Fifty billion dollars. That is what the US government spent in 2009 in caring for patients in their last two months of life (out of a total Medicare budget of $425 billion). To put this in perspective, Medicare expenditure constitutes nearly 20% of federal spending in the country, making it third only to social security and defence spending, and more than the budget allocation to homeland security and education. Prolonging the lives of terminally ill patients via injecting them with drugs and feeding tubes are some of the ends to which these funds are directed. This is because US law does not allow physicians to withhold or withdraw treatment for terminally ill patients or those in a vegetative condition, save for the states of Oregon, Montana and Washington. This law applies to most of the developed and developing world, where, although the euthanasia debate began in the 16th century with Thomas More (who envisaged a utopian society as one which would facilitate the death of those whose lives had become burdensome as a result of ?torturing and lingering pain?) efforts to create laws for voluntary euthanasia have only been framed in the past 100 years.
India has joined this global debate with the Supreme Court?s landmark judgement on mercy killing. Although the Court rejected the plea on behalf of Aruna Shanbaug for a mercy killing, it has made a provision for ?passive euthanasia?. This translates into the ability of a person to take a decision to not undergo/stop treatments that merely prolong years, without restoring quality. In other words, those diagnosed with terminal illnesses or conditions (being pronounced brain-dead or in a vegetative state) would be allowed to shorten the timespan of their pain via the right to refuse medical intervention.
Although the judgement lays out the regulatory framework within which treatment can be withheld or withdrawn, the ethical dilemma remains. The pro-choice camp frames its argument on the merits of compassion and self-determination. However, the disposition of choice lends itself to misuse?for personal gain, by withholding treatment in cases where palliative care can ease pain or in cases where people have expressed the desire to live, regardless of their quality of life. After all, no one wants to witness another Dr Kevorkian aka ?Dr Death?, who assisted 130 people to die in Britain in the span of just over a decade.
Having established the need for a sound regulatory framework, the cost factor cannot be denied. As harsh as it sounds, the cost of keeping a terminally ill individual or one who has been pronounced brain-dead alive plays a central role in determining who gets to live. In Delhi, it costs around R10,000-11,000 to keep a patient in the ICU overnight at a private hospital. That comes to a whopping R36,50,000 per year to keep alive an individual who may not even wish to live. All because the law doesn?t allow for her to make her own decisions about how long she wants to live with a disease that in any case will end her life?later rather than sooner because of the various attached lifelines. And how many people can even afford to pay this sum of money to keep their kin hooked up to a machine? Aruna Shanbaug?s is a very special case, exceptional if you will, in that the hospital is bearing the cost of keeping her alive.
This naturally brings up the issue of the number of assisted deaths that take place outside the system. A study by London University revealed that one in every 500 deaths in Britain involves voluntary euthanasia, and one in 300 involuntary euthanasia, which amounts to 3,000 deaths a year outside any legal framework. There is no such estimate for India, but given the 5.5 lakh female infanticides each year between 1991 and 2001?despite it being illegal?it?s clear people will do what they want to irrespective of what the law says.
Given the potential for misuse of the law, a regulatory framework that brings as many people as possible into the system needs crafting. One such provision could be what Americans term end-of-life counselling, which will encourage people to register their preference for mode of treatment instead of leaving doctors and family members to guess what they want in cases in which they’re no longer able to speak for themselves. That way neither the hospital nor the family members can be accused of wrong-doing, allowing patients to maintain their dignity even in death.
Now that the Supreme Court has opened the floodgates in allowing discretionary passive euthanasia, it must also set up the specialised panels of doctors empowered to make those decisions on their behalf. Given the average length of legal proceedings in India, they may do well to ensure that this panel works differently, otherwise the petitioners may no longer need their discretion.
nikhila.gill@expressindia.com