It was 27th November, 1973. For Aruna Shanbaug, in her mid-twenties and a junior nurse at KEM Hospital (KEMH), Mumbai, it was nearing the end of a tiring and extended day, stressed out of continuingly heavy workload from previous days, triggered by several cases of food poisoning in nearby locatons of the city; she traced her tired steps towards locker room at the basement, for change of clothes and collecting her personal belongings. Little did she know that it would be the last time she would be on her feet moving around, as a contract sweeper boy, who was lurking in the vicinity, pounces on her and sexually assaults her. Found by a ward attendant in a bleeding and unconscious state the next day morning, it was observed that she was sodomized, choked with a dog chain and robbed. Asphyxiation had cut off oxygen supply to her brain, putting her in vegetative coma for remainder of her life that dragged agonizingly on for another forty two years, nursed by her colleagues and later generations of nurses, in continuity and with loving care, as an in-patient at KEMH, till her deteriorated end came on the morning of 18th May 2015.
The case of Aruna would be recorded in medical history as the world’s longest survivor in a persistent vegetative state. A nursing college in Mumbai has since been named after her. Her story has also been incorporated into school text books as a glowing example of post trauma health care and compassion, that successfully pleaded for her dedicated care-taking, in spite of her family abandoning her and even against background of the highest court’s decision to permit passive euthanasia. The violence and human depravity in Aruna’s tragic story poignantly contrast with strong commitment and unstinting dedication of KEMH’s team of nurses in responding to the situation with extraordinary humaneness. It has set off a fresh debate within the country on the pros and cons of euthanasia, with the aye-sayers clamouring for a realistic approach to the issue, shorn off religious bindings and liberated from restraining legal complexities.
Euthanasia, or ‘good death’ from Greek éu’ for ‘well’ or ‘good’ and ‘thanatos, ‘death’, is the practice of intentionally terminating a life in order to relieve pain and suffering. The word was first used in a medical context by Francis Bacon in the seventeenth century to refer to an easy, painless, happy death, responsibly facilitated by a physician to alleviate physical suffering of the body, a deliberate intervention undertaken with the express intention of ending life, to relieve intractable suffering. The laws vary from country to country, with many countries prohibiting it and some allowing it under clearly defined categories and extenuating circumstances. Defined under various categories, Euthanasia is described as voluntary, non-voluntary and involuntary, active and passive, with rights and wrongs associated with each.
In active euthanasia, a person directly and deliberately causes the patient’s death, whereas in passive euthanasia, the patient is merely allowed to die. While the death, in active euthanasia, is effected by external action, like killing with an overdose of painkillers, it is brought about in passive euthanasia by anomission, that is, letting the patient die by withdrawing or withholding treatment. The distinction, however, is only technical; it does not make moral sense in that, whether active or passive, the intention of causing death is present in both. Voluntary euthanasia occurs at the request of the person seeking termination of life; non-voluntary euthanasia occurs when the person is unconscious or otherwise unable, as in the instance of an infant or a mentally challenged person, to make a decisive choice between living and dying, and a suitably placed external entity decides on their behalf. It is also inclusive of cases of normal children or legally minor teenagers where an external entity is involved in the decision making process. Involuntary euthanasia happens when the person, who is keenly opting to live, is done away with. Usually termed as murder, these are cases where the killing would be counted as beneficial for the victim. Yet another category is indirect euthanasia, where the well intended medical treatment, like administering anesthesia or pain-killers has the collateral effect of hastening the patient’s death. Called the doctrine of double effect in medical parlance, it is mostly seen to be morally acceptable, as the primary intention is to alleviate the patient’s suffering and not to cause harm.
Euthanasia is legally prohibited in India, and it is very unlikely if it will ever receive any consideration in the foreseeable future, given the sanctity accorded to preservation of life by various religions, belief systems and the myriad cultures that form the country’s social fabric. It is also prohibited in the United Kingdom. While non-voluntary euthanasia is illegal everywhere, voluntary euthanasia is legal in some countries, a few states in USA and provinces in Canada. Jurisdictions where euthanasia or assisted suicide is legal include the Netherlands, Colombia, Switzerland, Germany, Belgium, Luxembourg, Estonia, Albania, Japan, the states of Washington, Oregon, Montana and Vermont in USA, and, most recently, the Canadian province of Quebec.
