Life vs death: Debate that refuses to die

At a time when the world is preoccupied with longevity and anti-ageing drugs, India is fine-crafting the Medical Treatment of Terminally Ill Patients (Protection of Patients and Medical Practitioners) Bill 2006. Debates rage on whether the right to life includes the right to die with dignity. Words such as autonomy, dignity, freedom of choice, justice and mercy are frequently thrown into arguments, and have all been considered.

The bill deals with ‘the withdrawing or withholding of life support measures’ and does not include active euthanasia and assisted suicide. Active euthanasia is a crime under Section 302 or it may fall under the purview of Section 304 and physician-assisted suicide is a crime under Section 306 of the IPC.

Euthanasia and assisted suicide are illegal in most countries as they amount to murder or culpable homicide. Withholding life support systems to terminally ill patients, however, is universally accepted as lawful. Under common law, when a competent patient takes an informed decision to refuse treatment, the patient is not guilty of attempting to commit suicide nor is the doctor who omits to administer treatment guilty of assisting it.

The bill reflects the general flow of global thinking and the acceptance of withdrawal of life support systems to terminally ill patients. It aims at providing protection to patients and medical practitioners from liability in the context of withholding or withdrawing medical treatment from patients who are terminally ill. The House of Lords in the Airedale case makes a clear distinction between withdrawal of life support measures as opposed to active euthanasia and physician-assisted suicide.

The right to die is inherently inconsistent with the right to life. It must be clearly understood that the right to die with dignity in this context is the act of omission that results in easing and shortening the agony of a dying patient as opposed to a meaningless prolonging of life that is rife with pain and suffering. It is not the acceleration of death where the process of natural death has already begun but the mere absence of prolonging life. It is the notion of letting a person die as opposed to killing a person; it is the distinction between foreseeing an outcome and intending it.

In simpler times, when there existed neither ventilator nor artificial feeding, the terminally ill patient eventually died of natural causes. As a consequence of sophisticated advances in medicine and technology, patients now live longer. But sometimes, a mere artificial prolonging of life and treatment is just burdensome as there is no chance of recovery. From the principle of ordinary/ extraordinary and proportionate /disproportionate means of treatment flows the right to refuse treatment that is burdensome emotionally and economically, and is no longer medically beneficial.

As a result of rapidly developing medical science and technology, the medical definition of death has evolved into a narrowed version. Death is said to occur when brain stem function ceases, culminating in absent nervous signals to the heart and lungs which, as a consequence, stops circulation and breathing.

Profound questions

A person is not clinically dead if his brain stem which controls the body’s reflective functions is facilitating the heart beat, breathing and digestion even if the patient is unconscious with no sensory capacity. In these circumstances, two profound questions arise: Is the treatment burdensome or beneficial? And, will continued treatment sustain life or prolong life?

It is for terminally ill patients with a compromised quality of life that the world argues for the right to self-determination and individual autonomy. The right of a patient to accept or refuse treatment is the principle of self-determination which is a globally accepted principle of common law. As per English law, where a doctor administers invasive treatment to the patient without the patient’s consent, the doctor can be charged for the crime of battery and the tort of trespass to the person.

As per the bill, every competent person has a right to withhold/withdraw or start/continue medical treatment. When a patient communicates his decision to the medical practitioner, it becomes binding on the medical practitioner provided that the medical practitioner is satisfied that the informed decision was based on free will.

When the doctor takes the decision in the best interest to withhold/withdraw medical treatment in relation to a competent patient who has not taken an informed decision and in relation to an incompetent patient,s/he has to consult and get an opinion in writing from 3 doctors from the State Panel of Medical Experts. The majority opinion should be favourable. Best interest is not limited to medical interest of the patient alone, but includes, moral, ethi-cal, social, economical, emotional and other considerations.

The bill strives to bring some clarity to withholding/withdrawing life support measures. This is an area of grave apprehension to medical professionals who fear such withdrawal could be interpreted as abetting suicide.  With the non-inclusion of active euthanasia and physician assisted suicide, the bill has avoided a tangle of contradictions.

(Mathias is a legal Consultant and Jain is Associate Professor, School of Law, Christ University, Bengaluru)