Compassion and Deliverance, Not Mercy Killing

The advances in medicine have certainly made it possible for us to achieve recovery from disease states that were almost always fatal not so long ago

"I am the Pilot of life, mistakenly called
Terrible 'Death' by ignorant earth-folk…
I am thy brother, uplifter, redeemer, friend-
Unloader of thy gross burden of body-troubles..

Paramahansa Yogananda

"Treatment in search of cure in the face of hopeless prognosis is a travesty of medical care and goes against the ethical principle of the physicians' obligation to act in the best interest of the patient and his family" - Dr RK Mani Director, Pulmonary-Thoracic Unit, Chief, Medical ICU Fortis Rajan Dhall Hospital, New Delhi

The issue of life support limitation often evokes strong reactions both among professionals and the layman. The Law Commission has recently submitted to the Government a draft bill entitled 'Medical Treatment of Terminally Ill Patients' (for the protection of physicians and patients).

It should be clarified at the outset that euthanasia is illegal in India, as in most countries of the world, and the proposed law is certainly not about legalising medical killing in any form. The issue is in fact about stopping inappropriate use of life-support technologies when the patient is terminally ill with no hope of cure.

The advances in medicine have certainly made it possible for us to achieve recovery from disease states that were almost always fatal not so long ago, but it is also a painful fact that in many cases modern technology has only served to artificially prolong the dying process. While all of us accept the inevitability of death and hope for a peaceful and dignified end when the time comes, with inappropriate medical interventions, this natural process becomes prolonged, only adding to the agony of the patient and his/ her family. Medical care of patients requiring artificial life support such as ventilators, dialysis and so forth are very expensive, often leading to the families' financial ruin. Treatment in search of cure in the face of hopeless prognosis is a travesty of medical care and goes against the ethical principle of the physicians' obligation to act in the best interest of the patient and his family.

A Legal Vacuum

In the context of the ever increasing sophistication and capability of medical science to forestall, or to postpone death indefinitely, it was inevitable that experts throughout the world involved in the care of terminally ill should have developed guidelines for limiting treatment in such situations. Every civilised society has acknowledged the tragic consequences of misplaced application of life support both to the individual and to the society, at large. In our country, the difficulties are compounded by the fact that such treatment is beyond the means of most and scarce resources may be used up for hopeless cases and not be available for salvageable patients. Most countries of the developed world have sought to reduce the impact of futile life support by developing guidelines facilitating treatment limitation and introducing legal reforms to implement them. In India there is a complete legal vacuum on the issue, making it very difficult for physicians to restrict unwanted treatments even in response to the fervent pleas of patients or families.

Linked to the issue of artificial prolongation of death are patient's rights as a citizen. Every medical intervention requires consent of the patient. Basic ethical principles behold the doctor to respect the autonomy of the patient, even if the he / she were sure his/ her treatment is for the patient's benefit. The patient also reserves the right to refuse the treatment, even if the refusal may be clearly to his detriment. Particularly, in a very personal issue like choosing the manner of his death, the patient has the right to refuse artificial support which he considers burdensome. This right would remain even if the patient were mentally incapable of making those decisions. Only, his preferences as conveyed by the family need to be respected by the doctor. The exercise of the right to refuse treatment should not be cruelly misinterpreted as an attempt to commit suicide. Indeed, American law provides for citizens to execute an 'Advance Directive' wherein the individual can express his preference for the manner of his treatment towards the end of his life.

Guidelines

With this background, the Indian Society of Critical Care Medicine (ISCCM) took the initiative in developing ethical guidelines for intensivists in the care of the critically ill. The Society, as most professional bodies elsewhere in the world, has pronounced euthanasia to be unethical and illegal. The guidelines are about judicious and appropriate use of technologies, based on scientific and ethical principles followed throughout the world. As legal guidelines and safeguards do not exist for our country, last year the society requested the Law Commission of India to study the issue.

The Law Commission has now submitted a draft bill on 'Medical treatment of terminally ill patients (for the protection of patients and physicians)' to the government. It is a landmark in the history of modern healthcare in India. The draft bill opens the extensive document with a clarification that it does not deal with euthanasia or physician-assisted suicide. Rather, it is about allowing the natural process of dying to continue which is a blessing in the context of terminal illness. It is a graceful acceptance of death and avoidance of improper use of medical technology. It is also about respect for patients' rights and is in keeping with the ethical and moral obligations of the physician. The bill defines 'terminal illness' and the various ways of limiting treatment in this setting. It then goes on to provide precise legal guidelines for withholding, or withdrawing (terminating) treatment. It also defines what constitutes 'palliative' care or treatment aimed at providing comfort, not cure. There are adequate legal safeguards to prevent misuse of these provisions.

The document has exhaustively reviewed the case laws and legal guidelines all over the world and has carefully assessed the conditions unique to India. It goes a long way in protecting patients' rights and humanising modern healthcare that has come to be increasingly technology-driven. It would also set doctors free to act appropriately and wisely for their patients without the fear of being misrepresented. The draft bill has taken into account all aspects of the issue including its constitutionality and potential for misuse by unscrupulous persons. The Law Commission's recommendations are broad in their sweep and brilliant in their understanding of the needs of patients as well as physicians. Its recommendations are vitally important to protect us from the agony of inappropriate treatment, from violation of our rights as a citizen and the well-meaning physician from frivolous litigation.

Care vis-a-vis Cure

Medical care is to be applied with care, wisdom and compassion. The goal of treatment is to reduce human suffering and not add to it by a fanatical adherence to the principle of preserving life at all costs. When faced with inevitable death the patient seeks deliverance, and trusts that his doctor would help him be free from pain and distress through the process. Law should be for the people and in step with their changing needs. The proposed reforms are laudable and are indeed a milestone in our march towards a developed and caring society.

raj.mani@fortishealthcare.com