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Dr M A MuckadenProf & Head,

Dept of PalliativeMedicine

Tata Memorial Centre

India is culturally, linguistically, religiously and to a certain extent,

ethnically, the most diverse country in the world. As per the 1961 Census

of India, the country is home to 1652 mother tongues. The term

multiculturalism is not much used in India. Within Indian culture, the term

unity in diversity is more commonly used.

Religiously, the Hindus form the majority, followed by the Muslims. The

statistics are: Hindu (80.5%), Muslim (13.4%), Christian (2.3%), Sikh

(2.1%), Buddhist, Bahá'í, Jain, Jew and Parsi populations.

Ref: "Indian Census". Censusindia.gov.in. http://www.censusindia.gov.in/. Retrieved 2010-12-10

Indian Continent has a long and rich spiritual tradition. In ancient times, children were educated in ashrams, by

sages who spent years meditating in the forests. Spiritual help and guidance was close at hand According to the tradition, after fulfilling family

obligations, a person was free to retire from social lifeand meditate in the forest.

Fakirs or Buddhist monks who would often preach toanyone who would listen songs of enlightenment.

Religion & Caste system – The social structure is basedupon religion and casteFamily – Family as a unit is given much importance. Divorces not very common or appreciated. Couples prefer adjusting rather than breaking up a

marriage. Family system nurtures the well-being of the children

Marriage – Important social obligation Conducted with elaborate rituals and much money.

Patriarchal setup – Father having control over the family unit Man controls the reins of the family unit He is the head of the family bread-earner and shoulders the

responsibility of the family Dominating

Women – Remain submissive in some religions and regions

Religion- A prime source of strength and sustenance to people when they are dealing with death.

Different religious theories explain the inevitability and even necessity of death from different perspectives

Beyond all religions yet containing all religions Beyond all science yet containing all science Beyond all philosophy yet containing all philosophy

Allow natural death?

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1 year old male child with retinoblastoma, very advanced disease. Comes to casualty with severe bleeding from oral cavity Taken to Casualty- developing hypoxia from aspiration, poor respiratory effortSurgeon called for prophylactic tracheostomyReluctant as it was morbidity very highMother demanding for euthanasia, she could not see the suffering

7 days old female child of Mrs. X, born of prolonged labour with poor APGAR score

In Neo-natal ICU diagnosed as hypoxic ischemic encephalopathy. Child was on ventilator support for last 7 days with no signs of weaning.

Probability of survival poor Father does not want to

look after mother or child, Mother’s family do not want onus either

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What Medical decisions can be taken?

Who owns the child ?

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Girl child, one of manyAdvanced Head and Neck Sarcoma from small villageSevere painMorphine not available

Father wants to take her home but not sure what care is available

Is it ethical for the professionals to send her back where even basic Paediatric Palliative Care not available?

Steps to make it happen

•Indian Laws related to limitation of treatment are yet to evolve

•No discussion of withdrawal , informed refusal of Rx, withdrawal, withholding, surrogate decisions, laws on palliative care

•Courts Guided by•International precedent •National professional bodies

Article 21 provides Right to Life Autonomy, death with dignity not explored

Transplantation & Human Organ Act (1994) Brain death acceptable diagnosis

Illegal: Euthanasia & Physician Assisted Suicide

Unclear: Palliative Care The “Double Effect” or Terminal sedation

P Rathinam vs Union of India Court ruled that attempt to hasten death may be

viewed as a part of a natural process “A person cannot be forced to enjoy the right to

life to his detriment, disadvantage or dislike”P Rathinam vs Union of India 1994(3) Supreme Court

Cases 394-430 Gian Kaur vs State of Punjab

Judge ruled that permitting termination of life in the dying or vegetative, is not compatible with Article 21Gain Kaur vs State of Punjab 1996 Supreme Court

;83:12578-65

ISCCM position statement Isccm.org

The renal transplant analogy Transplants started in India in mid to late 70s All surgeons were at risk of 7 year imprisonment

for grievous bodily harm Law changed in early to mid 90s

Emphasizes the difference between WOLS & “euthanasia or assisted suicide”

Legalizes WOLS where appropriate Provides protection for doctors performing

appropriate EOLDs Focuses on minimizing abuse of the law Acknowledges ISCCM’s role BUT does not recognise patient autonomy or

the living will

PIL filed by NGO (Common Cause) Supreme court: June 2005 Living will should be allowed in terminally ill Including withholding & withdrawing Including authority for designated surrogate to decide in event

of patient incompetence ISCCM intervened (became a party to) in the petition

September 2008 EOL witholding / withdrawal of therapy in the ICU to be

considered ISCCM position statement as guideline

Is ‘Good Palliative Care’ – Passive Euthanasia?

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Ethical principles should be applied against a background of :

Respect for life .

Acceptance of the ultimate inevitability of death.

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