The sea inside

In the United Kingdom, two recent events have brought back to the forefront of the collective consciousness of people not only in that country, but pretty much all over the world, the issue of dying with dignity. In July of this year, Conductor Emeritus of the BBC Philharmonic, Sir Edward Downes and his wife, Joan, ended their lives with dignity at the Dignitas Clinic in Switzerland. Since it is illegal in the United Kingdom to commit or assist in the committing of suicide, they chose to go to a country where it is not, and having gone through the legal procedural formalities required in Switzerland, checked into the Dignitas Clinic which has been established for the purpose of ‘assisted suicide’, and allowed themselves to let go of their lives.

Technically, if a British citizen had accompanied them and facilitated the process, s/he could be open to the possibility of prosecution for abetting suicide. However, late last month, in response to a petition from Debbie Purdy, who suffers from multiple sclerosis, Britain’s highest court issued a historic judgement. Purdy was seeking to protect her husband from prosecution as an abettor of her suicide, if he accompanies her to Switzerland in the event she chooses to die there with dignity.

The law lords ordered the director of public prosecutions to draw up a clear policy on the subject. Although this does not yet mean that Purdy’s husband will not be liable for prosecution, there is now a fresh application of mind to the whole subject of euthanasia and assisted suicides.

Before we go any further, it may be appropriate to step back a bit and take a look at the whole canvas. Euthanasia, a subject of much ethical, legal and medical debate, basically refers to the right of the terminally ill individual to choose to die rather than go through the indignity of inexorably losing the functioning of organ systems one by one, or of suffering immeasurable pain as the body winds down.

‘Passive Euthanasia’ refers to the individual being permitted to decline medical intervention or life support systems (literally, pulling the plug off life support), thereby hastening the onset of death, provided this decision is taken when the individual is of sound mind. Active Euthanasia refers to the administration of a lethal dose of drugs that will cause death, administered by a health care professional. This is also referred to as ‘assisted suicide’.

Both active and passive euthanasia require an interface with the health care system in order to ensure that death happens without any suffering and in a humane manner. Put differently, the same system that seeks to save lives is also required, under special circumstances, to extinguish them. Physicians who have sworn the Hippocratic Oath, which specifically enjoins them never to administer a poisonous substance to a patient, are being asked to set aside this proviso under certain circumstances. Needless to say, medical associations in countries where they exist are very clear that ethical physicians should never engage in such an act.

The right right?
Laws in most countries used to be unambiguous on the issue of euthanasia, since the right to life is enshrined in most constitutions. However, the last few decades have seen a lot of heated debate and changes in legislative approaches in some countries in Western Europe (the Netherlands and Switzerland being notable examples) and some states in the United States of America, that have approached the issue from the perspective of dignity and quality of life.

Obviously, if euthanasia is to be permitted, a lot of safeguards have to be put in place to ensure that only the incurable terminally ill are provided a legal way out. However, here is where the ‘pro-life’ lobby came up with the ‘slippery slope’ argument, the basis of which is that once euthanasia is legalised, it is inevitable that more and more ‘special circumstances’ will keep getting added to the legally permitted list and this puts the whole concept of the state determining who is to live and who is to die on a very slippery slope indeed.

The question then is, Where do you draw the line? The ‘pro-dignity’ lobby is all for safeguards, but wants the individual in sound mind and clear conscience to be able to make a decision to die with dignity and have it endorsed by the state. Their argument is that the state should not decide, it is the individual who should.

But the central question is whether an individual in sound mind and clear conscience can actually take a decision to die. Is it not possible, it may be argued, that the loss of dignity or the intense physical pain that a sufferer experiences create a feeling of depression in the mind that prompts such a decision? And when depression enters the picture, can the individual truly be of completely sound mind? Legitimate questions, but answerable ones.
One needs to make a distinction between the feeling of depression and the existence of ‘clinical depression’. It is the latter that may interfere with decision-making capability.

