The Indian medical community is divided over the issue of euthanasia. Credit: Loz Pycock/CC-BY-SA-2.0

By Neeta Lal
NEW DELHI, Aug 4 2014 (IPS)

If a terminally ill patient, with scant hope of recovery, pleads for his death to be facilitated, should the doctors comply? Or, if the family of a patient who has been declared brain-dead requests that her life-support system be withdrawn, should their will be respected?

These and many other such fraught questions are currently roiling India as the country debates the moral and legal dimensions of legalising euthanasia or ‘mercy killing’, defined as the painless termination of an incurably sick person’s life in order to relieve them of their suffering, or end a long-term coma.

In response to a petition filed by the New Delhi-based NGO Common Cause, which wants both the right to refuse treatment and the right to die with dignity to be incorporated into law, the Supreme Court has ordered a public debate on the contentious issue after decades of eschewing adjudicating on it.

At the heart of the debate is the case of Aruna Shanbaug, a rape victim who has been lying in a vegetative state in Mumbai’s KEM Hospital since 1973, virtually brain dead.

“It was unbearable to see an athlete like [my brother] live in a vegetative state. One fine day my father made a decision. He went to the hospital and brought my brother home. He died within a month.” -- Sarita, 35, a New Delhi resident
In March 2011, Shanbaug’s friend, journalist Pinki Virani, filed a plea to the Supreme Court to free Shanbaug from the agony of a barely conscious existence, but the apex court denied the petition.

The ruling National Democratic Alliance (NDA) government helmed by Narendra Modi – which came to power this May – has also been firmly opposed to legalising euthanasia.

“The government doesn’t accept euthanasia as a principle,” Attorney General Mukul Rohatgi told the press. “Our stand on euthanasia, in whichever form, is that the court has no jurisdiction to decide this. It’s for Parliament and the legislature to take a call after a thorough debate and taking into account multifarious views.”

Experts say complexities are amplified further by the absence of agreement between lawmakers and public, as well as medical, opinions about the right to life granted by the Indian Constitution.

“Will legalising euthanasia require a Constitutional amendment?” asked Samta Khanna, a Delhi-based legal activist. “And suppose a terminally ill or comatose patient has no close relatives or next of kin, who will take the decision whether or not life support should be withdrawn?”

The lawyer told IPS there were “so many dimensions to this sensitive issue” that it needed to be discussed in close detail before the drafting of a law.

Still, it is not rare for Indian families to opt for euthanasia with full cooperation from physicians. Prohibitive costs of protracted treatment, as well as a desire to end the suffering of a family member, both play a catalytic role in these decisions.

“Even with insurance cover, private hospital care in India burns a deep hole in the pockets of middle-class Indian families,” Dr. Dineshwar Sharma, CEO of the Apollo Hospital in Noida, a city in the northern state of Uttar Pradesh, told IPS.

“And for the poor, for whom life is a daily struggle for survival, treatment costs of a long-suffering patient can be ruinous.”

Stories of small farmers being forced to sell their meager landholdings for treatment are not uncommon. Nor are tales of terminally ill patients from villages being abandoned by their relatives in big hospitals.

The cost of life

Passive euthanasia, defined as the withholding of life-saving medicines or treatment, is also a frequent occurrence, particularly among the poor.

Thirty-six-year-old Naina, the wife of Manik Ram, a farmer whose family withdrew life support for him after two years of brain hemorrhaging and confinement to the bed, told IPS, “In the beginning, we were hopeful that my husband would recover. So we sold our small agricultural plot. Then went the household furniture followed by all my jewelry.

“But gradually, we realised the futility of spending money on my comatose husband as doctors were clear he wouldn’t ever recover. I asked the doctors to release my husband so we could take him home. After all, I had four young kids to look after as well.”

Ram was then brought home where he breathed his last after three weeks. “I’m still under a heavy debt but as we don’t have to pay hefty hospital bills any more, I’m hoping things will gradually get back to normal,” she said.

Such tales are not unique in this country of 1.2 billion people.

Sarita, 35, whose young brother Mukesh was paralysed from the neck downwards in a motorcycle crash in 2011 in New Delhi, recounts the days of horror the family lived through after he was hospitalised.

“My mother had to sell off all her gold ornaments. My wedding was also put on hold because the hospital bills for my brother were phenomenal,” she told IPS.

