The Thin Line Between Need & Want: How Relevant Is Living Will In Indian Context?
History was made recently when the Supreme Court upheld that the fundamental right to a "meaningful existence" includes a person's choice to die without suffering. It has permitted 'living will' by patients, authorizing the withdrawal of medical support if they slip into medically irretrievable conditions like irreversible coma. Passive euthanasia is now legal. Patients are happy with the verdict and we, the medical fraternity, in principle, welcome the move.
The judgement is favorable for patients who will now be able to avoid needless medical interventions. The decision will also save a lot of money and agony for patients and their families, and prevent unnecessary treatments for terminally ill patients. The fact that there are strict and elaborate guidelines to govern the implementation of passive euthanasia is reassuring. As doctors, we may be able to avoid becoming a part of inheritance struggles and family feuds, because the decision to end the sufferer's life will be pre-decided. Sometimes, we are forced to keep the patient alive, apprehending court cases. This problem too will be removed.
Passive and active euthanasia
At this point, one must consider and understand the difference between Passive and Active euthanasia. Active euthanasia is one where medical professionals, or any relevant authority, deliberately do something pro-actively, upon declared patients' desire, (such as giving an injection or medication) that causes a patient to die. In Passive euthanasia, the patient dies because the mechanism that keeps the patient alive is removed (such as life-support machines; feeding tube; a life-extending operation or drugs).
Now, this is where we, as doctors, face a dilemma. Morally and ethically, both processes are difficult for us. Prolonging and maintaining life comes naturally to us and no doctor likes to have a patient die while under his/her care. Instinctively, we are pro-natural death. The idea of deciding to take out a life goes against the grain. Even in the presence of a living will, and when one is honour-bound to respect the patient's wishes, there are many questions and doubts. For instance, the patient may have been coerced to write the will. Sometimes a living will write at a certain juncture of a person's life may not be applicable after a period of time when circumstances may have changed. Without a foolproof system, we cannot give up on a patient, however desperate the circumstances. Also, to decide that there is no hope in treatment continuity and that there is a zero possibility of recovery precludes the astonishing ability of the human body to recuperate. As long as there is life, there is hope. Even with the legalisation of euthanasia, the "choice" to die may sometimes not be the final prerogative of the patient. The patient could be too ill to decide. Here, their decision makers possibly will be the medical team and the patients' relatives: not the patient.
Palliative care in India
Another question that comes to the fore is whether withdrawing treatment for a suffering patient, even for compassionate reasons, is a form of medical care. India needs improved access to high-quality health care for the terminally ill, so that they go in peace, whenever they do. This is referred to as palliative care - right from the time an illness is diagnosed until the end of life. Control over the manner and timing of a person's death has not been and should not be a goal of medicine.
Indian healthcare was introduced to palliative care only during the mid-1980s. Since then, committed individuals, including Indian health professionals and volunteers, in collaboration with international organizations and individuals from other countries have worked towards building this system of care in the country. However, the situation is still abysmal - there are 6 million people who need palliative care and the centres are only 1,400 in number, making it 1 centre per 4,300 patients!
WHO defines palliative care as a multi-disciplinary approach that improves the quality of life of patients with life-threatening illnesses, and their families by relieving suffering and pain-physical, psycho-social and spiritual. However, there is still a long way to go. Apart from the existing shortage in terms of funds, infrastructure, and medical professionals, what stalls progress in this area is that we are too busy in fighting diseases and not in offering palliative treatment and pain relief. In this context, how relevant is the move to allow a living will?
Perhaps, wisdom lies in the middle path, as the great healer Gautam Buddha advocated. The Supreme Court said that a living will from a patient to stop medical treatment at a particular stage - "particularly when he is brain dead or clinically dead or not revivable" - quells misgivings from the family and the chances of criminal action against doctors. It makes the individual in-charge of his medical treatment at all times. But is the individual really equipped to see the medical and situational conditions of the future?
In conclusion
Allow me to paint a scenario for you. An old man lies in the ICU, on a ventilator. He has left a living will, authorizing his death in just such a scenario. His family clings to the hope that he may revive. They beg you to wait another few days. What do I, as a good doctor, do under the circumstances? Here the younger son protests. He suspects that the will has been written under duress. I am torn between the two. The mechanisms of verifying and validating the medical condition of the patient for euthanasia will come into force in this situation and the medical boards of the hospital, independent medical team inspection, judicial approvals, etc. as laid out in the judgement will need to be executed.
While the decision to passively euthanise oneself can be left to the patient, the conditions on which this right may be invoked can be left to a medical board. A living will make sense when coupled with a medical power of attorney and independent third party monitoring. This will allow for a middle way between all the interests that are at play here: The right of the patient, the State's interest in human life, and the interest of the patient's family. The Court has taken a bold decision - only time will tell what course it will take. How easy it is for a family to put into action a patient's desire to die depends on how quickly the process of medical/judicial reviews and verifications take place; if done tardily and with insensitivity (as is the case in such situations, experience tells us), the whole purpose can be self-defeating!
