Byline: Vinod. Sinha, S. Basu, S. Sarkhel
In our society, the palliative care and quality of life issues in patients with terminal illnesses like advanced cancer and AIDS have become an important concern for clinicians. Parallel to this concern has arisen another controversial issue-euthanasia or "mercy -killing" of terminally ill patients. Proponents of physician-assisted suicide (PAS) feel that an individual's right to autonomy automatically entitles him to choose a painless death. The opponents feel that a physician's role in the death of an individual violates the central tenet of the medical profession. Moreover, undiagnosed depression and possibility of social 'coercion' in people asking for euthanasia put a further question mark on the ethical principles underlying such an act. These concerns have led to strict guidelines for implementing PAS. Assessment of the mental state of the person consenting to PAS becomes mandatory and here, the role of the psychiatrist becomes pivotal. Although considered illegal in our country, PAS has several advocates in the form of voluntary organizations like "death with dignity" foundation. This has got a fillip in the recent Honourable Supreme Court Judgment in the Aruna Shaunbag case. What remains to be seen is how long it takes before this sensitive issue rattles the Indian legislature.
The phenomenal advances in medical science and technology have not been without a significant impact on society. They have brought into forefront issues that are altering the pattern of human living and societal values. Pari passu with these changes is the upsurge of affirmation of human rights, autonomy, and freedom of choice. These issues compel us to re-evaluate our concepts of societal and medical ethics and value systems.
Amongst these issues, the palliative care and quality of life issues in patients with terminal illnesses like advanced cancer and acquired immune deficiency syndrome (AIDS) have become an important area of clinical care and investigation. Significant progress has been made in extending a palliative care/quality of life research agenda to the clinical problems of patients with cancer, including efforts that focus on mental health related issues such as neuropsychiatric syndromes and psychological symptoms in patients with terminal medical illness. However, perhaps the most compelling and clinically relevant mental health issues in palliative care today concern the desire for death and physician-assisted suicide (PAS) and their relationship to depression.
Desire for death has been postulated as a construct that is central to a number of related issues or phenomena, including suicide and suicidal ideation, interest in PAS/euthanasia, and request for PAS/euthanasia. This construct, which was initially proposed by Brown and colleagues [sup] and further developed by Chochinov et al . [sup] focuses on the degree to which an individual wishes his or her life could end sooner. It ranges from suicidal intent (i.e., a desire to end one's life immediately) to a complete absence of any desire to die.
Advocates demanding autonomy for patients regarding how and when they die have been increasingly vocal during recent years, sparked by the highly publicized cases of Drs Jack Kevorkian, Timothy Quill, and Aruna Shanbaug . These cases have centered on the plight of dying patients with terminal illnesses.
What has often been overlooked, however, in the political and legal machinations, is the importance of medical, social, and psychological factors (e.g., depression) that may contribute to suicidal ideation, desire for hastened death, or requests for PAS by terminally ill patients.
Definition of Euthanasia and Pas
The English philosopher Sir Francis Bacon coined the phrase "euthanasia" early in the 17 [sup]th century. Euthanasia is derived from the Greek word eu , meaning "good" and thanatos meaning "death," and early on signified a "good" or "easy" death. …