Euthanasia: Right to life vs right to die

Suresh Bada Math* and Santosh K. Chaturvedi

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See commentary "Dried blood spot testing: filling the gap between antiretroviral treatment & monitoring in
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The word euthanasia, originated in Greece means a good death1. Euthanasia encompasses various
dimensions, from active (introducing something to cause death) to passive (withholding
treatment or supportive measures); voluntary (consent) to involuntary (consent from guardian)
and physician assisted (where physician's prescribe the medicine and patient or the third party
administers the medication to cause death)2,3. Request for premature ending of life has
contributed to the debate about the role of such practices in contemporary health care. This
debate cuts across complex and dynamic aspects such as, legal, ethical, human rights, health,
religious, economic, spiritual, social and cultural aspects of the civilised society. Here we argue
this complex issue from both the supporters and opponents’ perspectives, and also attempts to
present the plight of the sufferers and their caregivers. The objective is to discuss the subject of
euthanasia from the medical and human rights perspective given the background of the recent
Supreme Court judgement3 in this context.
In India abetment of suicide and attempt to suicide are both criminal offences. In 1994,
constitutional validity of Indian Penal Code Section (IPC Sec) 309 was challenged in the
Supreme Court4. The Supreme Court declared that IPC Sec 309 is unconstitutional, under Article
21 (Right to Life) of the constitution in a landmark judgement4. In 1996, an interesting case of
abetment of commission of suicide (IPC Sec 306) came to Supreme Court5. The accused were
convicted in the trial court and later the conviction was upheld by the High Court. They appealed
to the Supreme Court and contended that ‘right to die’ be included in Article 21 of the
Constitution and any person abetting the commission of suicide by anyone is merely assisting in
the enforcement of the fundamental right under Article 21; hence their punishment is violation of
Article 21. This made the Supreme Court to rethink and to reconsider the decision of right to die.
Immediately the matter was referred to a Constitution Bench of the Indian Supreme Court. The
Court held that the right to life under Article 21 of the Constitution does not include the right to
die5.
Regarding suicide, the Supreme Court reconsidered its decision on suicide. Abetment of suicide
(IPC Sec 306) and attempt to suicide (IPC Sec 309) are two distinct offences, hence Section 306
can survive independent of Section 309. It has also clearly stated that a person attempts suicide
in a depression, and hence he needs help, rather than punishment. Therefore, the Supreme Court
has recommended to Parliament to consider the feasibility of deleting Section 309 from the
Indian Penal Code3.
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Arguments against euthanasia
Eliminating the invalid: Euthanasia opposers argue that if we embrace ‘the right to death with
dignity’, people with incurable and debilitating illnesses will be disposed from our civilised
society. The practice of palliative care counters this view, as palliative care would provide relief
from distressing symptoms and pain, and support to the patient as well as the care giver.
Palliative care is an active, compassionate and creative care for the dying6.
Constitution of India: ‘Right to life’ is a natural right embodied in Article 21 but suicide is an
unnatural termination or extinction of life and, therefore, incompatible and inconsistent with the
concept of ‘right to life’. It is the duty of the State to protect life and the physician's duty to
provide care and not to harm patients. If euthanasia is legalised, then there is a grave
apprehension that the State may refuse to invest in health (working towards Right to life).
Legalised euthanasia has led to a severe decline in the quality of care for terminally-ill patients in
Holland7. Hence, in a welfare state there should not be any role of euthanasia in any form.
Symptom of mental illness: Attempts to suicide or completed suicide are commonly seen in
patients suffering from depression8, schizophrenia9 and substance users10. It is also documented in
patients suffering from obsessive compulsive disorder11. Hence, it is essential to assess the mental
status of the individual seeking for euthanasia. In classical teaching, attempt to suicide is a
psychiatric emergency and it is considered as a desperate call for help or assistance. Several
guidelines have been formulated for management of suicidal patients in psychiatry12. Hence,
attempted suicide is considered as a sign of mental illness13.
Malafide intention: In the era of declining morality and justice, there is a possibility of misusing
euthanasia by family members or relatives for inheriting the property of the patient. The
Supreme Court has also raised this issue in the recent judgement3. ‘Mercy killing’ should not
lead to ‘killing mercy’ in the hands of the noble medical professionals. Hence, to keep control
over the medical professionals, the Indian Medical Council (Professional Conduct, Etiquette and
Ethics) Regulations, 2002 discusses euthanasia briefly in Chapter 6, Section 6.7 and it is in
accordance with the provisions of the Transplantation of Human Organ Act, 199414. There is an
urgent need to protect patients and also medical practitioners caring the terminally ill patients
from unnecessary lawsuit. Law commission had submitted a report (no-196) to the government
on this issue15.
Emphasis on care: Earlier majority of them died before they reached the hospital but now it is
converse. Now sciences had advanced to the extent, life can be prolonged but not to that extent
of bringing back the dead one. This phenomenon has raised a complex situation. Earlier diseases
outcome was discussed in terms of ‘CURE’ but in the contemporary world of diseases such as
cancer, Aids, diabetes, hypertension and mental illness are debated in terms best ‘CARE’, since
cure is distant. The principle is to add life to years rather than years to life with a good quality
palliative care. The intention is to provide care when cure is not possible by low cost methods.
The expectation of society is, ‘cure’ from the health professionals, but the role of medical
professionals is to provide ‘care’. Hence, euthanasia for no cure illness does not have a logical
argument. Whenever, there is no cure, the society and medical professionals become frustrated
and the fellow citizen take extreme measures such as suicide, euthanasia or substance use. In
such situations, palliative and rehabilitative care comes to the rescue of the patient and the
family. At times, doctors do suggest to the family members to have the patient discharged from
the hospital wait for death to come, if the family or patient so desires. Various reasons are quoted
for such decisions, such as poverty, non-availability of bed, futile intervention, resources can be
utilised for other patients where cure is possible and unfortunately majority of our patient's
family do accordingly. Many of the terminally ill patients prefer to die at home, with or without
any proper terminal health care. The societal perception needs to be altered and also the medical
professionals need to focus on care rather in addition to just cure. The motive for many
euthanasia requests is unawareness of alternatives. Patients hear from their doctors that ‘nothing
can be done anymore’. However, when patients hear that a lot can be done through palliative
care, that the symptoms can be controlled, now and in the future, many do not want euthanasia
anymore16.
Commercialisation of health care: Passive euthanasia occurs in majority of the hospitals across
the county, where poor patients and their family members refuse or withdraw treatment because
of the huge cost involved in keeping them alive. If euthanasia is legalised, then commercial
health sector will serve death sentence to many disabled and elderly citizens of India for meagre
amount of money. This has been highlighted in the Supreme Court Judgement3,17.
Research has revealed that many terminally ill patients requesting euthanasia, have major
depression, and that the desire for death in terminal patients is correlated with the depression18. In
Indian setting also, strong desire for death was reported by 3 of the 191 advanced cancer patients,
and these had severe depression19. They need palliative and rehabilitative care. They want to be
looked after by enthusiastic, compassionate and humanistic team of health professionals and the
complete expenses need to be borne by the State so that ‘Right to life’ becomes a reality and
succeeds before ‘Right to death with dignity’. Palliative care actually provides death with dignity
and a death considered good by the patient and the care givers.
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Counterargument of euthanasia supporters

