New Delhi: Doctors who have been campaigning for greater clarity and legal guidance for end-of-life care decisions have welcomed the Supreme Court ruling on "living will" and passive euthanasia but caution that its impacts will hinge on how people, doctors and hospital administrations respond.
"This is a beginning - a lot of work remains, members of the public and the medical fraternity need to understand their duties and responsibilities," said Roop Gursahani, a consultant neurologist at the Hinduja National Hospital in Mumbai.
"Hospitals need to have mechanisms for documenting such decisions, doctors need to counsel patients and their families - even when a cure is no longer possible, doctors still have a duty to care and prepare for the handover to the other side with grace and dignity," he said.
Some doctors point out that the concept of terminal illness might at times itself be a nebulous concept. A condition that doctors may consider potentially treatable might be considered terminal by patients for economic reasons, said Sanjay Nagral, a surgical gastroenterologist at the Jaslok Hospital, Mumbai.
"In the absence of universal health coverage, costs can sometimes creep into the equation," Nagral said. "We need to confront this question: is it possible some families might take costs into consideration to take decisions on passive euthanasia?"
The following are some of your questions and the answers:
Q: What has the Supreme Court ruled?
A: One, adults can in sound mind put it down in writing that if they suffer from a terminal illness that is causing intense pain and suffering and/or enter into a persistently vegetative state without hope of recovery, their family and doctors should withdraw or withhold life-sustaining medical support such as drugs, dialysis and ventilation.
Two, where there is no such "advance directive" or "living will", a medical panel constituted by the state will have to be approached. The panel will decide after taking the consent of blood relations. There must be a "cooling period" to allow any aggrieved person to approach the courts.
Q: How will the euthanasia be administered?
A: There's no question of euthanasia being "administered". What has been allowed, with safeguards, is passive euthanasia - the withdrawal or withholding of treatment or artificial life support - and not active euthanasia, which entails the use of lethal substances, such as an injection.
Active euthanasia continues to be an offence in India, as in most countries.
Q: Who can be subjected to passive euthanasia? Has the court specified any illnesses?
A: The court hasn't specified any illnesses as it cannot step into the domain of medical experts. If the doctors are convinced there's no hope of recovery, they can obtain the family's consent for passive euthanasia.
Doctors say they expect the question to arise only in the case of patients who are in a coma or a permanently vegetative state.
Q. If the patient is conscious and in control of his or her mental faculties, is it still the family's decision?
A. It's then the patient's decision alone.
Q: Will passive euthanasia be painful?
A. It's the doctors' job to ensure that withholding or withdrawing treatment does not worsen pain or suffering. Palliative care therapy seeks to minimize pain.
Q. Will relatives be allowed in the room?
A. Yes, if they want. If passive euthanasia is being carried out by withdrawing life support, the end may come in a matter of hours. However, if medicines are being stopped, no one can predict when death will occur.
Q. There have been suggestions that some hospitals already allow patients to be weaned off life support gradually because families cannot not afford ICUs or the medical condition was unbearable. Is this true?
A. Sanjay Nagral, a surgical gastroenterologist in Mumbai captured what he calls India's "distressing dichotomy." Nagral tweeted on Friday: "Rich patients are offered futile care in private hospitals as they profit from prolonging treatment. The poor are subject to systemic form of passive euthanasia because they cannot afford the cost of care."
Passive euthanasia has been in practice in the country - in poor and rich households - for lack of funds and to prevent further suffering by patients. Doctors and families take these decisions jointly and - in some cases - the hospitals get families to sign "left against medical advice" certificates so that doctors and hospitals cannot be blamed for sending a terminally ill patient home.