What is Euthanasia
In the 17th century, Sir Francis Bacon coined the term ‘Euthanasia’. The word euthanasia is comprised of two Greek words; ‘Eu’ meaning ‘Good’ and ‘Thanatos’ meaning ‘death’. Combining these two words, Euthanasia means ‘Good Death’. Practically it is defined as hastening of death of a patient to prevent further sufferings [1,2]. At a conceptual level, euthanasia is projected as a means to end the pain and suffering of a terminally ill patient (mostly incurable). In this broader sense, it is also referred to as ‘Mercy Killing’ [3].
Types of Euthanasia
Euthanasia is classified as per different schemes at different time points. The two widely recognised classifications are active vs passive and voluntary vs non-voluntary vs involuntary euthanasia. Active euthanasia refers to the administration of some lethal substance with clear intention to end the life of a patient suffering from an incurable and/or end-stage disease. Passive euthanasia refers to the act of omission by the treating doctor. The physician may decide to withhold aggressive treatment like resuscitation or withdraw life-sustaining measures like a ventilator in the best interest of the patient. Albeit the outcome in both the methods is the same, the latter is practiced worldwide without many legal hassles whereas active euthanasia is permitted in very few countries like Belgium, the Netherlands, Switzerland across the globe. It is difficult to conceptualise active euthanasia intuitively and hence, the phrase is replaced by Physician Assisted Suicide (PAS) in euthanasia debates [1,3].
Voluntary euthanasia involves the patient’s consent. The patient in his full consciousness expresses his desire to end his life and then euthanasia is performed by someone. In non-voluntary euthanasia, the patient is not in a position to decide for himself due to various reasons and the decision is taken by his/her kin. If the patient is in a coma, mentally unstable or in the extreme scenario; not even yet born, non-voluntary euthanasia can be performed. For example, if some severe growth retardation/neural tube defects etc., are detected through routine ultrasonography, the termination of pregnancy may be advised. Involuntary euthanasia is forced without consent of the patient and especially when the patient is in a position to express his/her will clearly and explicitly. This act is rightly considered as murder in most countries even if the intention might be alleviating pain and suffering of the patient [1-3].
Legality of Euthanasia
The world appears to be divided into three prominent categories when the legalisation of euthanasia is concerned.
Ultra-Orthodox-The countries in the Middle East, Africa, South America and South East Asia are not even debating about euthanasia and maintained a status quo of not legalising anything related to euthanasia. Ultra-Liberal-Few Countries in Europe and few states in the United States of America, Canada and Japan are in a process of making new laws that legalise more and more forms of euthanasia. Countries in Transition- These countries started deliberating on many aspects of euthanasia but the discussions are inconclusive to date. In other words, these countries are inclined towards Ultra-Liberal in conceptualising euthanasia but practically lean on Ultra-Orthodox in the absence of any concrete law pertaining to euthanasia [1-4].
Belgium and the Netherlands legally allow euthanasia and PAS when performed in line with the code and procedure formulated for the same. In 2014, both these countries legalised paediatric euthanasia that sparked a rage amongst the opponents of euthanasia. Belgian jurisprudence widens the spectrum for application of euthanasia - from terminally ill patients to including chronic diseases. Luxembourg allows euthanasia but not to minors [2,4]. Switzerland’s legal system is interesting. While active euthanasia is considered a criminal offense, the jurisprudence allows assisted suicide by patients themselves. These three countries are defamed as promoting ‘Suicide Tourism’ from the arch opponents of euthanasia. In the United States of America, only California, Oregon, Washington and Vermont states allow euthanasia. After some serious deliberations, Canada legalised PAS in 2015. Columbia became the first South American country to legalise euthanasia in 2016 under well-laid guidelines. The World Medical Association (WMA) resolution in 2013 discourages physicians from involving themselves in any form of PAS. This might be due to a verbatim interpretation of the Hippocrates Oath [4].
India’s journey in euthanasia is typical ‘one step forward-two steps backward’. Section 309 of the Indian Penal Code (1860) unambiguously declares suicide as a criminal offense. Euthanasia thus, becomes a criminal offense by default. However, under exception 5 to section 300, euthanasia is perceived as culpable homicide and not murder [5]. Aruna Ramchandra Shanbaug vs Union of India was a landmark case in starting vigorous deliberations about euthanasia in India [6]. The deliberations involve some humane steps towards the suffering individual [7]. Consequent to these debates over few decades, the Supreme Court of India in a landmark decision provided legality to passive euthanasia under strict conditions and also paved the way for comprehensive discussions in the parliament regarding euthanasia as well as establishing equitable healthcare in India [8].