With rapidly advancing technologies and, consequently, longer life spans, the question of euthanasia appears to pop up with increasing momentum and topicality. Even the mere consideration of it starts pricking society’s moral consciousness, like, is it ever right to end the life of a terminally ill patient undergoing severe pain and suffering, under what circumstances can euthanasia be justified, if at all, is there any difference between killing a person and letting him die? At the heart of the answer to these questions is the meaning and value attached to human existence. Can human beings arrogate to themselves the right to decide on life and death? If so, what is the guarantee that euthanasia will not be abused and used as a cover for murder? Quite often, euthanasia is described as ‘mercy killing’, appropriate for a terminally ill person, suffering prolonged, unbearable pain. Some surveys in the Netherlands and USA, however, indicate that only a small fraction of the requests for euthanasia attributed the cause to severe pain. People who are terminally ill may have other exacerbating conditions, such as incontinence, suffocation, nausea, paralysis, advanced stages of cancer, Alzheimer’s, not to discount psychological factors weighing on mind like depression, loss of control or dignity at becoming dependent and a burden on others, causing them to veer towards going to permanent sleep. If euthanasia is accordingly justifiable, can it be controlled by legislation once it is allowed? Not quite so, as there will always be people and situations where it may be enforced on the sly to eliminate vulnerable patients for reasons as selfish as the desire to gain early hold of ancestral properties or simply getting rid of the aged and sick who are considered an inconvenience.
The other pro-euthanasia argument is that the right to die, is as equal as the right to live a qualitative life with dignity, that it is implied in the numerous other human rights, that death is a personal matter and if there is no harm to others in one’s act of dying, then the state and the law must not interfere; the belief that human beings have the right to die when and how they want to is further strengthened by the specious notion that human beings are free and independent biological entities with the right to take own decisions on matters concerning themselves based on the belief that death is the end, hence nothing bad about dying and it is kosher to bring it about in the manner and time of one’s choice; that euthanasia in some manner is already happening as a matter of course, and hence allowing aged and terminally ill people to die, or facilitating it, may free up health care and economic resources for more deserving cases in the younger and productive age group. These arguments do not hold against the ill effects that such a provision can have on the emotional state of families of persons who put an early end to their lives; it is also as fallacious as the view that violence and murder already in exist in societies so it may as well be legalized. It also fails to counter the fact that permitting euthanasia can result in dilution of the commitment of health care professionals to safeguard life under all circumstances, especially in the case of the aged; in turn it may also end up with the gravely ill patient coming under indirect pressure to opt for voluntary euthanasia. Euthanasia weakens society’s respect for the sanctity of life, as it engenders the notion that lives of the disabled and gravely ill are less valuable than others. Voluntary euthanasia cannot be properly regulated, and is the beginning of a slippery slope leading to involuntary euthanasia and doing away of people considered undesirable. It is neither in the best interest of the patient nor the rights of others. It will discourage the search for new cures and treatments for major illnesses, and leaves undesirable power in the hands of doctors. It undermines society’s commitment to provide good care for the elderly and institute effective palliative care for the suffering and terminally ill, putting them under inhuman pressure to end their lives, allow materialism to entrench itself to such levels in the minds of people as to force families to abandon the gravely sick and aged, leaving them in the lurch, to inevitability of fate.
The observations of Immanuel Kant fit admirably into the context here. He maintained that rational human beings are to to be treated as an end in themselves, and not as a means to something else; the fact that we are human has value in itself. Our inherent value does not depend on anything else – it does not depend on whether we are having a good life that we enjoy, or whether we are making other people’s lives better. We exist, so we have value. We should not treat other people as a means to our own ends. Similarly, we must not treat ourselves as a means to our own ends, which means we should not end our lives just because it appears to be the most expedient way of putting an end to our suffering, as to do that is not to respect our inherent worth.
The compelling need is to look at the most acceptable option, accommodative and conservative, rather than destructive and extinguishing of life. The solution is to put in place the most advanced and regularly updated system of palliative care as a means of physical, emotional and spiritual support for the suffering and dying whose conditions are beyond cure. It includes compassion and support for family and friends, treating the patient as a human being and not as a cluster of ailments. Competent palliative care may well obviate any necessity for a patient to contemplate euthanasia. WHO points to the direction with their statement that palliative care affirms life and regards dying as a normal process, it neither hastens nor postpones death; it provides relief from pain and suffering; it integrates the psychological and spiritual aspects of the patient. The words of Dame Cicely Saunders, founder of the modern hospice movement, resonate meaningfully, “You matter because you are you. You matter to the last moment of your life and we will do all we can to help you die peacefully, but also to live until you die”.
There is no need to look into religions for sanction as all beliefs forbid taking away life. Even from a rational standpoint, all life forms are intrinsically valuable and, therefore, the order that sustains can only be upheld by preserving life to its fullest. Taking measures to relieve pain and suffering is desirable, nevertheless the other side is affirmative of concealed power in suffering, as it taps into one’s inner strength to bring out finest qualities of the spirit, which are transformative, not just of the individual, enabling his growth in wisdom, character and compassion, but of society at large. Integral to a person’s progress towards ultimate liberation, suffering is part of the moral force of the universe, urging the individual towards drawing upon all his faculties for elevating to the highest and noblest attributes. How else can there be the finest expressions of human spirit, like the sacrifice and dedicated struggle of a Nelson Mandela in undergoing a quarter century of incarceration in an island off Cape Town, or, as in given context, the saga of compassionate care taking of Aruna Shanbaug over a period of forty two long years by generations of nurses at KEMH, Mumbai?