EUTHANASIA – Panel Discussion

1. EUTHANASIA – Panel Discussion Moderator – Dr AmbarishPadhi Panelists – Dr Kavi Pd Mishra Dr SamirSahu Dr SuvenduMishra Mr P Routray

2. Euthanasia(PASSIVE EUTHANASIA)

3. ETHICS • For doctors, care of living is also care of dying as well. • The Indian Physician is reluctant to take an Ethical decision, as he is not sure whether his position would be understood by the law as it exists today. • Law should facilitate, not obstruct humane care. Dr R K Mani

4. Active Euthanasia • Actively shortening the dying process • Performing an act with the specific intent of shortening the dying process • Overdose of narcotics, anesthesia, paralytics, etc. • It is not the absolute dose of narcotics, but a change in the dose

5. HASTENING DEATH(Euthanasia) PASSIVE - Over dose of Medication ACTIVE - a person actually causes the death of a terminally ill individual. - Physician Assisted Suicide SUICIDE - (Self – Deliverance)

6. ISCCM Guidelines 2005 • As per the Indian Penal Code, this committee of the Indian Society of Critical Care Medicine forbids the use of Euthanasia and Physician Assisted Suicide.

7. Brain Death • Irreversible cessation of all functions of brain including the brainstem • Does not include persistent vegetative state • In India, brain death is defined only for the purpose of the Transplantation of Human Organ Act 1994. Indian law does not define the state of brain death in contexts other than organ transplantation. • In the opinion of the Committee(ISCCM guidelines) , brain death should be regarded, as equivalent of death in all circumstances and the law should be suitably amended.

8. Aruna Shanbaug (6.3.2011) • The honourable judges for the first time pronounced that brain death (when brain activity has ceased while the patients breathing is sustained artificially) is equivalent to death. • This would allay physicians apprehensions about removing life supports from such a patient & would improve organ retrieval opportunities for organ transplantation.

9. Indian Law Commission • The term “Passive Euthanasia” as opposed to active killing (Euthanasia) is misleading and therefore no more used in contemporary medical terminology. Mani R K • Withdrawal & withholding decisions are distinct from Euthanasia and therefore do not violate suicide laws. 196th report of Indian Law Commission, 2006, Justice Jagannadha Rao

10. Non-medically Beneficial Treatment(Futile Care) It is well established in medical ethics and law that it is appropriate to withhold medical intervention when such interventions provide no reasonable likelihood of benefit to the patient.

11. Non-medically Beneficial Treatment(Futile Care) • How is medical futility defined? • Disease must be terminal • Disease must be irreversible • Death must be imminent • Merely preserves permanent unconsciousness or cannot end dependence on intensive medical care • Clear legal definition does not exist

12. Non-medically Beneficial Treatment(Futile Care) “Physicians are not obligated to provide care they consider physiologically futile even if a patient or family insists. If treatment cannot achieve its intended purpose, then to withhold it does not cause harm.Nor is failure to provide it a failure of standard of care.” Luce, 2001

13. Non-medically Beneficial Treatment(Futile Care) “Physicians are not ethically obligated to deliver care that, in their best professional judgment, will not have a reasonable chance of benefiting their patients. Patients should not be given treatments simply because they demand them. Denial of treatment should be justified by reliance on openly stated ethical principles and acceptable standards of care, not on the concept of ‘futility,’ which cannot be meaningfully defined.”AMA

14. Futile Care & Unilateral Action • Judicial review has no precedence in India Therefore unilateral action is not available to the Indian physician at present. • Communication with patients relatives • Shared decision

15. Legal Issues • Indian law has no clearly stated position Needed • Right to refuse treatment act • Withdrawal & withholding of life-sustaining treatment act • Right to palliative care act • A consensus regarding the practices relating to End of Life care in Indian ICUs should eventually lead to evolution of appropriate legislation in keeping with the changing needs of critical care practice Mani R K, 2005,IJCCM.

16. Legal Issues • Only clear legal rule on medically futile treatment is traditional malpractice test • Likely to get better legal results when refuse to provide nonbeneficial treatment and then defend position in court as consistent with professional standards than when seek advance permission from court to withhold treatment

17. End of Life Issues • In the ICU doctors are called upon to make decisions to start or stop medically useless treatments or those based on respecting patients rights for self determination. • Such decisions have to be made in hours or days. • In most countries these are regarded as every day practice. • Developing a procedure covering such situations needs to be preceded by awareness of the issues & an open debate sans the use of emotive terminology

18. CONCLUSION • Do not use the term Passive Euthanasia • Consider Brain Death as Death (already legally defined) • Define Futile Treatment • Withhold Futile Treatment • Do not Prolong the Dying Process