He was paralyzed from neck down and the doctors had all but given up on him. He was a lost cause. He was never put on life support in the government hospital. But his family didn’t want to let him go. When his family finally got him transferred to a private hospital the administration put him on life support. But he did not survive. This is the dilemma faced by the loved ones of those left in a permanently vegetative state, family members are often stuck in limbo. And then there are cases where the paralyzing pain of the terminally ill may warrant euthanasia. In fact statistics of Sri Lanka Police from 2005 to 2011 indicate that those with terminal illness committing suicide show an ever increasing trend particularly in the over 60 age category
The right to die, the question posed by Thanatos looms large in the individual’s journey towards self-actualization, as living life is a prelude to memento mori. It is in the articulation of the ultimate full stop of physiology – ‘death’ that humanity seeks to transgress its limitations by seeking the potential of collective destiny through individual fates.
So what if the ‘I’ ceases to want to be? What if the ‘we’ have to make that decision on behalf of ‘I’ as is the case in Euthanasia?
According to head of the Department of Forensic Medicine and Toxicology at the Faculty of Medicine of the University of Colombo, Senior Prof. Ravindra Fernando, an acceptable medical and legal definition of euthanasia was a deliberate intervention undertaken with the express intention of ending a life to relieve intractable sufferings. The House of Lords Select Committee on Medical Ethics in the United Kingdom states the same. ‘Good death’ as the Greeks call it is an intentional ending and terminating of a life by a doctor at the explicit request and expressed will of a patient.
Physician-assisted suicide is euthanasia where doctors are involved. Many controversial ethical and moral dilemmas abound from such understandings. It is illegal for laymen even if they are the guardians of the patient to assist in suicide. There is voluntary or consensual euthanasia which are termed active euthanasia where lethal substances are injected or an overdose is prescribed and passive euthanasia where essential treatments for sustaining life and prolonging death are withdrawn.
There is non-voluntary or non-consensual euthanasia. Then there is involuntary euthanasia which is euthanasia done in violation of the express will of the patient. Suicides due to chronic illness and physical disabilities according to statistics of the Sri Lanka Police from 2005 to 2011 indicate that those with terminal illness committing suicide show an ever increasing trend particularly in the over 60 age category. Section 299 of the Penal Code outlaws the practice of euthanasia for both doctors and laymen.
Understanding the need of the hour, while calling for euthanasia to be legalized based on the antecedent models of the Netherlands, Belgium and the United States of America (USA) to help suffering patients, the Nation proposes to explain how this legalizing can be done as poetess Sylvia Plath puts it in ‘Lady Lazarus’, ‘exceptionally well’.
Since the 1950s, Sri Lanka has seen a dramatic rise in the number of victims of suicide.
Suicide, in itself, could be deemed legal in Sri Lanka on the grounds that there is no provision in the Penal Code preventing a person from doing so.
However, any such person who assists a person in suicide would be punished by virtue of Section 299 of the Penal Code of Sri Lanka which reads: “If any person commits suicide, whoever abets the commission of such suicide shall be punished with death”.
The subsequent provision in the Penal Code makes it illegal for a person to perform any act with intention or knowledge that such an act could cause death. Such an act, as according to Section 300 of the Penal Code, amounts to murder and would result in a punishment of 10 years, and if the act had involved harm to the victim, the sentence for the abettor could be increased up to 20 years in prison.
These provisions make it difficult for any person to assist a person in death, whether or not such an act is performed with good intentions and without pain. In other words, assisted suicide is prohibited by Sri Lankan law regardless of the circumstances.
The people most affected by such laws are essentially doctors whose patients are terminally ill and irrecoverable and the families who have to bear the brunt of the expenses. On most occasions, doctors are unaware when to pull the plug when a patient is on life-support and the patients must endure much pain in order to die a natural death. There are also persons of senile old age, who have lost the urge to live for longer and merely live until death comes to them naturally.
Suicides due to chronic illness and physical disabilities according to Sri Lanka Police statistics in 2005 included 554 males and 118 females, in 2007 it was 439 males and 92 females, in 2008 the figure was 461 males and 85 females, in 2009 the number was 467 males and 86 females, in 2010 it was 239 males and 66 females and in 2011 the statistics were 461 males and 84 females.
