdrawal of
support system. Such team shall consist of the doctor in charge of the
patient, Chief Medical Officer / Medical Officer in charge of the
hospital and a doctor nominated by the in-charge of the hospital from
the hospital staff or in accordance with the provisions of the
Transplantation of Human Organ Act, 1994.”
While MCI Code of Ethics rejects euthanasia, it does not talk about physician-assisted-suicide (where
a physician deliberately enables a patient to end his or her life by
prescribing or providing medical substances with the sole intent of
causing death. But practically it is included in the same as both acts
are contrary to the ethics of medicine and the role of the physician.
Medical
scientists have been, relentlessly and continuously, experimenting and
researching to find out better tools for not only curing the disease
with which human beings suffer from time to time, noble attempt is to
ensure that human life is prolonged and in the process of enhancing the
expectancy of life, ailments and sufferings therefrom are reduced to the
minimal. There is, thus, a fervent attempt to impress the quality of
life.
It is this very advancement in
the medical science which creates dilemma at that juncture when, in
common perception, life of a person has virtually become unlivable but
the medical doctors, bound by their Hippocratic Oath and medical ethics
want to still spare efforts in the hope that there may still be a
chance, even if it is very remote, to bring even such a person back to
life.
The Hippocratic Oath taken by a
doctor and the MCI Code of Ethics may make him feel that there has been
a failure on his part and sometimes also make him feel scared of
various laws. There can be allegations against him for negligence or
criminal culpability.
No physician
should be forced to participate in euthanasia or assisted suicide, nor
should any physician be obliged to make referrals to this end. However, the right to decline medical treatment is a basic right of the patient.
The physician does not act unethically in respecting the patient’s wish to
decline medical treatment, even if such a wish may result in the
patient’s death by allowing the natural dying process to unfold in the
course of terminal phases of sickness.
A doctor has a crucial role to play in such situations as there is a very thin line between this ethical and unethical act.
Remember
it is the patient who has a right to deny the treatment and not the
relatives. However, the patient must be in his or her sound state of
mind to take any such decision.
There
is a distinction between the administration of lethal injection or
certain medicines to cause painless death and non-administration of
certain treatment which can prolong the life in cases where the process
of dying that has commenced is not reversible or withdrawal of the
treatment that has been given to the patient because of the absolute
absence of possibility of saving the life. To explicate, the first part
relates to an overt act whereas the second one would come within the
sphere of informed consent and authorized omission. The omission of such
a nature will not invite any criminal liability if such action is
guided by certain safeguards. The concept is based on non-prolongation
of life where there is no cure for the state the patient is in and he,
under no circumstances, would have liked to have such a degrading state.
In the landmark judgment Common Cause versus Union of India, 2018 (5) SCC 1, the Hon’ble 4-Judge Constitution Bench of the Supreme Court held that Euthanasia is basically an intentional premature termination of another person‘s life either by direct intervention (active euthanasia) or by withholding life-prolonging measures and resources (passive euthanasia) either at the express or implied request of that person (voluntary euthanasia) or in the absence of such approval/consent (non-voluntary euthanasia).
Active euthanasia also
includes physician-assisted suicide, where the injection or drugs are
supplied by the physician, but the act of administration is undertaken
by the patient himself. Active euthanasia is not permissible in most
countries.
Passive euthanasia is
when medical practitioners do not provide life-sustaining treatment
(i.e. treatment necessary to keep a patient alive) or remove patients
from life sustaining treatment. This could include disconnecting life
support machines or feeding tubes or not carrying out life-saving
operations or providing life extending drugs. In such cases, the
omission by the medical practitioner is not treated as the cause of
death; instead, the patient is understood to have died because of his
underlying condition.
Further, in Gian Kaur versus State of Punjab, (1996) 2 SCC 648,
the Hon’ble Constitution Bench of Apex Court expounded that the word
"life" in Article 21 has been construed as life with human dignity and
it takes within its ambit the "right to die with dignity" being part of
the "right to live with dignity". As part of the right to die with
dignity in case of a dying man who is terminally ill or in a persistent
vegetative state, only passive euthanasia would come within the ambit of
Article 21 and not the one which would fall within the description of
activeeuthanasia in which positive steps are taken either by the
treating physician or some other person. That is because the right to
die with dignity is an intrinsic facet of Article 21.
In Aruna Ramachandra Shanbaug versus Union of India, 2011 (15) SCC480,
Hon’ble Supreme Court has observed that autonomy means the right to
self-determination where the informed patient has a right to choose the
manner of his treatment. To be autonomous the patient should be
competent to make decisions and choices. In the event that he is
incompetent to make choices, his wishes expressed in advance in the form
of a Living Will, or the wishes of surrogates acting on his behalf
(substituted judgment) are to be respected.
Thus, all
adults with the capacity to consent have the common law right to refuse
medical treatment and the right of self - determination. Doctors would
be bound by the choice of self-determination made by the patient who is
terminally ill and undergoing a prolonged medical treatment or is
surviving on life support, subject to being satisfied that the illness
of the patient is incurable and there is no hope of his being cured.
In “Common Cause versus Union of India, 2018 (5) SCC 1 the Constitution Bench of Hon’ble Supreme Court held that Advance Medical Directive would
serve as a fruitful means to facilitate the fructification of the
sacrosanct right to life with dignity. The said directive will dispel
many a doubt at the relevant time of need during the course of treatment
of the patient. That apart, it will strengthen the mind of the treating
doctors as they will be in a position to ensure, after being satisfied,
that they are acting in a lawful manner. However, Advance Medical
Directive cannot operate in abstraction. The Hon’ble Court in the said
judgment has enumerated various safeguards and procedure of advance
medical derivatives and also in cases where there is no advance medical
derivatives which will remain enforced till Parliament makes a law on
Advance Medical Derivatives.
Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA
