Palliative care and euthanasia: A Nepalese scenario

Abstract

Palliative care, namely the relief of pain, is a priority for cases of incurable diseases in Nepal. However, since oral morphine is not available, pain control is often inadequate. Euthanasia is not permissible by law but could be a better solution in some cases and should be made understandable to patients and physicians as in developed countries. Should euthanasia be legal? If cheap and effective palliative care were easily accessible, most terminally ill Nepalese would avoid pressure to practise euthanasia because it is a cheaper option.

Euthanasia can be defined as a deliberate intervention by a physician to end intractable suffering. ¹ In Nepal, euthanasia is not lawful and does not feature in the penal code or the constitution, and palliative care remains the priority in cases of incurable disease. However, oral morphine is not available for this purpose and pain relief is often inadequate in Nepal.

While countries including the Netherlands, Belgium, Luxemburg, Colombia, Canada and most recently Spain ² have legalised euthanasia/assisted suicides, in others, the issue remains highly controversial with ethical concerns and the balance of a patient's rights versus a doctor's duty. However, where effective pain relief is unavailable, the debate is heightened. ³

The Hippocratic oath prohibited doctors from giving drugs to kill their patients, even when the patient requested them.

In the 1870s, it was argued that anaesthetics and morphine could be used intentionally to relieve pain in patients who were incurable so that they had a pain-free death. ⁴ The debate continued about euthanasia inter alia in the United States (USA) and Britain. In 1906, an Ohio bill to legalise euthanasia was passed in the USA but ultimately defeated, ⁵ most probably due to religious beliefs that it amounted to an assault on the sanctity of life. On 1 April 2002, the Netherlands became the first country to legalise it, and as at June 2021, euthanasia is legal in Belgium, Canada, New Zealand, Spain and several states of Australia. In East Asian countries like Japan, South Korea and Taiwan, there is no legal regulation of euthanasia; the continuing resistance to lawful active euthanasia is on religious grounds. ⁶ In India, active euthanasia is still illegal, although the Supreme Court has allowed involuntary passive euthanasia. ⁷

In Nepal, euthanasia is not legalised. A major obstacle is the lack of understanding of the term ‘Euthanasia’, which is often conflated with suicide, and suicide is contrary to almost religious practice here.

Attitude towards euthanasia in Nepal

Nepal is one of 108 countries that does not believe in capital punishment. ⁸ Nepalese law does not permit killing of any kind including mercy killing. Euthanasia is not defined or mentioned in the Penal code or the constitution, and Nepal’s Supreme Court has not engaged in much discussion on the topic since 2017. ⁹

In developing countries like Nepal, access to adequate health care is limited with palliative care for most terminal diseases barely available, making euthanasia a better solution for many. ¹⁰ People die from untreatable pain because proper palliative medication, like morphine (the gold standard), is not available. In such cases, ending life is a better option than prolonging it. ¹¹ Additionally, palliative care is expensive, and in Nepal, a low-income country, unaffordable for the majority, with the money better spent elsewhere, ¹¹ e.g. organ donation. ¹²

However, euthanasia may also prove disadvantageous in Nepal. The implementation of constitutional rights is still facing many challenges, for political reasons. ¹³ If it were legalised, it would probably not be well implemented and result in a sudden rise in illegal killing rather than voluntary euthanasia. The Nepalese believe in the concept of a joint family with only 17.1% of families being nuclear families in 2015/16, ¹⁴ so there is a high commitment to palliative care in Nepalese culture. However, a policy enabling cheaper euthanasia instead of expensive palliative care could put pressure on a family and an individual towards ending life, ⁹ in a way detrimental to traditional Nepalese culture. Assessing a person as mentally capable of giving consent to euthanasia could become challenging.^15,16 The challenges are greater in developing countries where most citizens cannot afford the tests needed to determine their mental capacity and increases the risk of involuntary termination of life breaching the right to life and liberty. ¹⁷

Advantages of euthanasia

Dying is the thread that connects death and life. Letting go of life can be extremely difficult, especially for people living with incurable diseases, whose bodies are partially or fully paralysed, slipping in and out of consciousness often in a state where the person barely recognises him/herself. In these situations, euthanasia may provide a gateway to put an end to suffering. Cancer patients receiving palliative care believed that euthanasia should be lawful as an individual's right, and pain being a secondary reason to do so. ¹⁸ Rather than investing resources in futile medical treatment, it would be better applied to patients who can be cured and contribute to society.

