Care for the terminally ill
DR. RAM E. RAJAGOPALAN
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`Treatment limitation' in appropriate cases should not be confused with the morally contentious issue of `euthanasia'. Antiquated laws stand in the way of what needs to be done.
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... it is the intent of the act of treatment limitation (to enhance comfort and to respect patient preferences) that morally distinguishes it from euthanasia (that intends to terminate a life).
Limited options: Contradictions in law limit patients from making their own decisions on treatment, especially during terminal illness. Photo: REUTERS
THE Union Law Ministry and Law Commission have initiated efforts to develop legislation to regulate the treatment of terminally ill patients, a move that brings hope to many such patients and their caregivers. Cases such as that of Venkatesh, a terminally ill young man who requested the discontinuation of life-prolonging treatment, have stirred the public and the press to examine the issue.
However, in the discussions of these issues the media has often misused the term `euthanasia', even labelling the proposed legislation as "euthanasia laws". This is a misinterpretation of facts.
As a medical professional with interest in the provision of compassionate care to the terminally ill, I think there is an urgent need to make the public aware of the distinction between `euthanasia' (also called `mercy killing') and the limitation or withdrawal of life-prolonging treatments (`treatment limitation') in individuals who have a negligible chance of recovery (`the terminally ill').
Recent advances in medical treatment and life-support technology have offered immense benefit to many patients who may not have survived an illness of comparable seriousness even a few decades ago. However, for every life saved by these innovations, there are many others who do not recover and who are left inexorably on treatments and support that only aggravate their pain and suffering.
Ethically, a physician is bound to provide only treatments that are beneficial and must have the honesty to admit when his or her treatment is no longer efficacious. Under such circumstances, the doctor is obliged to explain the unavailability of `curative' options and give the patient (or his surrogate) choices for future treatment. In many such situations, patients opt to focus on comfort care and would like to discontinue treatments such as medications, dialysis or mechanical ventilation, which no longer have any curative value.
The ethics of euthanasia
Although such actions appear to be morally correct, it may be argued that discontinuation of some treatments might hasten the demise of the patient, making `treatment limitation' qualitatively no different from `euthanasia.' There is, however, a subtle but important difference between the two acts that needs to be highlighted. Euthanasia is an act that, however well intentioned, aims to end a life. The primary purpose of the act is to use the termination of life as a mode of `providing relief' from discomfort.
In contrast, the act of treatment limitation provides relief by minimising or eliminating treatment options that do not enhance survival. While, as noted, the cessation of certain processes (for example, mechanical ventilation) may accelerate the death of the patient, this is not the intended goal nor is it an inevitable outcome. Thus it is the intent of the act of treatment limitation (to enhance comfort and to respect patient preferences) that morally distinguishes it from euthanasia (that intends to terminate a life). This is the principle enshrined in the doctrine of `double effect' that has been used by jurists and ethicists worldwide to justify the limitation of futile treatments while simultaneously rejecting euthanasia.
Even if we accept the moral appropriateness of treatment limitation, archaic provisions in the Indian Penal Code restrain its wide application in India. Thus, while the individual has a constitutionally guaranteed liberty to decide on his or her treatment options, the refusal of some treatments may have life-threatening consequences and the act of refusal might be viewed as a suicide attempt — a criminal offence in India. This was probably the reason that the courts ruled against the request of Venkatesh, whose neuromuscular problems made him ventilator-dependent, but did not compromise mental function to prevent him from rationally evaluating his choices in requesting the termination of ventilatory support.
The need for new laws
While the media have been reporting on this case as a ruling against euthanasia, cases such as this highlight the contradictions in Indian law that limit patients from making their own decisions on treatment options, especially during terminal illness. India stands out as one of the few countries in the world that have no laws on limitation of treatment. It is this issue, not euthanasia that is being addressed by the Law Commission. As we recognise the burdens imposed by modern medical technology and realise that the constitutional guarantees of individual liberty are being neutralised by an antiquated Penal Code, we come to appreciate the urgent need to formulate new laws. These laws will go a long way in minimising the emotional and financial hardships faced by patients who are condemned to unwarranted therapeutic excesses. It is therefore imperative that the public not confuse these vital goals of the Law Ministry with the morally contentious issue of euthanasia, as this will delay or even derail the legislative process.
Dr. Ram E. Rajagopalan is Consultant & Head, Department of Critical Care Medicine, Sundaram Medical Foundation, Chennai; and immediate past president, Indian Society of Critical Care Medicine, Mumbai. He can be reached at ramer@vsnl.net
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