SUICIDE & EUTHANASIA

SUICIDE & EUTHANASIA

Commission of the crime is more serious than attempts of the same – How much surprising is this ?

 Suicide is the only crime where commission is not punishable but attempt is.

This is because if you succeed, you are beyond all laws. Recently there was  a news that Suicide is getting decriminalised.

In July 2014 dealing with a situation, The Supreme court of India has desired a nationwide debate on the issue, while accepting that the jurisdiction of finalizing the issue is with law makers and not with the Court of law.

In India recently the topic of Suicide came for discussion in parliament and it is stated that the Law Commission of India in its 210th report on "Humanization and De-criminalisation of Attempt to Suicide" had recommended that section 309 of IPC needs to be done away with. This has also revived the debate on euthanasia. Terminal punishment and euthanasia are two diametrically opposite subjects, wherein debates are on for “Right to life” and “right to death”. Both are on their track without mutual interference of interaction. It is always argued that the right to speak doesn’t compel you to speak, it is your option to exercise whether to speak or to be silent.

Issues for introspection in case of suicides :-

Isn’t it really barbaric and cruel to punish a person who fails in extinguishing his ‘miserable more than death’ life, by putting him in prison? If the state cannot provide a person with humane living conditions, can it be just in restraining his right to die ? These are issues which need serious introspection.

Continuation of CPC-Section 309 is considered an anachronism unworthy of human society in the 21^st century.

It is shocking to learn that in India, suicide rates are highest in southern States which are richer and more developed with better literacy, social welfare and health care. The rise in suicide rates may be due to disappointments as a result of un-met expectations of achievement and new technologies like mobile phones. Social networking sites contributing to loneliness also lead to breakdown of family units traditionally relied on for support during distress. The government has initiated the process to de-criminalise attempt to suicide, a move that will ensure that people who are driven to kill themselves do not end up in jail if they don’t succeed.

Suicide is not something new or unknown to civilisation. It has definitely been part of human behavior, since the dawn of civilisation. Humanity has been confronted with this problem of self-destruction since then. It is argued that no individual has complete autonomy with respect to life. His family does have a claim over him. The ‘right to die’ is based on a conservative and individualistic argument whereby suicide is considered a private affair which in no way can cause damage to others.

But these logics are certainly false, as far as most of us are concerned. A person may be the sole bread winner of his family and if he commits suicide, his family would certainly be driven to destitution. The holding of a ‘right to die’ is in accordance with a capitalistic, property-oriented outlook which prefers to treat everything including the human body, organs and even emotions as a form of commodity.

Flawed reasoning  -- The so-called ‘right to die’ was also justified in the name of ‘globalisation of Indian economy.’ The divisional bench in its 1994 decision observed that by effacing Section 309 we would be attuning this part of our “criminal law to the global wavelength.” This kind of reasoning clearly ignores the peculiarities of the social and economic conditions of our country and the rapid increase in suicide rates in general and that of dowry deaths in particular. The better option is not to punish anyone for attempting suicides but the law may be allowed to remain on the statute book as the chances of abuse of its deletion are very high, particularly by mother-in-laws or even by children in case of elderly parents. Suicide and mercy killing are different and should not be confused as one and the same. In the former no third party is involved but in the latter the third party is crucial. We should certainly have a law permitting euthanasia, but not suicide.

The Indian Society of Critical Care Medicine (ISCCM) and Indian Association of

Palliative Care (IAPC) on Saturday clarified that end of life (EOL) was distinct from 'euthanasia' and the two terms should not be confused.

In a PIL filed by NGO, Common Cause, seeking "the right to die in dignity" be declared as a fundamental right, the Supreme India had appointed a five-judge Constitution bench to look into the issues around euthanasia. The ISCCM has filed an "impleadment petition" as a respondent in the case.

Both the associations are planning to lobby with the Medical Council of India (MCI) on clarifying the difference between "withholding and withdrawing therapy" and euthanasia.

At present, ISCCN and IPAC are working with lawyers to develop a policy and definitions for EOL care. They have already developed a position paper, guidelines for EOL care and implementation norms, said Dr R Chawla, senior critical care consultant, Indraprastha Apollo Hospital. Members said the policy was particularly important as India ranked 39{+t}{+h} among 40 countries in 'quality of death' in a study by Economic Intelligence Unit in 2012.

“The Ministry of Home Affairs is in the process of effacing Section 309 of the Indian Penal Code,” Minister of State for Home Haribhai Parathibhai Chaudhary told the Rajya Sabha. As many as 18 States and four Union Territories are in favour of deletion of Section 309, he added. The tenth Law Commission in its report has also favoured such a deletion. The move is justified because suicides are committed during temporary loss of soundness of mind and insanity, as such is a complete defense even for killing other human beings. Section 309 is also arbitrary as it paints all suicides with one brush and makes no room for the particular circumstances.