Conceptualisation of Euthanasia in a Sociocultural and Religious Milieu
Euthanasia is not merely a medicolegal issue. It interacts with sociocultural belief systems and norms, religion as well as politics. Euthanasia was practiced much before the euthanasia debate started. Plato endorsed death for the physically and mentally ill. Hippocrates seems to be opposing euthanasia through the oath for physicians. A strong supporter of non-violence or ‘Ahimsa’, Gandhiji also had favourable opinion towards euthanasia. However, he strongly advocated trying all possible options to relieve pain and suffering before considering euthanasia [9].
All Abrahamic religions consider euthanasia as interference in Gods’ will. Catholics strongly oppose euthanasia whereas protestants have more liberal views for euthanasia and PAS. Death is considered as punishment for the sins and it is the temporary separation of body and soul till the ‘Judgement Day’ [10].
In Islam, sanctity of life is valued most as life is created by ‘Allah’ and hence, it is banned to hasten death against Állah’s wish. Interestingly, it is allowed to use Narco drugs to relieve pain but not for hastening death. Some sects like Dawoodi Bohras have arcane practice of ‘Rahemat Ka Pani’ or ‘Mercy Water’ but no one wants to even talk openly about it [10,11].
As the famous banter goes- “If there are 2 Jews, there will be (at least) 3 opinions”. This actually points towards heterogeneity in Judaism. There are three main opinions in Judaism about euthanasia and PAS. The orthodox condemn any form of euthanasia unequivocally. The conservative movement presents the same view but with some voices of descent accepting euthanasia under exceptional situations. The reformist movement accepts passive euthanasia but with a lot of deliberations and heated arguments [12].
The eastern religion like Hinduism and allied sects (Jain, Buddhist) have a broader view of the sanctity of life. Hinduism believes that the soul is immortal and the aim of life is to advance towards ‘Moksha’ or ‘Nirvana’ that makes a pious soul free from the birth-death-rebirth cycle. Suicide is called as Átma Ghata and is forbidden for all types of selfish intentions. However, many saints and seers; in the past, had ended their lives at their own will (Ichha Mrityu). Lord Ram, with his brothers; entered river ‘Sharayu’ and allowed themselves to be drawn to death. ‘Pandavas’ practiced ‘Mahaprasthana’ in which they visited holy places in Himalaya till they died. Saints and seers practiced ‘Samadhi’, ‘Santhara’ or ‘Prayopvesa’ that involves stopping food intake gradually to embrace death [2,5].
The religious belief systems are deeply rooted in both Health Care Practitioners (HCPs) and the general population. A systematic review revealed that religious Muslim, Christian and Jew HCPs have little acceptance towards passive euthanasia as well as PAS. The acceptance rates deteriorate further in general population groups. On the contrary, HCPs as well as the general population from Hindus and Buddhist communities expressed high acceptance for euthanasia as well as PAS [13].
There is a basic difference in the conceptualisation of euthanasia in western and eastern cultures. In western cultures, Euthanasia is debated in light of severe pain and suffering out of some disease. Thus, euthanasia is conceptualised out of ‘Sense of Hopelessness’. In eastern cultures, hastening of death was allowed only after one completes his/her duties towards the society. The euthanasia is thus, conceptualised out of ‘Sense of Fulfillment/ Self-Realisation/ Self-Actualisation’ [1-3,5,13].
In May 2008, David Goodall, an Australian academician opted for PAS in Switzerland. He was 104-year-old and without any life-threatening ailment [14]. This probably will initiate a fresh debate on euthanasia out of the ‘sense of fulfillment’ in western media.
Cinematographic Expression of Euthanasia
Euthanasia debate does not seem to attract filmmakers. There are a handful of regional films like 1941 German film “Ich Klage An” to a 2012 Dutch film “Tot Altijd”. The first Indian film on euthanasia was ‘Gujarish’ released in 2010. All these films projected euthanasia as a need for a paraplegic/end-stage disease patient [11].