“We have an aging population. The ever increasing trend of those with terminal illnesses committing suicide particularly in the over 60-year-age range means that maybe there is no one to look after them. Suicide among the elderly is going to become a major problem,” Prof. Fernando observed.
This is where the legalizing of euthanasia comes in.
Euthanasia conducted with the consent of the patient is termed voluntary euthanasia. It can be active or passive. In active euthanasia lethal substances or an overdose is used to end the life of a terminally ill patient. Passive euthanasia is withholding of common treatments, such as antibiotics or intravenous fluids, necessary for the continuance of life including drugs to keep the heart pumping efficiently for patients with heart failure or oxygen.
Euthanasia conducted where the consent of the patient is unavailable is termed non-voluntary euthanasia and is, according to Prof. Fernando, tantamount to murder along with involuntary euthanasia which is when the patient who is able to provide informed consent does not do so because they do not choose to die or because they were not asked.
“Sometimes the distinction between killing and letting a person die is unclear. For example, consider the case of a patient suffering from motor neurone disease who is completely respirator dependent who finding the condition intolerable, competently and persistently requests to be removed from the respirator”, said Prof Fernando.
“More than doctors it is mainly the relatives of a patient dying of cancer for example that may exacerbate the death by giving drugs or whatever other means. The complications that can arise by running solely on the interests of the individual particularly in cases where they are in a persistently or permanently vegetative state or are of unsound mind is that one cannot do anything other than let the person die a natural death.
“Euthanasia is killing somebody because a person is suffering from a disease which cannot be cured,” Prof. Fernando said. “The Dutch in Holland in 2001 set out narrow guidelines in going in for euthanasia.”
As Dr. Ruwan M. Jayatunge’s article on the subject states in the Netherlands: “The patient, who must be suffering unbearably and have no hope of improvement, must ask to die. The patient must clearly understand the condition and prognosis and a second doctor must agree with the decision to help the patient die.”
“Two doctors must certify that the patient is not going to live and the patient wants death and that the patient is of course sane and of normal mind or mental state and that he or she is not mad,” Prof. Fernando noted.
“In Belgium since the legalization of euthanasia it now accounts for two per cent of the deaths averaging over 2000 per year. Dutchman, Dr. Els Borst, the former Health Minister and Deputy Prime Minister who guided the euthanasia law through Parliament recently admitted that medical care for the terminally-ill had declined.”
“In the long run, concerns that euthanasia could be utilized as a measure of health-care cost containment should not be a consideration at all. It will be but it is not fair. The standards of medical care of the terminally ill should not change and doctors should continue their treatment of the patient till the issue of euthanasia is raised by the patient,” Prof. Fernando said.
“Again in Belgian law which came into effect in 2002, two doctors must be involved confirming that the patient is going to die and that there is no hope of recovery or is in very severe pain that cannot be treated (patient is given drugs like morphine in very high doses to relieve pain and yet does not respond). A psychologist or psychiatrist has to be involved if the patient’s competency is in doubt. The doctor and patient then negotiate whether death is to be by lethal injection or prescribed overdose”, said Prof Fernando.
“Suffering is gauged in that any physiological pain causes psychological pain. The reason for the pain however should be obvious. Just because the patient says that they have pain one cannot go ahead unless the patient has a cancer somewhere which impinges on nerves or causes severe difficulty in breathing, all of which cause pain. The doctor should clearly understand as to what is happening to the patient. Mere fact that the patient states ‘I am in pain’ is not allowed. Euthanasia should be the last course of action when all other means are exhausted and prove unfruitful. For an example, with patients who have lung cancer with secondary tumours in the brain where the doctors put drips and nasal feeding is used, relatives sometime ask for voluntary passive euthanasia requesting the doctor to stop and allow the patient to die peacefully”.
“There are other cases where the patient is unconscious and has not given his or her consent. Only the relatives’ consent is on the table. This is a very difficult situation if the patient has a wife and children, all must unanimously decide to consent as otherwise one child could come and say ‘you have killed my father, I have not given my consent’ and because it can be deliberately done by one son to obtain the property. I recorded a detailed statement from a wife and children at a private hospital in a case where the patient had severe lung cancer and the wife and children wanted the treatment stopped and afterwards I told the doctors they could do it. In a way we practice it. We do not call it euthanasia but state that the patient’s relatives insisted,” Prof. Fernando said.