Caregivers burden: ‘Right-to-die’ supporters argue that people who have an incurable,
degenerative, disabling or debilitating condition should be allowed to die in dignity. This
argument is further defended for those, who have chronic debilitating illness even though it is not
terminal such as severe mental illness. Majority of such petitions are filed by the sufferers or
family members or their caretakers. The caregiver's burden is huge and cuts across various
domains such as financial, emotional, time, physical, mental and social. Hence, it is uncommon
to hear requests from the family members of the person with psychiatric illness to give some
poison either to patient or else to them. Coupled with the States inefficiency, apathy and no
investment on health is mockery of the ‘Right to life’.
Refusing care: Right to refuse medical treatment is well recognised in law, including medical
treatment that sustains or prolongs life. For example, a patient suffering from blood cancer can
refuse treatment or deny feeds through nasogastric tube. Recognition of right to refuse treatment
gives a way for passive euthanasia. Many do argue that allowing medical termination of
pregnancy before 16 wk is also a form of active involuntary euthanasia. This issue of mercy
killing of deformed babies has already been in discussion in Holland20.
Right to die: Many patients in a persistent vegetative state or else in chronic illness, do not want
to be a burden on their family members. Euthanasia can be considered as a way to upheld the
‘Right to life’ by honouring ‘Right to die’ with dignity.
Encouraging the organ transplantation: Euthanasia in terminally ill patients provides an
opportunity to advocate for organ donation. This in turn will help many patients with organ
failure waiting for transplantation. Not only euthanasia gives ‘Right to die’ for the terminally ill,
but also ‘Right to life’ for the organ needy patients.
Constitution of India reads ‘right to life’ is in positive direction of protecting life. Hence, there is
an urgent need to fulfil this obligation of ‘Right to life’ by providing ‘food, safe drinking water
and health care’. On the contrary, the state does not own the responsibility of promoting,
protecting and fulfilling the socio-economic rights such as right to food, right to water, right to
education and right to health care, which are basic essential ingredients of right to life. Till date,
most of the States has not done anything to support the terminally ill people by providing for
hospice care.
If the State takes the responsibility of providing reasonable degree of health care, then majority
of the euthanasia supporters will definitely reconsider their argument. We do endorse the
Supreme Court Judgement that our contemporary society and public health system is not
matured enough to handle this sensitive issue, hence it needs to be withheld. However, this issue
needs to be re-examined again after few years depending upon the evolution of the society with
regard to providing health care to the disabled and public health sector with regard to providing
health care to poor people.
The Supreme Court judgement to withhold decision on this sensitive issue is a first step towards
a new era of health care in terminally ill patients. The Judgment laid down is to preserve
harmony within a society, when faced with a complex medical, social and legal dilemma. There
is a need to enact a legislation to protect terminally ill patients and also medical practitioners
caring for them as per the recommendation of Law Commission Report-19615. There is also an
urgent need to invest in our health care system, so that poor people suffering from ill health can
access free health care. Investment in health care is not a charity; ‘Right to Health’ is bestowed
under ‘Right to Life’ of our constitution.
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