Obviously when one chooses to die, one is going to feel sad, but what seems to be evident from the literature in thanatology (the study of death and dying) is that such a decision is the end stage of a long process. In 1969, in her seminal book On Death and Dying, Elizabeth Kübler Ross, a Swiss psychiatrist, based on interviews with 400 people who were soon going to die, elucidated the five stages of coming to terms with the idea of death and dying.

Even today this theory remains a major cornerstone when it comes to the experience of dying, and is also considered relevant to any form of grieving or mourning. In very simple terms the theory says that to come to terms with the possibility of dying, people go through five stages: Denial, anger, bargaining, depression and acceptance.

Of course, these are not watertight stages and some people may skip a few or in some cases, they may happen together. Some people may get stuck in any of these stages too, but such people are then unlikely to opt for dying with dignity. It is only those who reach the stage of acceptance who would make such a decision and get all their loves ones to buy into it.

No law can permit such a decision to be implemented without being absolutely sure that the individual is in a position to make such a judgment. Some countries have provisions where such events can be anticipated and decisions taken in advance.

In the United States, The Uniform Rights of the Terminally Ill Act, 1985, provides for people making ‘living wills’ or ‘advanced directives’ on the way they would like to be treated (in terms of whether or not to withdraw life supports) were they ever to get into a terminally ill situation, and even nominate a proxy who will take such a decision on their behalf if they are legally incapacitated from doing so.

In Switzerland, extensive legal procedures are in place to ensure that the individual in question is of sound mind and is really in an incurable situation, before charitable organisations like Dignitas are permitted to ease the individual’s passage into death. But, as the ‘pro-life’ lobbyist would have it, no safeguard is completely free of loopholes that may be exploited.

There is, of course, some truth to this, and certainly in our country I would be apprehensive, for I have seen well-intentioned laws like Section 498-A of the Indian Penal Code and the Domestic Violence Act, being abused by unscrupulous elements. And when it comes to a life and death situation, the possibility of exploitation is a terrifying one.

In our country, attempted suicide is viewed as a criminal offence by Section 309 of the Indian Penal Code. Section 306 of the Indian Penal Code criminalises the abetment of suicide and proven offenders face up to 10 years of imprisonment, although this law is usually invoked when offenders goad somebody into attempting suicide.

Needless to add, euthanasia and assisted suicide are explicitly treated as offences, even though the 196th report of the Law Commission on Medical Treatment to Terminally Ill Patients in 2006, does not classify withdrawal of life support systems in the best interest of the patient, as falling under the same category of euthanasia or assisted suicide, and therefore recommends that it be permitted in special situations and with adequate safeguards as long as stringent procedures are followed and consent is obtained from ‘competent’ patients to do so.

Also, the progressively-thinking Law Commission of India, in its 210th report in October 2008,  has recommended that Section 309 of the Indian Penal Code (which criminalises suicide) be repealed.

Living, as we do, in a strongly family oriented culture, we also need to provide for the needs of the family when it comes to letting go of a terminally ill loved one. As I was researching this piece, I learned of what may be the ‘Gandhian way’ of taking the decision out of the hands of the health care and legal systems. On Friday, September 4, 2009, in Vadnagar, Gujarat, the 94-year-old Dr Dwarkadas Joshi, a Gandhian and a staunch follower of Acharya Vinobha Bhave passed away in the same manner as did the Acharya. The ailing doctor, who had dedicated his life serving the people of Gujarat as an ophthalmologist and social reformer, fractured his leg in a fall. Severely incapacitated, he chose dignity over prolonging his life and went on a fast unto death for 21 days, only sipping Ganga jal during this period. His family stood by him and were at his side when he attained samadhi. 

As a health professional who swore the Hippocratic Oath, I can get my head around the idea of withdrawing life support systems for ‘brain-dead’ individuals or for incurable terminally ill patients whose lives are slowly ebbing away.

But I still can’t get my head around the idea of physician-assisted euthanasia. I do, however, accept the validity of the argument that dignity and quality of life are of greater importance than the mere prolongation of life, but I still can’t quite see myself being the bearer of a goblet of hemlock.  Maybe it’s just me.