Last rights: The right to die with dignity should be upheld both in letter and spirit

He was spared the pain but did not want to suffer the loss of memory and degradation of the quality of life that comes with Alzheimer’s. He invoked Canada’s right to die when he was still in control of his mental faculties and passed away a day after spending an enjoyable evening out with his close friends.

As much as I will miss his long-distance friendship and sage advice, I was not unhappy to see him depart the way he did. Death is an important subject, but there is both a psychological and social aversion to discussing it. It is inadequately discussed in the public sphere, and even in policy debates, we engage with the topic more in the context of healthcare than something in and of itself.

As a consequence, we continue to hang on to old mindsets, norms, social attitudes and laws concerning death even though the world around us has changed. Now, there is a case to be conservative in matters of life and death. But there is also a need to be responsive to our present and future contexts.

Nearly two-thirds of deaths in urban India occur in hospitals. Even in rural areas, more than four out of ten are hospital deaths. Frequently, family members feel compelled to continue with medical treatment even for terminal conditions because they feel it would not be morally appropriate to do otherwise.

Hospitalization turns a person into a patient, with an attendant loss of dignity. Families incur medical expenses even if they are aware of a negligible chance of recovery. Patients suffer—and not just pain. Scarce medical facilities, from hospital beds to intensive care units, mean others are deprived who might have a better chance of survival.

Yet, this way of dying appears to have an unspoken family or social consensus. Unless the individual is able to clearly express a desire not to be hospitalized, or has left written instructions to such an effect, families do whatever they can to ensure medical treatment until the very end.

So it is a good sign that the Supreme Court of India ruled some years ago that the fundamental right to life guaranteed by the Constitution includes the right to die with dignity. Kerala and Karnataka, among other states, have implemented this through orders enabling an individual to record an Advance Medical Directive (AMD) or ‘living will’ stating precise preferences of medical treatment in the future. Families can request Withdrawal of Life-Sustaining Therapy (WLST) through a due process that involves approvals by medical boards.

The Supreme Court has relaxed AMD norms from requiring registration with a judicial magistrate to a gazetted officer or notary, but state governments still require multiple government officials to sign off on a WLST.

Procedural safeguards and bureaucratic hurdles are perhaps warranted at the outset. It is better to be prudent in such a sensitive matter. At the same time, policymakers must recognize that a deep involvement of our heartless bureaucracy in such matters at emotionally fraught moments can have unintended but anticipable consequences.

Indeed, political leaders should resist the temptation to tighten regulations or roll back this policy merely because of a few high-profile instances of malpractice.

Canada and a few European countries allow Medical Assistance in Dying (MAID). This goes beyond an AMD. Here, like David, a person can decide to terminate their life with medical assistance. A decade after its implementation, the MAID death rate has risen to around 5% of all deaths in Canada and is stabilizing at this level, according to its government.

Critics point out that only a fifth of the people who request MAID had serious medical conditions, a quarter did so out of loneliness and isolation and half because they didn’t want to burden their families and caregivers. Even so, if there is a right to die with dignity, it is for the individual to decide what dignity is.

Society can try to dissuade a person from opting out of life, but the old notion that suicide is a crime, and people should not be allowed to end their lives under any condition, is not only illiberal, but also sadistic and cruel. Do we have the right to insist that another person live in unending pain, indignity and dependence? Who gave us that right?

The Roman philosopher Seneca wrote, “Life, if well lived, is long enough.” It is not the duration of one’s life that matters, but its subjective quality. I like to think of human life on earth as being similar to a good guest at a party: make your presence enjoyable for everyone and leave before the hosts get tired. There is such a thing as overstaying.

Even the new billionaires who are preoccupied with longevity are merely pursuing what old potentates did. Even if scientific advances extend lifespans, they cannot resolve the issue of overstaying. Wisdom lies in knowing what’s a good time to leave and leaving at that time. Like David Malone did.

The author is co-founder and director of The Takshashila Institution, an independent centre for research and education in public policy.