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Saturday, February 22, 2014

In Quest of Quietus by Sukriti Ghosal

In Quest of Quietus by Sukriti Ghosal

Euthanasia is a highly controversial form of medical intervention, for here physicians use their skill not to resuscitate the ailing but to pre-pone their death. The topic remains contentious, for medical issues have here got entangled with ethico-sociological questions like the distinction between homicide and mercy-killing, sanctity of life and death, the validity of surrogate decision about one’s life and the like. Suffering, albeit justified in the scriptures as conditioning of the soul for life divine, is a challenge to medical scientists. While ‘kill if you fail to heal’ cannot be the choice of a doctor whose first duty is non-maleficence, beneficence also demands that a physician should not be indifferent to the suffering of a patient. We seek medical intervention to alleviate suffering but, paradoxically enough, prefer medical inaction when it is a question of terminating suffering or vegetative state of existence through administration of euthanasia. Since both life and death should have grace and dignity, it would be irrational to neglect this option when curative and palliative treatments have failed to rein in agony. If prescribing euthanasia involves violation of any ethical code, ethical transgression is to be preferred here, since ethics is to be judged in the light of reason. With ample scriptural, literary and medical references the article attempts to evaluate euthanasia from multiple perspectives as also to justify it on non-economic, non-eugenic grounds.

In Quest of Quietus
In his poem ‘The Ship of Death” D. H. Lawrence is skeptical about the power of death in making quietus:

And can a man his own quietus make
with a bare bodkin?

With daggers, bodkins, bullets, man can make
a bruise or break of exit for his life;
but is that a quietus, O tell me, is it quietus?

Surely not so! For how could murder, even self-murder

ever a quietus make? (ll. 17-23)

The quietus that Lawrence has in mind is metaphysical, and hence has little relevance to the issue of euthanasia (eu, well + thanatos, death) in which death is prescribed to medically terminate long stretched physical suffering. It is a highly controversial form of medical intervention, for here physicians use their skill not to resuscitate the ailing but to pre-pone their death.  Recently the choice of death when a disease proves intractable or irreversible has been de-criminalized in some countries, thanks to the untiring efforts of Dr Jack Kevorkian, nicknamed Dr. Death, and the right-to- die movements of Hemlock Society (1980), an American activist group inspired by Dr Kovarkian’s mantra that "Dying is not a crime"1. Yet the topic remains contentious, for medical issues have here got entangled with ethico-sociological questions like the distinction between homicide and mercy-killing, sanctity of life and death, the validity of surrogate decision about one’s life and the like. The present article is an attempt to explore the multi-dimensionality of the controversy so that one may judge the matter from a more rational perspective.

Broadly speaking there are two categories of euthanasia: Voluntary when a terminally ill patient like Roosevelt Dawson2 opts for euthanasia; and non-voluntary (also called mercy killing), when surrogate decision precedes euthanasia because a patient like Aruna Shanbaug3 who is in PVS4 cannot give consent. There are two more classifications depending on the method selected for termination of life. Euthanasia is designated as active if a doctor quickens a patient’s death by administering life-killing gas or drug. It is passive when it is a death by omission, that is, when the patient dies due to planned medical non-interference, be it withholding or withdrawing of supply of food and drink, or non-application of life-support devices like ventilator, dialysis and oxygen mask.

Thomas More’s Utopia (1516) may be looked upon as a blueprint of an ordered society as envisioned by a civilized thinker. With the progress of civilization, many of its ideas have become dated. For example, we do not consider it civilized to employ war-captives as slaves as proposed in Utopia. However, of More’s insightful ideas euthanasia merits serious attention. The main points raised by More are that sick people in Utopia receive due care and attention. But when anybody is down with lingering pain and there is no hope, either of recovery or ease, (s)he is counseled to choose death to get rid of that ‘pestilent and painful disease’. No man is forced to end his life ‘against his will’. This form of death is ‘without pain’ as it is induced by starvation or overdose of opium. This form of death is to be approved, for taking away one’s own life without the approbation of ‘the priests and the council’ is suicide which is considered an offence in Utopia. So More recommends voluntary euthanasia in extreme cases of unappeasable agony when all other care has failed, but rightly insists on approval of competent authority to distinguish it from suicide.

