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GUEST EDITORIAL  
Year : 2012  |  Volume : 54  |  Issue : 2  |  Page : 108-110
Euthanasia: Evolving role of the psychiatrists in India


Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India

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Date of Web Publication8-Aug-2012
 

How to cite this article:
Chavan BS, Patra S. Euthanasia: Evolving role of the psychiatrists in India. Indian J Psychiatry 2012;54:108-10

How to cite this URL:
Chavan BS, Patra S. Euthanasia: Evolving role of the psychiatrists in India. Indian J Psychiatry [serial online] 2012 [cited 2020 Sep 24];54:108-10. Available from: http://www.indianjpsychiatry.org/text.asp?2012/54/2/108/99528


The honorable Supreme Court of India passed a landmark judgment of legalizing passive euthanasia on 7 th March 2011. The 110-page long document which gave this verdict was delivered in response to a criminal writ petition filed on behalf of Aruna Ramchandra Shanbaug in 2009. The petitioner requested for withdrawal of feeding to bring an end to her suffering. She has been lying in a persistent vegetative state since last 36 years following attempt of sexual assault and strangulation by a ward boy when she was on duty at the K. E. M. Hospital. The staffs of the hospital have been providing her with supportive medical care since then. Justice Markandey Katju and Justice Gyan Sudha Mishra in their judgment commended the dedicated efforts of K. E. M. hospital in providing selfless continuous care to Aruna and dismissed the petition.

The judgment accepted the significance of the doctrine of "parens patriae" while deciding the case where the affected person has lost the decision-making capacity. This doctrine recognizes the responsibility of the state in taking care of its citizens when they are in need of a father figure to take decision on their behalf. The bench felt that withdrawal of life-supporting measures cannot be left to the sole discretion of the treating physician, relative, care giver, or friend of a person. The judgment has laid provision for care givers of cognitively incapacitated persons to request for non-voluntary and passive euthanasia to the High Court. Till the legislation from the Parliament is in place, the judgment has cited the powers of article 226 of the constitution for such a provision. On receipt of any application for passive euthanasia, the High Court would appoint a board of doctors comprising a physician, a psychiatrist, and a neurologist to examine the patient based on which the court would take the decision about life-supporting treatment. Passive euthanasia is legalized in India in this process. [1]

Persistent vegetative state has resulted in Aruna being partially conscious and awake but unaware of her surroundings. Her higher mental functions as well as motor and sensory functions are compromised. The inability to experience self and the environment and the loss of capacity of voluntary control over self questions the very definition of being alive. Being alive is a continuous state of experience from the past to the future and the relationship with family, society, work, and culture rather than being a machine capable of carrying out biological functions. [2] Mere presence of biological functioning cannot define life. The current clinical state of Aruna has sparked off the debate on euthanasia; is life unworthy of living worthy of ending? Is moral dimension of continuing life more important than quality of life? What would Aruna wish had she been capable of expressing her desire?

Persistent vegetative state resulting from asphyxiating injury to brain has a poorer prognosis than a traumatic insult. [3] With only 7% chance of improvement in the state of consciousness, the efficacy of current medical interventions remains questionable. Though these interventions can prolong life, their impact on quality of life is not encouraging. Many a times, these interventions are felt as merely prolonging the process of dying. Adding to this is the amount and extent of emotional and financial burden imposed on the care givers. Withdrawal of life-supporting treatment in such states is a difficult decision to take both by the treating physician as well as by the care givers. [4]

End of life decisions are complex with ethical, religious, moral, and legal implications. Autonomy and self-determinism have become the guiding principles of life. People have started talking about right to die. They have started deciding their time and mode of death. The whole idea is to have a comfortable painless death at a convenient time. "Living will" has attained legal sanctions in many countries across the world, enabling people to express their will about the choice of kind of treatment they would like themselves to be subjected to when in a state of physical and mental incapacity.

