End of Life: Ethical Dilemma

End of Life: Ethical Dilemma

UPSC General Studies: Paper IV

Question: Thanks to massive advance in medical science, we now live longer and better, but what do we do when the end comes? How to decide the fate of life?

Purpose of medical school was to teach how to save lives, not how to tend to their demise. But that’s what’s inevitably happening. How to take the crucial decision of pulling the plug? Should there be guidelines for de-escalating medical care?

Outline the ethical dilemmas involved. What can be done to address these dilemmas?

Backgrounder: Why we need to discuss these issues in India? (This is just for the sake of putting things in a perspective and not for the actual answer)

Problems of the elderly:

Medical science has ensured longer lives and India with its focus on its young “demographic dividend” will find that by 2050 its over-60 population will have increased from 8% of the population to 19%, finds a 2015 report by HelpAge India. Average life expectancy then will be 74 years.

At the same time, fertility rates will have declined from 5.9 children per woman at the time of Independence to 2.6 children per woman by 2050. What this simply will mean is more older people with fewer children to take care of them—and that’s just the impact on families without factoring in the implications on public healthcare that increased longevity will inevitably pose.

Pointers that will help tackle the above question:

Ethical dilemmas involved:

At what point do you tell the doctors that you cannot bear to hear the struggling breath of your mother?

How do you decide that it’s OK to feed her through a tube but not OK for doctors to cut a hole and insert a tube so that a ventilator can breath for her?

Home or hospital?

Dialysis or do nothing?

How do you decide the fate of a life? When that life belongs to a parent—ironically, the person who gave you life—the dilemma is unbearable.

Does wanting my mother to die quickly, unwilling to have her linger on and fade away make me a bad daughter or a son? What will the society think?

How to address these dilemmas?

Address the issue within lifetime within family: We have to tackle the issue of mortality during our lifetime. We all know that death is an inevitable finality. Yet, we are not at all open about discussing death within families. We need to have a discussion in advance. How do our parents want to die? In a hospital or at home? With the maximum medical intervention or the least? What about organ donation? But, he warns, this is a discussion for families to take at an appropriate time, when the going is good, not when confronted with a sudden decline in a parent’s health.

Have a relook at the laws: Laws are not supportive of end of life either. For instance, once a patient is on a ventilator then it cannot be withdrawn in the hospital without a court order that must be approved by a three-member committee.

Doctor’s must have guidelines as to how to respond in various emergencies: In an emergency, there is an implicit consent that you have to do everything to save the life of the patient, which could mean even attempting a heroic surgery on a 75-year-old stroke patient. Doctors don’t have guidelines on when to de-escalate care. There are so many grey areas. Address these grey areas.