In 1994 the Supreme Court not only de-criminalised the attempt to suicide but also observed that the ‘right to life’ includes the ‘right to die.’ The court strangely observed that all fundamental rights have positive connotations as well as negative connotations. Thus freedom of speech included right to silence, freedom to do business includes freedom not to do any business. Similarly the right to life includes the right not to live. But then de-criminalising attempt to suicide is one thing and conferring a right to die is another. Right to silence or right not to do business or trade constitutes merely temporary suspension of rights and on any future date a person may exercise these rights. But once a life is extinguished, it is lost forever. In 1996, a five-judge bench headed by Justice J.S. Verma overturned the 1994 decision which brought Section 309 back to life. Attempt to suicide should stay on the statute book because suicide comes in conflict with the monopolistic power of the state to take away life.

Not limiting the issue of suicide i.e extinguishing one’s own life the issue has raked up another aspect of End Of Life for those who are terminally ill. This talks of Euthanasia.

The word  Euthanasia means “Assisted Death”. Some have the opinion that the word euthanasia has originated from Greek words Eu and Thanatos – which mean Good Death. The word "euthanasia" seems to have first used in a medical context by Francis Bacon in the 17th century, to refer to an easy, painless, happy death, during which it was a "physician's responsibility to alleviate the 'physical sufferings' of the body." Bacon referred to an "outward euthanasia"— the term "outward" he used to distinguish from a spiritual concept—the euthanasia "which regards the preparation of the soul."

The debate is decades old and has taken many-many rounds all over the world. It is understood that in some countries euthanasia is legitimate. The Netherlands is the only country in the world where euthanasia is openly practiced, though it is not exclusively supported by statute. Active euthanasia is currently only legal in Belgium, Holland and Luxembourg, with some laid down criteria wherein it is ensured that the patient has consciously requested for it and medical practitioners are convinced that it is a necessity.

The issue concerns the rights of a terminally-ill person, after doctors unanimously rule out chances of survival. There is a minute difference in Euthanasia and assisted death. In Euthanasia, having fully convinced with the need person (may be a medical doctor) other than patient, administers a lethal injection on patients repeated requests for it. In case of  assisted death patient is assisted to do the needful for peaceful death, a better end of life. Proper care is taken to ensure that the decision of ending life in a better way is sole and voluntary in sound (capable of making such decisions) mental condition, from the patient without any external persuasion.

1. Types of euthanasia (Different classifications)

1. Active and Passive Euthanasia.

A.1   Active euthanasia –

Active euthanasia would involve a doctor injecting a lethal medicine to trigger cardiac arrest. It is administration of a lethal agent by another person to a patient for the purpose of relieving the patient’s intolerable and incurable suffering – for example, by injecting them with a large dose of sedatives

A.2   Passive euthanasia –

In passive euthanasia, doctors, with consent from relatives (attendants sometimes), withdraw the life support system of a person being kept alive with the help of machines. It could be by withdrawal of life saving systems / Medications or by injecting  suitable medicines to relieve a terminally the patient  from the sufferings anymore. Summarily it is death of a person causes by withholding or withdrawing treatment that is necessary to maintain life, such as withholding antibiotics from someone with pneumonia

2. Voluntary-Non voluntary and Involuntary:

B.1   Voluntary euthanasia –

Where a person makes a conscious decision to die and asks for help to do this

B.2   Non-voluntary euthanasia –

Where a person is unable to give their consent (for example, because they are in a coma or are severely brain damaged) and another person takes the decision on their behalf, often because the ill person previously expressed a wish for their life to be ended in such circumstances.

B.3    Involuntary euthanasia –

Where a person is killed, against his/her expressed wishes. Involuntary euthanasia is almost always regarded as murder.

International Code of Medical Ethics is:

"A physician shall always bear in mind the obligation to respect human life", and the euthanasia in its various forms is just against this code.

2. End of life care decisions

Any person approaching the end of life has a right to good palliative care to control pain and other symptoms, as well as psychological, social and spiritual support. The person is entitled to have a say in the treatments you receive at this stage in following .

1. Refusing treatment
2. Advance decisions
3. CPR and "do not attempt CPR" orders (DNACPR)
4. Palliative sedation
5. Withdrawing life-sustaining treatments.
6. Living Wills.

2.1     Refusing treatment

Within the purview of the Voluntary Euthanasia under English law, all adults have the right to refuse medical treatment, as long as they have sufficient capacity (the ability to use and understand information to make a decision). A legally binding advance decision (previously known as an advance directive) sets out the procedures and treatments that you consent to and those that you do not consent to. This means that the healthcare professionals treating you cannot perform certain procedures or treatments against your wishes. Under English law, all adults have the right to refuse medical treatment, even if that treatment is required to save their life, as long as they have sufficient capacity (the ability to use and understand information to make a decision).

