Euthanasia – Review and update through the lens of a psychiatrist

ABSTRACT

Euthanasia is not infrequent in the modern practice of medicine. Active euthanasia is legal in seven countries worldwide and passive euthanasia has recently been legalized in India by the Supreme Court. In India, physicians and nurses generally have a favorable attitude towards euthanasia but lack in adequate training to deal with such requests. The role of a psychiatrist is very important in evaluation of request for euthanasia on medical as well as psychiatric grounds. Among patients with end-stage medical illnesses who make a request for euthanasia or physician-assisted suicide, many may have underlying untreated depression. In the complex backdrop of long-term chronic medical illnesses, depression can be very difficult to diagnose and treat. Patients with dementia and other neuropsychiatric illnesses have the issue of consent and capacity. Legalizing euthanasia in these patients can heave dire moral implications. There is clear need of adequate training, formulation of guidelines, and supportive pathway for clarity of clinicians regarding euthanasia in India.

Death – it affects all of us including physicians. We all have to die, and we all have an interest in the idea of a good death. So, unlike other bioethical issues, decision-making regarding end-of-life is a particularly challenging discussion for all of us. Post-World War II, science has made ample progress to prolong the life span of an average human by almost 20 years. We have great palliative care measures in the face of terminal illnesses, but when it comes to the ultimate question of choosing death over life, most of the physicians dither.

DEFINITIONS

The word euthanasia, with its origin in Greek words “eu” and “thanatos” means a “good death.” Euthanasia means compassionately allowing, hastening, or causing the death of another. Generally, someone resorts to euthanasia to relieve suffering, maintain dignity or shorten the course of dying when death is inevitable. The concept of euthanasia has multiple dimensions. Active euthanasia means giving something to cause death, while passive euthanasia means withdrawing the supportive measures. Euthanasia can be voluntary if the patient has requested it, non-voluntary if the decision is made without the patient’s consent, or involuntary if the decision is made against the patient’s wishes. Many a times it’s difficult to distinguish between euthanasia and physician-assisted suicide (PAS), because both have a desire to end life and consequently assisted death.[1] To distinguish between the two one must look at the last act resulting in the death of the patient. If the patient himself performs the last act, for example death resulting from ingesting the pills prescribed by the physician is PAS, while a doctor giving lethal injection would be euthanasia.

INTERNATIONAL CONTEXT AND INDIAN LEGISLATIONS

Internationally, as of March 2021, active euthanasia is legal in seven countries worldwide. Most notable are Netherlands, Belgium, Luxembourg, Canada, and Spain. PAS is legalized in Germany, Switzerland and few US states like Oregon, California, Washington, and District of Columbia. Passive euthanasia is allowed in many countries across the world, India being one of them. The debate on euthanasia has been particularly puzzling in Indian context as according to Indian Penal Code (IPC) the attempt to commit suicide as well as abetment to suicide are punishable under section 309 and 306, respectively.[2] In the legal context, in 1986 M.S. Dubal vs. State of Maharashtra[3] was the first case in the subsequent long path that led to legalization of passive euthanasia in India. Maruti Sripathi Dubal was a police constable with psychiatric illness who tried to commit suicide and was tried under section 309 of IPC. In the decision, the Bombay High Court held that “right to life” under article 21 of the Indian Constitution includes “right to die” as well. On the other hand, in Chenna Jagadeeswar vs. State of AP,[4] the Andhra Pradesh High Court ruled that “right to die” is not a fundamental right under Article 21 of the Constitution^. In this case accused was a doctor who attempted to commit suicide along with his wife after killing his four children. He was convicted for murder as well as tried under section 309. Another case P. Rathinam’s vs. Union of India,[5] accused was tried for attempting suicide following unruly circumstances. The Supreme Court of India observed that the “right to live” includes “right not to live” i.e., right to die or to terminate one’s life. In this ruling, Supreme court also held section 309 unconstitutional. The supreme court noted that section 309 may result in punishing the person doubly and is irrational and cruel. In Gian Kaur vs. State of Punjab,[6] a five-member bench overruled the P. Rathainam’s case and held that right to life under Article 21 does not include Right to die or the right to be killed. The court held that Article 21 is a provision guaranteeing protection of life and personal liberty and by no stretch of imagination can extinction of life be read into it. In this case, Smt Gian Kaur and her husband were convicted by the court for abetting suicide of their daughter in law, by pouring kerosene over her. The most discussed and highlighted case on the debate of euthanasia in India is the Aruna Shanbaug case. Aruna Ramchandra Shanbaug was a former nurse from Haldipur, Karnataka. In 1973, while working as a junior nurse at King Edward Memorial Hospital, Mumbai, she was sexually assaulted by a ward boy and was left in a vegetative state since the assault. After 37 years of being in vegetative state, on 24^th January, 2011, the Supreme Court of India responded to the plea for euthanasia filed by activist Pinki Virani. The mercy killing petition was rejected as the hospital staff taking care of Aruna requested against it. However, in its benchmark judgment, the Supreme Court allowed passive euthanasia in India.[7] The court issued guidelines for passive euthanasia stating that the decision to withdraw treatment, nutrition, or water must be taken by spouse, parents, or a close relative, or in absence of them by a next friend after court’s approval. In 2018, a five-judge constitution bench of the Supreme Court[8] declared that the government of India would honor the living wills of patients in vegetative state or the ones suffering from terminal illness, thus, legalizing passive euthanasia in India.