“It was unbearable to see an athlete like him live in a vegetative state. One fine day my father made a decision. He went to the hospital and brought my brother home. He died within a month.”

Still, the Indian medical fraternity’s views over the matter are splintered.

While some doctors oppose it, calling it “murder”, others believe that extenuating circumstances make a case for passive euthanasia.

“Family members should be at liberty to decide whether to withdraw the life-support system from a patient if there is no hope of revival,” Dr. Rajendra Prasad, medical director of the Indian Head Injury Foundation, told IPS.

“Several patients die because of a lack of such systems,” he said. “However, active euthanasia, in which the terminally ill are killed [by lethal injection] should be prohibited.”

The anti-euthanasia lobby contends that doctors have a moral responsibility to keep their patients alive, as enshrined in the Hippocratic Oath.

“The line dividing euthanasia from murder is a fine one, and legalising euthanasia might result in an abuse of law, unfairly targeting the poor and disabled, and create incentives for insurance companies to terminate lives in order to save money,” according to Dr. Sanjay Dheer, an oncologist at Max Healthcare in New Delhi.

“There should be a system of checks and balances to review such situations on a case-to-case basis so that both doctors and families can take an informed decision,” added Dr. Sumit Ray, vice chairperson of critical care medicine at the Sir Ganga Ram Hospital in New Delhi.

“Just like most hospitals have a panel to certify whether a person is brain dead or not, a similar panel for euthanasia should be in place,” he told IPS.

Doctors say there is mounting pressure on them as most big hospitals are getting at least three to four such requests from families per week.

Worsening the situation is the crisis in the Indian health sector where a dearth of doctors and hospital beds is forcing the medical community to reconsider huge investment in patients who are unlikely to live.

According to the 12th Five-Year Plan, the doctor-patient ratio is 45 per 100,000, against the desirable ratio of 85 per 100,0000.

Similarly, the number of nurses and midwives is only 75 per 100,000, compared to the goal of 255 per 100,000 patients. The crisis is worse in rural areas, which are especially poorly served.

Euthanasia as a concept isn’t new to India. Seers and sages have for centuries practiced yogic concepts like samadhi, nirvana and santhara, voluntarily opting for death at a particular stage in life, or to escape terminal illness. But successive governments of ‘modern’ India have been reluctant to draft these ancient practices into law.

Until Indian courts make a firm decision on the issue, those forced to make life-or-death choices for their loved ones say they will be plagued by confusion and guilt.

Edited by Kanya D’Almeida

The Sixth BRICS Summit which ended Wednesday in Fortaleza, Brazil, attracted more attention than any other such gathering in the alliance’s short history, and not just from its own members – Brazil, Russia, India, China and South Africa.

Two external groups defined by divergent interests closely watched proceedings: on the one hand, emerging economies and developing countries, and on the other, a group comprising the United States, Japan and other Western countries thriving on the Washington Consensus and the Bretton Woods twins (the World Bank and the International Monetary Fund).

The first group wanted BRICS to succeed in taking its first big steps towards a more democratic global order where international institutions can be reshaped to become more equitable and representative of the world’s majority. The second group has routinely inspired obituaries of BRICS and gambled on the hope that India-China rivalry would stall the BRICS alliance from turning words into deeds.The stature, power, force and credibility of BRICS depend on its internal cohesion and harmony and this, in turn, revolves almost wholly on the state of relations between India and China. If India and China join hands, speak in one voice and march together, then BRICS has a greater chance of its agenda succeeding in the international system.

In the event, the outcome of the three-day BRICS Summit must be a disappointment to the latter group. First, the obituaries were belied as being premature, if not unwarranted. Second, as its more sophisticated opponents have been “advising”, BRICS did not stick to an economic agenda; instead, there emerged a ringing political declaration that would resonate in the world’s trouble spots from Gaza and Syria to Iraq and Afghanistan.

Third, and importantly, far from so-called Indian-China rivalry stalling decisions on the New Development Bank (NDB) and the emergency fund, the Contingency Reserve Arrangement (CRA), the Asian giants grasped the nettle to add a strategic dimension to BRICS.

With a shift in the global economic balance of power towards Asia, the failure of the Washington Consensus and the Bretton Woods twins in spite of conditionalities, structural adjustment programmes and “reforms”, financial meltdown and the collapse of leading banks and financial institutions in the West, there had been an urgent need for new thinking and new instruments for the building of a new order.