The Nucleus of the Euthanasia Debate
The euthanasia debate slowly moved from religious ‘Sanctity of life’ argument to morality, justice and equity based ‘Dignity of life’ argument. Physicians like Christiaan Barnard redefined the role of health care providers in the treatment of a patient. He explained that HCPs should try to “cure sometimes, to relieve often, to comfort always.” He also elaborated on the difference between quality of life and quantity of life [15]. These concepts are the central part of palliative care today as Dr. Robert Twycross explains that palliative care is not about adding days to the life but about adding life to remaining days [16].
Proponents of Euthanasia Argue around Three Central Themes
Right to die (autonomy): It is argued that the patient has the right to decide the course of his own life. It is partially linked with the concept of ‘Die with Dignity’ [1,3]. However, it might expand to embracing death out of ‘sense of fulfillment’.
Beneficence: Sometimes it is more humane to perform euthanasia than allowing patients to suffer unbearably. It also provides a chance to reallocate scarce resources for the larger benefit of the society [3].
Active vs Passive Euthanasia: There is no moral difference between active and passive euthanasia as the intended outcome is the same. Further active euthanasia is almost instantaneous and pain-free whereas passive euthanasia might cause more pain and suffering to the patient [1].
Opponents of Euthanasia Argue Around One Central Theme- Misuse/Abuse of Provisions
Autonomy vs Vulnerability: While ‘right to die’ may be accepted theoretically, it is difficult to believe that the patient is in a stable state to exercise his rights. The patient might receive direct or indirect indications by relatives and even by health care providers about the futility of the treatment. In such a condition, their decision may not be Voluntary [1]. In fact, a study revealed that two-thirds of the patients who requested euthanasia/assisted suicide changed their mind in due course as they rediscovered new ways to make life better [17].
Beneficence (real or imaginary): While unbearable pain and suffering are not advocated, the real problem lies in the lack of well-established palliative care units. Other co-morbid conditions especially depression also act as a catalyst for the patient to request euthanasia [1]. Palliative care team members in Italy recently rejected the role of euthanasia citing adequate pain relief by current measures [18].
A slippery slope: Many countries including India waded through the legal system to accept passive euthanasia especially for terminally ill patients. But very quickly the scope was widened to include chronically ill patients as well as patients with psychiatric problems. It is a dangerous pattern as the scope might include mentally retarded, non-productive (elderly) and unwanted (politically, religiously or even racially) people. The patient’s right to die does not mean society’s right to kill [1]. This also might be misused by politicians and people in power for genetic cleansing.
Euthanasia in Future
If one observes the advancements in the last few decades, it is clear that at least passive euthanasia will get legality in most countries over a period. In fact, the debate in South Africa over legalising voluntary active euthanasia redefined the scope of human dignity [19]. However, there were instantaneous counter arguments about the exact scope of human autonomy explaining that many times it is pseudo-autonomy [20]. The potential vulnerability of old and differently abled people to euthanasia is portrayed long back by Anthony Trollope in his fiction “The Fixed Period” [21]. While everyone is elated by the lofty and philanthropic principle of “Equal treatment to all”, this utopian scenario does not exist in reality. No country in the world today possesses unlimited resources {except probably Canada where the main (and only?) job of provincial Governments is to provide universal healthcare to all}. Nations will need to take tough decisions without compromising equity. The emergence of chronic illnesses coupled with increased life expectancy and the advent of life-saving drugs/equipment will pose a formidable challenge to the health care systems in the near future.
The revenue from PAS is another concern for the entire world. Fortunately, only a handful of countries allow it legally but their revenue generation form this tainted business called suicide tourism is huge and maybe too lucrative for less developed countries [11].
The Governments and the jurisprudence need to be extra cautious in legalising any form of euthanasia. The norms must be rigid enough so that they are not misused but at the same time practical enough to provide solace to the suffering in time. A special drive to develop universal guidelines pertaining to all aspects of euthanasia might minimise its misuse.
Conclusion(s)
Euthanasia is a complex and controversial issue. There exist sociocultural and geopolitical differences in conceptualisation, legalisation and implementation of euthanasia. It has a potential of misuse. Considering the proliferation of noncommunicable diseases and increased life expectancy, a bare minimum universal common framework that will guide governments and jurisprudence to formulate laws which can be universally adapted is the need of the hour.
Author contribution: SAP conceived the idea of the monograph out of his applied philosophy assignment. Both authors performed the literature review. AGP prepared the initial draft and SAP provided intellectual inputs. Both authors approved the final version of the manuscript.
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