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NEW DELHI – India’s Supreme Court on Monday laid out guidelines for the use of euthanasia in extreme situations involving terminally ill patients, even as the justices rejected a plea for its use in the case of a woman in a vegetative state for nearly four decades.

With the decision, India joins a handful of nations _ including Belgium, Luxembourg, the Netherlands and Switzerland _ and the U.S. states of Oregon and Washington in allowing some form of euthanasia. India has no law on the topic, making the guidelines legally binding until parliament passes legislation.

As outlined, “passive” euthanasia in which life-saving treatment is withheld _ such as ending an antibiotics course or turning off a heart-lung machine _ is allowed in exceptional cases after a review by medical experts and approval by the High Court.

Active euthanasia, in which a patient is given life-ending drugs or other lethal intervention, is not allowed, the court said.

This was not an easy decision, the panel added. “Euthanasia is one of the most perplexing issues,” it said. “We feel like a ship in an uncharted sea.”

Hospital workers who’ve taken care of the woman in the vegetative state, Aruna Shanbaug, for the last 37 years said they were pleased she will continue to live. Euthanasia advocates said they were happy the issue was partially clarified and a social debate initiated.

“It will help others in a similar situation,” said Dr. Surendra Dhelia, joint secretary of the Society for the Right to Die with Dignity, a Mumbai-based civic group. “In cases where it’s this bad, you’re not prolonging life, you’re prolonging agony and suffering.”

Shanbaug, 60, was beaten and sexually assaulted in 1973 by a co-worker, a hospital janitor at Mumbai’s King Edward Memorial Hospital, where she remains today.

She suffered severe brain damage and paralysis after her attacker, Sohanlal Bhartha Valmiki, reportedly choked her with a chain. Valmiki was convicted of robbery and assault in 1974 and imprisoned for seven years. After his release, he reportedly moved, changed his name and found another hospital job.

The petition asking that Shanbaug be allowed to die was brought by Pinki Virani, an author and right-to-die activist, after Shanbaug’s family abandoned her. Virani argued that with the patient unable to see or speak properly, keeping her alive violated her basic dignity.

Virani expressed regret Monday that the court didn’t put an end to Shanbaug’s force-feeding. “She still does not, after more than three and a half decades, receive justice,” Virani said. “The bizarre postscript to Aruna’s story is that those who claim to ‘love’ her and ‘look after her’ are the ones who want her not to rest in peace.”

The euthanasia debate in India is often closely linked to ideas of fate and reincarnation. While the Jain religion believes in santhara, allowing those who choose to do so to stop eating, many in India’s majority Hindu culture believe euthanasia upsets the reincarnation cycle and amounts to meddling with the divine.

“To intervene is to defy fate,” said Ravinder Kaur, a social anthropology professor at New Delhi’s Indian Institute of Technology. “For many, the idea is that life is not yours to take.”

The staff at King Edward Memorial has become fond of Shanbaug after caring for her since the attack, said Pragna Pai, a retired dean. “She’s like a baby,” she said. “She’ll smile and laugh but can’t talk. She particularly likes mangos and fish.”

Some members of India’s medical establishment said Monday that India isn’t ready for euthanasia, given weak legal enforcement and a large rich-poor gap.

“When an old person with a bit of money becomes comatose, their family will 100 per cent exploit them,” said Dr. Devi Prasad Shetty, director of Bangalore-based Narayana Hrudayalaya hospital, who criticized many in India’s medical business as “quacks.” “Every elderly person’s life will be in danger.”

But Dhelia, with the Mumbai-based civic group, said decisions on denying care are already made discreetly, and clear laws, living wills and related guidelines will allow qualified medical professionals to make these important choices. Furthermore, while those at King Edward Memorial deserve enormous credit for taking care of Shanbaug for so long, in reality, most hospitals turn such patients away.

“Whatever’s used can be misused,” he said. “But that doesn’t justify something that’s right and in the interest of society.”

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