Economics of euthanasia in India
Aug 17 2014
But what may appear like an entirely emotional issue has strong financial undercurrents.
Heeralal Kansal, 70, a middle class cloth merchant from Dholpur in Rajasthan, is transferred from a local hospital to a private cancer institute in Delhi for tertiary care. The daily ICU bill is Rs 30,000 and after 45 days of intense treatment, the family, which survives on a cloth-shop, has set back by nearly Rs 20 lakh.
The pauperisation and misery of the family apart, the patient is tired of suffering —pain, vomitting, diarrhea, breathlessness, and weakness — and does not wish to live anymore. So how does one provide Kansal a dignified exit?
While ethics favour Kansal, legal hurdles remain. The Supreme Court had earlier allowed passive euthanasia but now wants a fresh debate. The apex court favours reform with consensus. At present, when relatives and doctors see no light at the end of the tunnel, they mutually agree to withdraw life support. In absence of a clear-cut legal framework, such a ‘proxy killing’ is the accepted norm in Indian hospitals.
But all stakeholders — people, courts and the government — need to realise that resources are limited. For a population of 1.2 billion, there are merely 40,000 ventilators and 70,000 ICU beds in the country. The total requirement of ICU beds stands at five million. It is imperative that ventilators and ICU beds should be made available for those who stand a better chance of survival.
An RTI application at AIIMS reveals that between April 2013 and March 2014, 3,394 patients out of 14,083 who were admitted at their cardio neuro centre, died. Similarly, 226 out of 1,410 patients admitted in Faculty One’s medicine department succumbed to their illnesses while 251 out of 1,010 died in Faculty Two.
The point to note is that survival depends on the machines and ICU support. A study done at various hospitals puts ICU mortality of seriously ill at 70 per cent. The mortality rate for single organ failure patients is 40 per cent, double organ failure stands at 60 per cent and for triple or multiple organ failure, the death rate lies at a whopping 98 per cent.
Certainly, it makes better economic sense to substitute expensive ICU stay with palliative care of a hospice. Hospice care can be immensely valuable for terminally ill patients where they can live with minimal medical and maximum human support. It is particularly important in our country where less than 10 per cent of people have insurance cover, while roughly 70 per cent fall under the out of pocket expenses (OOP) category.
Perhaps, the palliative care system is need of the hour in an aging country like India, home to 100 million senior citizens. Unfortunately, we are yet to develop it beyond some primary steps. Here, the involvement of private sector can make a huge difference.
However, it is a misconception that once the ‘autonomy’ to die becomes a reality, doctors will be flooded with such requests. The case in point is a study conducted by the Oregon state in the US where assisted dying is legal. Here a patient pushes a lethal dose himself or herself with the consent of two doctors to call it quits. The pre-condition is this: the patient who is suffering from an incurable disease should have less than six months of life expectancy, should be conscious and oriented. Statistics reveal that only one in a population of 9,800 has requested for assisted end to life; the rest are satisfied with palliative treatment and care. The intention should be to discount sillier objections to euthanasia and try to acknowledge the genuine premise.
Health is not all only about modern gizmos and gadgets; care has to be culturally prudent as well. In some private hospitals, subjecting the patient to ICU care has become a money-spinning racket.
R K Mani, ex-president of Indian society and critical care medicine (ISCCM) has filed a petition in the Supreme Court saying they should be made a party in cases regarding euthanasia because the issue is basically between the patient and the doctor. Most medicos believe that the autonomy to choose an honourable exit is the right of the patient and life support systems need not be forced. However, we must keep in mind that the Indian religious system backs deh-tyag or sacrifice the body doctrine. The spirit is likened in the Bhagwad Gita to the atman (soul) changing body like clothes and therefore being imperishable.
(The writer is chairman of Arthritis Foundation of India)