The wish to have a comfortable death is not a recent phenomenon. The concept of "good death" dates back to medieval era when historian Seutonius described death of Emperor Augustus as euthanasia, i.e. dying quickly without suffering, which was the kind of death he had wished for. Euthanasia was first used in the medical context by Francis Bacon in the 17 th century to refer to easy, painless, and happy death during which it was the physician's responsibility to alleviate physical sufferings of the body, though he did not approve of administration of poison by physicians to hasten death. [5]

Euthanasia is currently carried out by physicians with the intent of bringing about a gentle and easy death for someone suffering from an incurable terminal disease or conditions of intolerable suffering or irreversible coma. It is considered legal in countries like Luxemburg, The Netherlands, and Belgium, and Oregon and Washington states of the USA. There are certain mandatory conditions to be met for euthanasia. Explicit request by a patient expressing a persistent and well-considered desire to end life is essential for euthanasia. Before this, the patient should be fully informed about his medical condition and prognosis and there should be no alternative treatment available for the current medical condition. At the same time, the suffering of the person must be unbearable for him. [6]

Based on the wish of a patient, euthanasia is voluntary, involuntary, or non-voluntary. Voluntary euthanasia is based on explicit wish of the patient, non-voluntary is when the patient does not have the cognitive capability to take a decision, and involuntary euthanasia is against a patient's wish. It is considered active when acts of commission like administration of lethal medicines result in death. Passive euthanasia results from withdrawal of life-supporting measures. [7]

The current judgment, having legalized non-voluntary passive euthanasia and including a psychiatrist in the board of doctors for clinical assessment, has entrusted a huge responsibility over them. Though the physician and the neurologist would be entrusted with the responsibility of clinical assessment of the case, the evaluation of mental status of the patient would be the duty of a psychiatrist.

The judgment has opened doors to those in terminal clinical state to request for passive euthanasia. People with intact cognitive capacity would express their wish of ending their lives when in futile clinical state or when the suffering is beyond endurance. The psychiatrists would be in the key position to decide about the decision-making capacity and the underlying reasons in such cases. Evaluation of the mental status would include diagnosis of psychopathology and presence of cognitive capability for decision making.

Patient autonomy and beneficence are the ethical principles of medicine which are taken into consideration while deciding in such cases. [8] Autonomy in common usage denotes the capability to act according to one's beliefs or desires without interference. It thus requires the capacity to think rationally and to make a reasoned decision consistent with one's values, and the ability to think and act freely without undue influence from others. Beneficence would be the decision to continue or withdraw life support, whichever is in the best interest of the person. Withdrawal may be considered in the best interest if it is felt that continuation of life support is merely prolonging suffering and interfering with natural process of dying.

To ensure autonomy and will of the patient and at the same time act as a measure of safeguard, mental state examination (MSE) is done. This provision of a safeguard helps to rule out the possibility of such a decision of the patient under the influence of others. An assessment of psychological underpinnings of the wish to end life has to be made. Perception of being a source of financial burden for the family, feelings of dependence and incapacity, and emotional persuasion by near and dear ones to end life for their own selfish interests might be the cause of such a wish.

The presence of a mental disorder can impair the appreciation of one's situation and the ability to comprehend the consequences of decisions and the ability to rationally manipulate information. A fleeting desire to have death is experienced by majority of terminally ill patients, but a serious and pervasive desire to have death is expressed by only 8.5% of terminally ill patients. Though correlated with severity of pain and low family support, the desire for death is more significantly correlated with diagnosis of depression. The diagnosis of depressive syndrome was seen in 58.8% of patients expressing a death wish. Being a potentially treatable condition, appropriate psychiatric management can often reduce psychological suffering and disappearance of death wishes. [9]

For assessment of mental capacity of an individual, the capacity to understand and retain the information necessary to make decision and the ability to use and weigh that information is essential. A stringent test for mental capacity should be mandatory for making the decision for ending of life. There are no guiding principles for making such evaluation of decision-making capacity and psychopathology in such a stage. The effect of psychopathology on decision-making capacity is a highly debatable issue. It is also questionable whether psychiatric evaluation is mandatory for all cases where passive euthanasia can be considered. [10]

The intent to end one's life is considered a sign of psychopathology; psychiatrists are trained to treat the underlying psychiatric disorder. Assessing the mental capacity of an individual making a death wish and acting as an agent for euthanasia is contrary to traditional training of a psychiatrist. The shift from the therapeutic role of treating psychological despair to facilitate ending of life would be anathema to psychiatry as a discipline.

