What does the judgment say?
In a judgment on March 9, the Supreme Court said people suffering from a terminal illness had a right to a dignified death, as part of the right to life enshrined in Article 21 of the Constitution. The judgment restricts itself to the withdrawal or withholding of life-support, which it refers to as “passive euthanasia.”
But this phrase is obsolete in medical circles. A 2018 document from the Indian Council of Medical Research says ‘passive euthanasia’ is an inappropriate term because it suggests that the doctor is actively shortening the patient’s life with lethal drugs.
Why will it be hard to follow?
Experts say the procedure laid down by the court for withdrawing life support is unduly complicated. “The procedure is frankly half-baked and confused,” says Roopkumar Gursahani, a neurologist at Mumbai’s PD Hinduja Hospital and a member of the team that framed the 2006 draft Bill on medical treatment of terminally ill patients.
The court’s guidelines talk of an advance directive, a document in which a patient can specify conditions under which life-prolonging interventions should not be given. Such interventions could mean feeding tubes, ventilators, cardiopulmonary resuscitation (CPR) or even antibiotics. The family of a terminally ill person can also refuse such treatment if an advance directive is not available.
But the judgment makes the execution of advance directives too complicated for patients, says Dr. Gursahani. For example, the judgment requires the directive to be countersigned by a Judicial Magistrate of First Class, and copies to be given to the jurisdictional district court, the district judge and the local government. Dr. Gursahani worries that these authorities may drag their feet, leading to needless delays. “You are asking them to take on an additional responsibility, which they are not going to be willing to do,” he told The Hindu. Also, if a patient wants to execute the advance directive, two medical boards — one in the treating hospital and the other headed by the district medical officer — have to give the go-ahead.
While safeguards are necessary to protect patients against vested interests, like illegal organ traders, a balance must be struck between the safety and usability of the law, says Dr. Gursahani. Instead of two medical boards, he suggests, it is enough if one team of medical consultants confirms the treating physician’s decision to withdraw life support. The decision must be well-documented, however, so that an ethics committee can study it later to confirm that due process was followed. “In principle, we accept the judgment,” he adds. “But the procedure they have suggested has to be fine-tuned by experts.”
To avoid hiccups, Indian doctors will also need training to communicate end-of-life options better. Studies from the U.S. show that even patients who have made a Do Not Resuscitate (DNR) request are sometimes given CPR because the emergency physician is not aware of the DNR. “This happens in a lot of cases and is painful for the patient,” says Ashish Goel, an associate professor at the University College of Medical Sciences, New Delhi. Communication training is vital to avoid such misunderstandings.
Who may opt for it?
Few estimates exist today for the number of Indians who seek withdrawal of life-support. A 2009 study in a Delhi hospital found that over half of the ICU patients who died during a period of 19 months sought withdrawal or withholding of life support.
Dr. Gursahani says that in large tertiary hospitals like Hinduja, doctors receive 2-3 requests each week. For such patients, the judgment brings welcome legal clarity on a course of action.
But the worry is that unless patients are counselled by palliative-care experts about how their illness will progress, they may not prepare advance directives to reject futile medical interventions. Anwar Husain, director of Kerala’s Institute of Palliative Medicine, says over 80% of palliative-care recipients die in homes or hospices, while those who do not receive palliative care end up in ICUs. As on today, India has poor palliative care systems. A 2015 Quality of Death Index by the Economist Intelligence Unit, which looked at palliative-care systems across 80 countries, rated India among the 15 worst.
(Adapted from The Hindu)