Euthanasia is a civilized way of bidding goodbye to life where suffering makes life a veritable hell. Literature has examples galore of such excruciating agony which makes life literally insufferable. One may refer to the suffering of Emma in Gustave Flaubert’s Madame Bovary. In vain hope of expiring gracefully, Emma consumes arsenic and writhes in indescribable pain before her final exit from life:

Gradually, her moaning grew louder; a hollow shriek burst from her; she pretended she was better and that she would get up presently. But she was seized with convulsions and cried out—
"Ah! my God! It is horrible!"

… She soon began vomiting blood. Her lips became drawn. Her limbs were convulsed, her whole body covered with brown spots, and her pulse slipped beneath the fingers like a stretched thread, like a harp-string nearly breaking.

… Her chest soon began panting rapidly; the whole of her tongue protruded from her mouth; her eyes, as they rolled, grew paler, like the two globes of a lamp that is going out so that one might have thought her already dead but for the fearful labouring of her ribs, shaken by violent breathing, as if the soul were struggling to free itself (Flaubert 270-78).

Death is indeed a relief worth opting for if life is not only sans sweetness but full of torments without any promise of respite or remission. Euthanasia is thus related to the question of human endeavour to tackle a situation of irremediable suffering. 

Medically considered, we suffer when we feel "pain" which may be described as a pinchingly unpleasant sensation. The source of this sensation may be physical when "the body is hurting" or psychological when the mind is tormented by reflection on a sorry experience in the past (working of memory) or configuration of something fearful (working of imagination). So experience of suffering is the result of exposure to what is physically or psychologically unwholesome. As memory relates us to the past and imagination to the future, the suffering involved therein is virtual. As such it is outside the purview of euthanasia which is concerned with control of actual, physical distress or with ending a vegetative state of existence.

The traditional Indian attitude to suffering is that it is a form of penance for wrong-doing in past life (karmafal). This attitude to suffering exhorts us to accept suffering with composure without looking for any redressal. What is more perplexing is that in many religions suffering is not deemed as cruel but rather justified as necessary. Christianity urges upon us not only to accept it ungrudgingly but to rejoice in it (1 Peter 4.13). The principal Biblical arguments in this regard are (1) that suffering is a passing experience which prepares us for Life Eternal (Romans 8.18); (2) that it is a providential design for the trial of faith (1 Peter 1.7), as in the book of Job; (3) that it is meant for spiritual tempering (Romans 5.3-4); (4) that in its purest form suffering, as exemplified by the Passion of Christ, is redemptive (Paul II  Intr.).

Despite such justification, there is ambivalence even in the scriptures or why should Christ heal a leper or cure the afflicting sores of Job. Non-metaphysically speaking, suffering is an uneasy condition which cannot be relished and hence calls for remedy. It is not a righteous punishment to be glorified but an organic disorder, a mal- or dys-functioning of the bodily system that ought to be restrained. In other words, instead of projecting it as a divine yoke to be shouldered ungrudgingly, medical science interprets it as an extreme form of anguish to be alleviated. Progress in medical science – from the application of anesthesia (1846) to the introduction of laparoscopic surgery (1981) – may be interpreted as progressive triumph in pre-empting the pang of suffering.

But what about unmitigated suffering which exposes the impotency of miracle or medicine? If medical progress is synonymous with alleviating bodily affliction, death is the only alternative one is left with where suffering cannot be reined in. The pet phrase in the dystopic universe of Aldous Huxley’s Brave New World is ‘Ending is better than mending’ (Huxley Chapter III). But is it at all a humanly acceptable solution? ‘Kill if you fail to heal’ does not always seem to be a rational prescription, for it apparently goes against the right to life that everyone is entitled to.