In India, life is considered pious, and God's sacred gift. Hinduism considers life and death as cycles perpetuated by rebirth. Physical being of a person is considered perishable, "atman" or soul as perpetual. The Bhagavad Gita preaches, "The one who has taken birth has to die and rebirth after death is the rule, so in discharging one's duty one should not feel sorrowful." It is the "karma" of a person which decides the fate of his "atma." "Moksha" is the ultimate goal of "atma." This phenomenon of ultimate reunion of "atma" with God is interfered when man tries to interfere with life death cycle. The "karma" of both the agent as well as the person undergoing self-determined death is said to be affected by this act. [11]

The ethos of Indian culture lies in family values. The old and the disabled are taken care of in the family. They are not sent to old age homes or nursing homes as in the west. End of life care is usually provided by the family. Ending life deliberately would be considered contrary to the values of the Indian society.

Medical science is yet to define the "clear and convincing" standard of proof needed for withdrawal of life-sustaining treatment. Death by dignity is gradually gaining acceptance in the community. With the current judgment opening the doors toward legalizing euthanasia, psychiatrists should prepare themselves for acting in the best interest of their patients and the society as a whole.

 
   References Top

1.Available from: http://judis.nic.in/supremecourt/helddis3.aspx[Last accessed on 2011 Mar 20].  Back to cited text no. 1
    
2.Cassell EJ. Clinical incoherence about persons: The problem of the persistent vegetative state. Ann Intern Med 1996;125:146-7.  Back to cited text no. 2
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3.Krimchansky BZ, Galperin T, Groswasser Z. Vegetative state. Isr Med Assoc J 2006;8:819-23.  Back to cited text no. 3
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4.Marco CA. Ethical issues of resuscitation: An American perspective. Postgrad Med J 200;81:608-12.  Back to cited text no. 4
    
5.Dowbiggin I. A concise history of Euthanasia: Life, Death, God, and Medicine. Maryland: Rowman and Littlefield; 2005.  Back to cited text no. 5
    
6.Onwuteaka-Philipsen BD, van der Heide A, Muller MT, Rurup M, Rietjens JA, Georges JJ, et al. Dutch experience of monitoring euthanasia. BMJ 2005;331:691-3.  Back to cited text no. 6
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7.Chao DV, Chan NY, Chan WY. Euthanasia revisited. Fam Pract 2002;19:128-34.  Back to cited text no. 7
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8.Mclean GR. Euthanasia a problem for psychiatrists. S Afr Psychiatry Rev 200;7:10-8.  Back to cited text no. 8
    
9.Chochinov HM, Wilson KG, Enns M, Mowchun N, Lander S, Levitt M, et al. Desire for death in the terminally ill. Am J Psychiatry 1995; 152:1185-91.  Back to cited text no. 9
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10.Hotopf M, Lee W, Price A. Assisted suicide: Why psychiatrists should engage in the debate. Br J Psychiatry 2011;198:83-4.  Back to cited text no. 10
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11.Abbas SQ, Abbas Z, Macaden S. Attitudes towards euthanasia and physician assisted suicide among Pakistani and Indian doctors: A survey. Indian J Palliative Care2008;14;2:71-4.  Back to cited text no. 11
    

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Correspondence Address:
Bir Singh Chavan
Department of Psychiatry, Government Medical College and Hospital, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5545.99528

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