Euthanasia could reduce the emotional and financial burden that weighs down family members and friends taking care of a terminally ill person. Caregivers are often hesitant to support euthanasia, but their emotional well-being may be overlooked and compromised. ¹⁹ In a nutshell, euthanasia can end suffering, improve the quality of life of carers of terminally ill people and may be a better option when palliative care is unaffordable or unavailable. The resources used to prolong the life of a moribund person may be better given to those who have a chance of being cured or to improve the health of the population. Accordingly, the issue needs to be properly considered and debated with laws prohibiting euthanasia reviewed.

Disadvantages of euthanasia

Medicine aims to save patients’ lives, so giving support to euthanasia is contrary to its philosophy not only from medical perspectives but is morally controversial.

The suicide contagion theory, described by sociologist David Phillips in the 1970s, makes the point that if euthanasia was commonly practised there would be a broad spike in assisted suicides. ²⁰ This proposition is particularly apparent in those whose demographic profiles are similar to people who committed suicide. ²¹ For instance, Oregon’s Death with Dignity Act (DWDA) was enacted in late 1997, and from 1998, Oregon started recording data till 2013, only to discover that the number of lethal prescriptions written each year had increased at an average of 12.1%. ²² This data undoubtedly demonstrates that favouring euthanasia over hope for the future could lead to more deaths.

Depression often manifests somatically; ²³ inadequate diagnosis and screening may result in clinicians missing as many as half of all cases of clinical depression. ¹⁵ If that occurs, elderly people who are severely depressed might be euthanised having regard for their somatic condition which could be both wrong and unfair to the patient. Euthanasia is only legal if someone is mentally capable of making the choice and determining someone’s mental capability may be challenging ²⁴ and may push them in the direction of ending their lives.

Doctors' predictions of how long a patient will survive a terminal illness are rarely accurate, and the use of generalised medical statistics may result in serious errors which in turn would make euthanasia a controversial solution. A Mayo Clinic survey in 2005 found that only one in five patients received an accurate terminal diagnosis; 17% of people lived longer or much longer than the doctor initially expected. ²⁵ Therefore, as the terminal diagnosis could prove inaccurate, euthanasia as a solution would be wrong too.

The concept of euthanasia ignores the benefits of palliative care. This can improve the patient’s and their family’s quality of life, while euthanasia will take away what is left of their life. A doctor whose message is to give up on life is opposing the very oath that a doctor takes at the outset, namely to preserve it. Additionally, people receiving palliative care may benefit from the opportunity for new social, spiritual, and physical improvement to their health. Improving health is the core aim of medicine while euthanasia is the reverse.

Choosing euthanasia rather than palliative treatment sends a clear message of ‘choosing to kill rather than finding a solution for making life better’. Drug therapies, surgery, radiation therapies were developed by doctors whose aim was to save their patients and who benefited mankind. As an example, diabetes was a terminal diagnosis before 1922, but is now one that can be treated. ²⁶ Therefore, recommending euthanasia may restrict efforts to find a breakthrough treatment and discourage research.

Conclusion

Euthanasia may be appropriate in some cases but detrimental for a patient in others. In Nepal, generally available and affordable palliative care is not available, but neither is euthanasia likely to be rendered lawful any time soon. Therefore, the concept of euthanasia needs to be explained to people and physicians as is the case in developed countries. There is need for a debate before euthanasia is lawful but meanwhile cheap and readily available palliative care needs to be easily accessible so that Nepalese who are given a terminal diagnosis are not pressured to practise euthanasia to avoid the cost of care irrespective of their actual medical prognosis.