Despite the felt need and multilateral meetings that involved developing countries, including China and India which bucked the financial downturn, there had been no sign of alternatives being formed.

It is against this backdrop – of the compelling case for firm and feasible steps towards a new global architecture of financial institutions – that BRICS, after much deliberation, succeeded in agreeing on a bank and an emergency fund.

From India’s viewpoint, this summit of BRICS – which represents one-quarter of the world’s land mass across four continents and 40 percent of the world population with a combined GDP of 24 trillion dollars – was an unqualified success. The success is sweeter for the National Democratic Alliance (NDA) government led by the Bharatiya Janata Party (BJP) because the BRICS summit was new Prime Minister Narendra Modi’s first multilateral engagement.

For a debutant, Modi acquitted himself creditably by steering clear of pitfalls in the multilateral forum as well as in bilateral exchanges – particularly in his talks with Chinese President Xi Jiping, with Russian President Vladimir Putin and with Brazilian President Dilma Rousseff – and by delivering a strong political statement calling for reform of the U.N. Security Council and the IMF.

In fact, the intensification and scaling up of India-China relations by their respective powerful leaders is an important outcome of the meeting in Brazil, even though the dialogue between the Asian giants was on the summit’s side-lines. Nevertheless, Modi and Xi spoke in almost in one voice on global politics and conflict, and on the case for reform of international institutions.

The new leaders of India and China, with the power of their recently-acquired mandates, sent out an unmistakable signal that they have more interests in common that unite them than differences that separate them.

Against this backdrop, Indian Prime Minister Modi’s outing was significant for other reasons, not least because of the rapport he was able to strike up, in his first meeting, with Chinese President Xi. The stature, power, force and credibility of BRICS depend on its internal cohesion and harmony and this, in turn, revolves almost wholly on the state of relations between India and China. If India and China join hands, speak in one voice and march together, then BRICS has a greater chance of its agenda succeeding in the international system.

As it happened, Modi and Xi hit it off, much to the consternation of both the United States and Japan. They spoke of shared interests and common concerns, their resolve to press ahead with the agenda of BRICS and the two went so far as to agree on the need for an early resolution of their boundary issue. They invited each other for a state visit, and Xi went one better by inviting Modi to the Asia-Pacific Economic Cooperation meeting in China in November and asking India to deepen its involvement in the Shanghai Cooperation Organisation (SCO).

Modi’s “fruitful” 80-minute meeting with Xi highlights that the two are inclined to seize the opportunities for mutually beneficial partnerships towards larger economic, political and strategic objectives. This meeting has set the tone for Xi’s visit to India in September.

Although strengthening India-China relationship, opening up new tracks and widening and deepening engagement had been one of former Indian Prime Minister Manmohan Singh’s biggest achievements in 10 years of government (2004-2014), after a certain point there was no new trigger or momentum to the ties. Now Xi and Modi are investing effort to infuse new vitality into the relationship which will have an impact in the region and beyond.

As is the wont when it comes to foreign affairs and national security, Modi’s new government has not deviated from the path charted out by the previous government. BRICS as a foreign policy priority represents both continuity and consistency. Even so, the BJP deserves full marks because it did not treat BRICS and the Brazil summit as something it had to go through with for the sake of form or as a chore handed down by the previous government of Manmohan Singh.

Before leaving for Brazil, Modi stressed the “high importance” he attached to BRICS and left no one in doubt that global politics would be high on its agenda.

He pointed attention to the political dimension of the BRICS Summit as a highly political event taking place “at a time of political turmoil, conflict and humanitarian crises in several parts of the world.”

“I look at the BRICS Summit as an opportunity to discuss with my BRICS partners how we can contribute to international efforts to address regional crises, address security threats and restore a climate of peace and stability in the world,” Modi had said on eve of the summit.

Having struck the right notes that would endear him to the Chinese leadership, Modi hailed Russia as “India’s greatest friend” after he met President Vladimir Putin on the side-lines of the summit.

India belongs to BRICS, and if BRICS is the way to move forward in the world, then BRICS can look to India, along with China, for leading the way, regardless of political change at home. That would appear to be the point made by Modi in his first multilateral appearance.