NEED OF THE DISCUSSION

The statistics suggest that PAS is not a rare event. Telling results have been reported globally in various surveys and studies. Surveys done worldwide indicate that almost all physicians involved in taking care of terminal illnesses like AIDS receive requests for PAS or euthanasia at least once in their practice. In response to a hypothetical case vignette, almost half of the practicing physicians indicated they were likely to grant such requests.[9] There is also evidence to show increasing acceptance of PAS and euthanasia among treating physicians and critical care nurses.[10,11]

In Netherlands, euthanasia was granted legal status in 1984 after a Dutch Supreme Court decision authorized this practice. Few years later, it was reported in that in 1995 euthanasia was responsible for nearly 5% of all deaths in Netherlands as compared to 2.7% in 1990.[12] Supporters of PAS point to data from Netherlands as evidence that legalization has not led to widespread abuse or overuse of euthanasia or PAS. However, critics suggest that almost 75% increase in deaths involving euthanasia or PAS (from 2.7 to 5%) demonstrates a growing tendency toward their more frequent use and thus a greater number of potentially inappropriate cases of euthanasia. In Southern India, a survey[13] conducted in a tertiary care hospital in Manipal, showed euthanasia to be an acceptable concept to majority of doctors (69%). Most common reason cited by these doctors was to relieve unbearable pain and suffering. Another study from New Delhi[14] found that withholding or withdrawal of treatment was acceptable to majority of palliative care physicians and nurses. There are other factors like gender, medical specialty, religious affiliation which have a role in determining one’s attitude towards euthanasia, but nevertheless, these data indicate that requests for assistance in dying are clearly not rare events and physicians not so uncommonly grant such requests despite legal prohibitions.

The role of a psychiatrist carries distinctive importance in the debate as well as the practice of euthanasia. Psychiatrists can help in dealing with issues ranging from presence of depression or suicidal ideations in the terminally ill requesting for euthanasia to the ultimate question of capacity to give consent for the same.

EUTHANASIA ON MEDICAL GROUNDS-ROLE OF A PSYCHIATRIST

Out of all the patients with end stage medical illnesses who make a request for euthanasia or PAS, many may have underlying untreated depression. According to World Health Organization,[15] suicidal thoughts or acts are among the core symptoms of depression. Almost always there are feelings of hopelessness, helplessness and worthlessness associated with major depression, which may present itself in the form of a patient requesting for help in ending one’s life.[16] Also, depression can be very difficult to diagnose in the backdrop of long term chronic medical illnesses. Most of these patients are under the care of physicians who may be ill equipped to diagnose and treat depression in such complex scenarios.