In the USA, physician-assisted suicide is legal in the states of Oregon, Washington and Montana.
Non-voluntary euthanasia including child euthanasia was decriminalised under certain specific circumstances in the Netherlands under the Groningen Protocol describing procedures and guidelines as to how to actively end the life of infants. Termination of a child’s life (under age 12) is acceptable if the requirements of the presence of hopeless and unbearable suffering, the consent of the parents to termination of life, medical consultation having taken place and careful execution of the termination are fulfilled and doctors who end the life of a baby must report the death to the local medical examiner, who in turn reports it to both the district attorney and to a review committee.
In 1973 in India, Aruna Shanbaug was discovered in the basement of the Mumbai’s King Edward Memorial Hospital with an iron chain around her neck, 11 hours after she had been sodomized by a ward boy. The chain used to strangle her had cut off the supply of oxygen to her brain. The damage was irreversible. She has not walked or spoken a word in years and she had not left the hospital where she was once a capable nurse.
A petition for euthanasia was filed for Shanbaug by Pinky Virani, a journalist who has written a book on the woman who she says is being forced to live her life stripped of basic dignity. The Supreme Court in March 2011 ruled that euthanasia and in this case mercy killing was not a permissible option for Shanbaug as they had no indication of Shanbaug’s views or wishes.
The verdict of this case allowed passive euthanasia depending on the circumstances, for the right to withhold medical treatment – take a patient off a ventilator, for example, in the case of an irreversible coma. The Indian judgement made it clear that passive euthanasia will “only be allowed in cases where the person is in a persistent vegetative state or is terminally ill.” In each case, the relevant High Court will evaluate the merits of the case, and refer the case to a medical board before deciding.
“Euthanasia based on the models of Holland, Belgium and the USA should be legalized to help the suffering patients. Religions say that this cannot be allowed. The practical implications are such that if we legalize it we must ensure checks and balances. There should be clear provisions which must state that it should be done in a hospital, both State and private, otherwise there could be cases like the one with British Dr. Harold Shipman who is said to have claimed the lives of 250 persons by going to houses and giving injections,” Prof. Fernando explained.
“There should be severe uncontrollable pain in a terminally ill patient who has no hope of cure or recovery and the patient should be able to give consent or have given consent for euthanasia. If these criteria are fulfilled there should be a clear protocol to follow and ideally, the procedure to be followed should be comparable to terminating ventilator support in a brain dead patient.”
“The two doctors on separate occasions must examine the patient and when certifying must give reasons as to why they have decided upon euthanasia, like in the Dutch system. A set of broad guidelines must be prepared which state under what conditions a patient could be euthanized, the situations and types of illnesses. The qualifications of the doctors must be mentioned including specifying that at least one of the two doctors be a specialist in the particular disease. Otherwise in a hospital in Kataragama, two Medical Officers can get together and allow euthanasia which is a bad situation. Principles governing contractual law do not apply. Doctors need to enter into a contract with the guardian or relatives of the patient or with the patient. The doctors must record in the patient’s bed head ticket as to why they think the patient will not recover,” Prof. Fernando said.
“The doctors should obtain informed consent for euthanasia in the presence of a relative or an independent witness. The death should be referred for an inquest. The advantages of euthanasia are that there will be a painless death which relieves the patient through speedy termination of physical and emotional suffering, saves family’s money by eliminating the need to spend money on expensive, painful, or debilitating treatments, surgery, medicine and life-support”.
There are also the cases of Dr. Jack Kevorkian aka. Dr. Death and the Scottish, Exit (Right-to-Die Organization). In cases where medical procedures and products are prohibited by religious doctrines and belief and are denied by parents or guardians to children (as in the case of blood transfusions by the followers of the non-orthodox, non-denominational Christian sect – Jehovah’s Witnesses), Prof. Fernando said that “the doctors should go ahead and give the blood transfusion even if the parents object and no one can sue the doctors for damages as they are acting in good faith. The doctors can also get a Court order against the parents.”
Prof Fernando emphasized that there is “no problem if the law is there and it is properly legislated and the people are aware of it, they might demand it.”