The ethical aspect of euthanasia gets more complicated if one judges it from the physician’s point of view. It has been rightly maintained that euthanasia is no sweet death: ‘Euthanasia is when the doctor kills the patient’ (Wilke Ch 27). The doctor’s dilemma is that he is oath-bound to save life not to destroy it5. The first lesson in medical ethics is non-maleficence, the motto being primum non nocere, meaning ‘first of all do not harm’. If so, taking away life to relieve suffering cannot be described as virtuous conduct (beneficence). To justify this act would be Machiavellian, for here the end (giving relief) may be noble but the means (killing) for achieving the end is not honest. That is why in any discourse on euthanasia a distinction is to be made between physician assisted suicide and criminal homicide. Beneficence demands that a physician should attend the ailing and try to relieve their suffering. But what comfort is there for a terminally ill patient writhing in unbearable pain? The next viable alternative is palliative care. However, according to medical survey, it is ineffectual in about 5% cases6. Admittedly, DNR (Do Not Resuscitate) is the only rational option left to the doctor attending patients remaining unresponsive to curative or palliative treatment.

The polemical issue of euthanasia is also to be judged in the light of dignity of life and dignity of death. First, although the sanctity of life entails its inviolability, living means living with dignity. Artificial continuance of life where death is deferred because the patient has been put upon ventilator is bereft of all graces that make life worth sustaining. Borrowing the words of Sebastian Horsley one may humorously describe such a life as ‘the misery left between abortion and euthanasia’. Secondly, life, biologically considered, begins with the formation of zygote through fusion of two gametes, not with the slitting of the umbilical cord after the birth of a child. If so, medical termination of pregnancy (MTP) would not only be immoral but a criminal act of homicide, as it actually is in countries like Ireland. But to ban MTP in the name of preserving the sanctity of life is to put the cab of civilization into reverse gear. The awful consequence of this orthodox mindset in the 21st century is illustrated by the case Savita Halappanavar7, a shameful instance of sacrificing life in the name of saving life (!).

This puritanical attitude to life springs from an irrational view that death should be deterred by all means no matter whether the gain by such deterrence is worth boasting. In J. M. Synge’s Riders to the Sea Maurya desperately tries to save her sons but having lost all of them finally reconciles herself to death with a rational insight into its inevitability in the scheme of life: ‘No man at all can be living for ever and we must be satisfied’ (Synge 69). If Maurya accepts death because it is impossible to escape it, Tithonus in Tennyson’s eponymous poem discovers that immortality can be a curse. Robbed of his youth, Tithonus is a mismatch for his eternally young wife Aurora. But as he is condemned to be immortal, the aged, decrepit Tithonus now realizes the value of death in the scheme of existence:

The woods decay, the woods decay and fall
The vapours weep their burthen to the ground
Man comes and tills the field and lies beneath
And after many a summer dies the swan
Me only cruel immortality
Consumes (Green 116).

So death is not always to be feared; rather its help is to be solicited if we do not want the woes of a sufferer to be prolonged. But like life death, natural or induced, should not be bereft of dignity. One of the reasons why Owen raged against war is that in any battle soldiers ‘die as cattle’ with no passing-bells but ‘the monstrous anger of the guns’ (Hewett 158). Medical scientists have tried to itemize some of the main principles of dying with dignity8. Of these the most important are (1) having control over when & where one dies, (2) having access to therapeutic, medical and other benefits, (3) not having life prolonged pointlessly against will. The end of Lily Bart in Edith Wharton’s The House of Mirth (1905) illustrates what might be termed as death with dignity. Having self-administered overdose of sedative, Lily waits with ‘a sensuous pleasure for the first effects of the soporific’:

She knew in advance what form they would take—the gradual cessation of the inner throb, the soft approach of passiveness, as though an invisible hand made magic passes over her in the darkness. The very slowness and hesitancy of the effect increased its fascination: it was delicious to lean over and look down into the dim abysses of unconsciousness. Tonight the drug seemed to work more slowly than usual: each passionate pulse had to be stilled in turn, and it was long before she felt them dropping into abeyance, like sentinels falling asleep at their posts… Slowly… sleep began to enfold her. She struggled faintly against it, feeling that she ought to keep awake on account of the baby; … for a moment she seemed to have lost her hold of the child. But no—she was mistaken—the tender pressure of its body was still close to hers: the recovered warmth flowed through her once more, she yielded to it, sank into it, and slept (Wharton 320-21).
The depiction of Lily’s death, if assisted by a doctor to relieve her of her unbearable physical torments, would convince us why euthanasia should be accepted without hesitation – because in it the dignity of life and the dignity of death both are preserved.