Depression is highly prevalent amongst people with chronic terminal medical illnesses like AIDS, cancer etc.[17,18] In these patients with terminal illnesses, depression is highly correlated with hopelessness and desire for hastened death.[16] This further necessitates the need of a psychiatric consult in patients with medical illnesses who request for PAS or euthanasia. The proposed guidelines offered till date have all suggested that psychiatric evaluation must be included in the critical assessment of a patient’s request for PAS. If PAS or euthanasia (active or passive) is to be legalized in any country, the role of mental health professional becomes even more important. Despite the apparent importance of a mental health professional’s evaluation in assessing the requests for PAS, very little research has been conducted in this area. Only 2% physicians seek mental health consultation for patients who request for euthanasia.[19] Psychiatric evaluation for these patients can result in better decision making and improvement in quality of end-of-life care for medically ill patients.

EUTHANASIA IN PSYCHIATRIC PATIENTS

There are legitimate clinical and ethical concerns when a patient with mental illness makes a request for euthanasia or PAS. The hopelessness found so commonly in patients of severe depression can lead to a request for euthanasia or PAS. However, people in favor of the legalization put forth the argument, that chronic severe mental illnesses cause intense suffering to the patient for which a solution might not always be available.[20] A few of the diagnoses in question are dementia, treatment resistant depression etc., Various reasons for requesting for euthanasia or PAS in these patients may include absence of improvement, feeling of loss of dignity and burden on the significant others. Although majority of such requests are denied but there are few isolated incidents wherein euthanasia has been granted to mentally ill patients. In 2017, the incidence of assisted death for psychiatric reasons was found to be 1.1% of all assisted deaths in Belgium and 1.3% in Netherlands.[21] In such cases psychiatrist is usually the treating doctor and has to be the one granting euthanasia. In a survey only 6% psychiatrists felt confident that they could assess in a single assessment whether mental illness was influencing a person’s decision for requesting PAS.[22] The euthanasia training modules in various countries like Support a Consultation for Euthanasia in the Netherlands and Life End Information Forum in Belgium, do not have provision for assessment by a psychiatrist. There is evidence that exploration of psychological issues can lead to withdrawal of request for euthanasia.[23] Few experts have also raised the question whether the exclusion of psychiatric patients from PAS legislation is discriminatory.[24] Their argument is based on two assumptions – that not all psychiatric patients either have impaired decision-making ability or are effectively curable. But by erasing the distinction between medical and psychiatric disorders, there is fear of implication that PAS should be available to all patients (whether medical or psychiatric) for all reasons or, ultimately no reason.[25] There is a genuine risk of strengthening the link between PAS/euthanasia and organ donation as psychiatric patients are much more likely to be a source of reusable healthy organs. In Indian context, with the implementation of Mental Healthcare Act, 2017 there is a further convoluted situation with respect to the provision for advance directive and nominated representatives for patients with psychiatric illness. Moral implications can be many for geriatric healthcare delivery, wherein someone else can decide whether an elderly with dementia wants to live or die.

CONCLUSION

The strongest arguments by the proponents of euthanasia are based on right to self-determination and dignified death. They suggest that not all pain can be relieved or cured in cases of long term mental or physical illness and death can be slow and miserable for these patients. In such scenario, the role of compassionate and skillful training for end-of-life palliative care cannot be denied. The provision of active euthanasia can be considered as an act of killing, which must never be sanctioned to doctors. There is already a growing sense of mistrust regarding doctors in general public and legalization of active euthanasia may further weaken this bond. There is a risk that euthanasia will not only be limited to people who are terminally ill and may become non-voluntary for people who are dependents on others for care. It also carries the risk of becoming a tool for healthcare cost containment by caretakers as well as medical practitioners. As of present day, passive euthanasia has been granted legal status in India by supreme court, but the clear lack of any guidelines or supportive pathway for clarity of clinicians is evident. This is even more difficult for patients with psychiatric illnesses, thus calling for the need of further research and discussions regarding euthanasia in India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.