In the case of living will, it is argued that if a person had the right to refuse a particular medicine or treatment, why should he/she be not allowed to execute a will in sound mind saying if he/she ever slipped into a vegetative state with a terminal disease with no chance of recovery, doctors shouldn't keep him/her alive with the help of life support?

Under the Mental Capacity Act (2005), all adults are presumed to have sufficient

capacity to decide on their own medical treatment, unless there is significant

evidence to suggest otherwise.

1. The evidence has to show that:

1. A person's mind or brain is impaired or disturbed
2. The impairment or disturbance means the person is unable to make a decision at the current time

2. Examples of impairments or disturbances in the mind or brain include:

1. Brain damage caused by a severe head injury, stroke or dementia
2. Mental health conditions, such as psychosis (where a person is unable to tell the difference between reality and their imagination)

3. Any physical illness that causes delirium (illusions, disorientation or

hallucinations)

2.2     Advance decisions

If you know that your capacity to consent may be affected in the future – for example, because you may become unconscious – you can arrange a legally binding advance decision (previously known as an advance directive), an advance decision clearly sets out the treatments and procedures that you do not consent to. This means that the healthcare professionals who treat you will be unable to carry out certain treatments and procedures that are against your wishes.

For an advance decision to be valid, you must be very specific about what

treatments and procedures you do not want and under what circumstances. For

example, if you want to refuse a certain treatment, even if it means your life is at risk, you must clearly state this. As long as the advance decision is valid and applicable, the healthcare professionals treating you must follow it. In other words, it must cover exactly the condition you go on to develop and the treatment decision being debated.

There must not be any doubt about your capacity at the time of drawing up the advance decision, and it must be clear that you have a good understanding of your condition and any treatment you are refusing. There must also be no suggestion that you were being coerced (or unreasonably influenced) by others when you made the decision.

2.3     DNACPR

Even when CPR is successful, a person can often develop serious and sometimes painful complications, such as: fractured ribs, damage to the liver and spleen, brain damage, leading to disability

2.4     Palliative sedation

Palliative sedation is when a person is given medication to make them unconscious and, therefore, unaware of pain. It is often used in cases where a person has a terminal illness.

Many terminal illnesses can cause distressing and painful symptoms when the

person reaches the final stages.

These can include: muscle spasms, bone pain, unpleasant and sometimes frightening breathing difficulties; upsetting emotions and feelings – such as fear, apprehension and distress.

Palliative sedation is a way of relieving needless suffering. Although palliative sedation is not intended to end a person's life, the medication carries a risk of shortening their lifespan. This has led some critics to argue that

palliative sedation is a type of euthanasia.

A counter-argument is known as the "doctrine of double effect". This states that a treatment that has harmful side effects is still ethical as long as it is in the best interests of the patient and the harmful side effects were not intended.

2.5     Withdrawing life-sustaining treatments : -

There are many different types of treatment that can be used to sustain life in

people with serious or terminal illnesses. These include: nutritional support through a feeding tube, dialysis – where a machine takes over the kidneys' functions, ventilators – where a machine takes over breathing. Eventually, there may come a time when it is clear that the prospects of a person recovering are zero and – in the case of terminal illness – the life-sustaining treatments are only prolonging the dying process.

If the person has not made an advance decision outlining the care they would

refuse to receive in these circumstances, a decision about continuing or stopping treatment will need to be made, based on what that person's best interests are believed to be. In such circumstances, the medical team will discuss the issue with family members and give them time to consider all the implications. If there is an agreement that continuing treatment is not in the person's best interests, treatment can be withdrawn, allowing the person to die peacefully.

In Britain it is expected that Lord Falconer's Assisted Dying Bill will eventually become law. The legislation would allow adults, expected to live six months or less, to be provided with assistance to end their lives. Some doctors are unhappy about the part they'd be asked to play, as this is infringing with the basic medical principle of saving the lives.

2.6     Living wills

A living will is a document that sets out a patient's wishes regarding health care and how they want to be treated if they become seriously ill and unable to make or communicate their own choices. Living wills are also called active declarations.

Such a document may be helpful to relatives and to medical professionals in the case of a seriously ill and incapacitated patient.

Living wills are a part of planning what to do in the event of serious illness or disability. The phrase has been used as a handy media label to such an extent that many people focus on the document itself, rather than the actual process of advance care planning. It may well be that:

The best discussions and plans for care may never be documented in a discrete, recognisable living will.