The principal objection to euthanasia is not so much medical as ethical. Ethics, incidentally, is a normative science that tries to formulate principles for judging the right-ness or wrongness of human conduct. Two common characteristics of moral principles are universalizability and unconditionality. In other words, they are not only inviolable but their applicability is not subject to spatio-temporal laws. Yet ethical principles have been flouted and such transgressions have sometimes been vindicated ethically. In the Mahabharata, when, in order to make Drona give up fighting, Yudhisthira utters ‘Ashwathama hatha iti kunjara’ (Ashwathama, the elephant, is dead) – ‘the elephant’ whisperinglyhe is guilty of telling a lie, for he makes an expedient use of equivocation.  Ethics takes into consideration intention and here Yudhisthira’s intention is politically expedient rather than morally impeccable. An opposite example is found in the conduct of sage Kaushika who refuses to tell a white lie to save an innocent life. Interestingly, both are to go to hell, Kaushika is condemned to suffer there, Yudhisthira is just a visitor. The conclusion that may be drawn from the story of Kaushika is that saving the innocent is more important than keeping a personal oath of truthfulness. Here transgression of moral principle would have been more rational if less in accordance with dry ethical code. Dehydrated of this human touch, ethics becomes a barren and irrelevant exercise. The ethical transgression on the part of Yudhisthira is prompted by a nobler aim of defeating the Kauravas who represent the vicious and the unjust. Yet since it involves moral stooping, despite his life-long truthfulness, Yudhisthira cannot avoid visiting the hell. The story of Yudhisthira teaches us that violation of ethical principles is not desirable even when unavoidable. The moral that can be abstracted from these two stories is that if virtuous conduct is divorced from true goodness (i.e. where both end & means are good), it ceases to be a virtuous conduct. It has been rightly held that ethics is to be judged in the light of reason, for what is rational may not always be ethically satisfying. Where the moral is in conflict with the rational, the rational is to be preferred, or else we will be doomed to have the destiny of sage Kaushika. Euthanasia, if rationally acceptable, is to be administered despite the fact that it goes against some codes of medical ethics.  Here it would be unwise to avoid the rational course of action. To rank the moral above the rational is to repeat the tragedy of Savita Halappanavar whose life could have been saved if only the particular law had made some provision for exception or if all concerned had followed the law in spirit rather than to the letters.

Advocates of euthanasia who defend it on eugenic or economic grounds seem to be devil’s advocate. As disability is deemed an aberration, eugenics – the science of good genes –   demands that the defective life in any form is to be removed. But upholding euthanasia on this ground is a barbarous proposition, for the wicked might interpret it as an incentive to ethnic cleansing.  One recalls how the Nazis projected the Jews as unter menschen or subhuman before they launched their programme of extirpating the Jews, a programme which was euphemistically designated as Die Endlösung – the Final Solution. Astronomical expenses of palliative care in hospices have prompted many pragmatists to support euthanasia. This sounds realistic, for where our means are limited, we cannot afford to put to practice the noble ideal of caring for every life. If five critically ill patients are admitted to a three bedded CCU, the doctor is to go by priority. So ignoring the demands of the ‘lost’ cases, he makes the life support system available for those who have most chance of survival. The doctor’s decision may be rational but justifying euthanasia for limitedness of our resources would reveal the weakness of our argument. Here the rational solution will be maximizing the means so as to make provisions comprehensive enough, not dispensing with any single life on calculation of medical expenses involved in arranging for palliative care. 