According to Linda Emanuel, vice president ethics standards, American Medical Association : A living will is not an instrument of euthanasia, but a request in advance to doctors not to give certain medical treatments. In fact, a living will need not block treatment, but could specify that doctors must continue treatment until the patient is dead, regardless of pain or suffering.

A philosophical problem : To make the use of a living will sensible, we have to assume that the wishes of the person would be the same when they become incompetent as when they make the will.  There is some evidence that it is much harder to anticipate one's state of mind when dying (or when receiving significant medical treatment) than had been thought, and equally hard, if not impossible, to anticipate what one's state of mind (if any) will be when one is in a coma.

Some people take this further, and say that "an individual is as discontinuous from itself at a later time as it is from other individuals". If you accept this then it's not logical to accept the usefulness of a living will at all.

1. Advantages of living wills

They respect the patient's human rights, and in particular their right to reject medical treatment creating living wills, encourages full discussion about end of life decisions knowing what the patient want means that doctors are more likely to give appropriate treatment. They help medical professionals in taking difficult decisions. A patient's family and friends don't have to take the difficult decisions

2. Disadvantages of living wills

• Writing them may be very depressing.
• It's difficult for a healthy person adequately to imagine what they would really want in the situations where a living will would take effect.
• It may be hard to translate the words of the living will into actual medical action.
• Patients may change their minds but not change their living wills.
• They're no use if they can't be found quickly when needed.

3. When to make one

People in good health find it hard to imagine the whole range of situations that might befall them, so it may be more effective for living wills to be compiled in the early stages of a disease or disability, as this will allow doctors to give realistic guidance about possible future situations.

4. Attitudes to living wills

A survey reported in the British Medical Journal in June 2000 found that although elderly inpatients were confused by the term "living will", most would welcome the chance to discuss issues about facing the end of life, and many would want to limit their health care if they were terminally ill.

5. Contents of a living will

e.1     Such a document would offer a set of particular medical scenarios  - an example prepared by the American Medical Association:

• Vegetative state
• Coma
• Brain damage and terminal
• Brain damage not terminal
• Chronic and incurable
• Serious but treatable

e.2     It would allow the patient to specify the goals of their medical care in each scenario from a list:

• Prolong Life; Treat Everything
• Attempt to Cure, but Reevaluate Often
• Limit to Less Invasive and less burdensome interventions
• Provide comfort care only
• Other (please specify)

e.3     It would also allow the patient to say what their wishes are in respect of specific medical interventions in the case of each of the scenarios above. They could say for each type of intervention:

• I want this treatment
• I want this treatment tried, but stopped if there is no clear improvement
• I don't want this treatment
• I am undecided about this treatment

The form of living will offered by the UK Voluntary Euthanasia Society also includes a set of medical scenarios and continues in a more general form than the American Version:

e.4     It includes a statement by the author of the will - :

I consent to anything proposed to be done or omitted in compliance with the directions expressed above and I absolve my medical attendants from any civil liability arising out of such acts or omissions. I wish it to be understood that I fear degeneration and indignity far more than I fear death. I ask my medical attendants and any person consulted by them to bear this statement in mind when considering what my intentions would be in any uncertain situation.

3. The ethics of euthanasia

• Euthanasia raises a number of agonising moral dilemmas:
• Is it ever a right to end the life of a terminally ill patient who is undergoing severe pain and suffering?
• Under what circumstances can euthanasia be justifiable, if at all?
• Is  there a moral difference between killing someone and letting them die?
• Should human beings have the right to decide on issues of life and death?

There are also a number of arguments based on practical issues.

Some people think that euthanasia shouldn't be allowed, even if it was morally right, because it could be abused and used as a cover for murder.

4. Mercy killing

Very often people call euthanasia 'mercy killing', perhaps thinking of it for someone who is terminally ill and suffering prolonged, unbearable pain.

It is understandable, though tragic, that some patients in extreme duress--such as those suffering from a terminal, painful, debilitating illness--may come to decide that death is preferable to life. However, permitting physicians to engage in euthanasia would ultimately cause more harm than good. Euthanasia is  fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.

The involvement of physicians in euthanasia heightens the significance of its ethical prohibition. The physician who performs euthanasia assumes unique

responsibility for the act of ending the patient’s life. Euthanasia could also readily be extended to incompetent patients and other vulnerable populations.

Instead of engaging in euthanasia, physicians must aggressively respond to the needs of patients at the end of life. Patients should not be abandoned once it is determined that cure is impossible. Patients near the end of life must continue to receive emotional support, comfort care, adequate pain control, respect for patient autonomy, and good communication

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I is to clarify that I am only the compiler of the article having collected the material from different sources and intend only to enlighten the general mass about the subjects.

Compiled by : M R Iyengar