The debate over euthanasia has laid bare another medical dilemma which springs from the duality of our expectations. Instead of leaving everything to nature we welcome medical interference when it is a question of curing a disease or curbing suffering by medication. But we oppose medical interference and demand clinical indifference, if it is a question of putting an end to suffering by having recourse to euthanasia. One should not forget that advancement in medical technology has infinitely complicated the issue of life and death. Whereas in the past a terminally ill person would have taken seven hours to die naturally, today, thanks to medical miracles, he might take seven years to breathe his last. When days are numbered, to artificially prolong life is virtually to compromise with the dignity of life9.

The Parable of the Good Samaritan contains a moral which might act as a lighthouse for the doctor in this ocean of moral conflict. Unlike the priest or Levite who did not take care of the wounded man wincing in agony by the side of the road, the Samaritan  ‘bound up his wounds’ out of compassion and then ‘brought him to an inn, and took care of him’ (Luke 10. 25-37). When he left the place next morning, he arranged for his recuperative care at his own expenses. The parable exhorts us not to be indifferent but to be sensitive to other’s sufferings. What is required is not dry compassion but compassion as an incentive to action.  And if we are genuinely concerned, we should not sentimentalize the point of death which may be medically pre-scheduled to relieve agony of a patient at the irreversible stage of a disease. Euthanasia may be a human gesture to stand a sufferer in good stead or an excuse for killing with an ulterior motive. In his book The Forgotten Art of Healing and Other Essays Dr. Udwadia rightly observes that ‘It is the intention that defines the act and not the method used’ (Udwadia 33). The most convincing argument for choice of involuntary euthanasia for patients who have slipped into irreversible coma or who are in persistent vegetative state has been articulated by Lord Hoffman in his judgment on the case of Anthony Bland: 

But the very concept of having a life has no meaning in relation to Anthony Bland. He is alive, but has no life at all....There is no question of his life being worth living or not worth living, because the stark reality is that Anthony Bland is not living a life at all.

The point stressed by Lord Justice Hoffman is that when the patient is in PVS, the question of medical termination of life should not be raised at all because the patient, strictly speaking, is ‘not living.’

To sum up, it is the acuteness of unremitting suffering and indignities associated with the natural process of dying that have strengthened argument in support of euthanasia. Even when one finds it justifiable, precaution against its abuse is a must. First of all, voluntary euthanasia may be allowed if the attending doctor is certain about the futility of continuing treatment. This exit-state should preferably be determined by a board rather than by a single medical practitioner in order to minimize chances of error.  As consent must precede administration of VE, what is to be ensured is that the choice of death is well-judged, and not a fleeting thought prompted by a gnawing suffering. Considerable time must elapse between the first choice of euthanasia and its administration. The case of Seema Sood10 illustrates that if some time is given to adjust with adversity, many sufferers may find life sweeter than death. It is also to be ensured that euthanasia not prompted by emotional breakdown which time may heal but acute physical affliction unchecked by curative treatment or palliative care. Moreover, in order to differentiate euthanasia from suicide it may be allowed to a patient whose days are literally numbered or who cannot survive at all.

So it is wrong either to rhapsodize over euthanasia or object to this civilized way of bidding farewell to the world on religious, moral, economic or medical grounds. All discourses on euthanasia will be incomplete if the issue is not considered from the standpoint of the sufferer, since it is the wearer who knows where the shoe pinches. We will surely have no hesitation in welcoming it if we look upon death as a merciful deliverer rather than a fearful tormentor. The more science advances, the less will we have any need for exercising choice for euthanasia. Finally, where there is any conflict between the ethical and the rational, we should opt for the rational, for what is rational cannot be unethical unless we are using ethics in a very narrow sense. But when the rational is in conflict with the humane, we should not scruple to embrace the humane solution, for what is humanly acceptable has an intrinsic value whether or not ratified by our wit and reasoning.

1. Although this has never been officially acknowledged, Faye Girsh, President Hemlock Society of San Diego, in a posthumous tribute to Dr Kevorkian, wrote: ‘Love him or hate him, Jack Kevorkian was the face of the right-to-die movement for almost a decade. … He felt our attempts were too timid. And, reciprocally, movement leaders made an effort to distance themselves from his "antics." But the rank and file in our movement loved Jack Kevorkian.’ <>

2. Roosevelt Dawson, a twenty one-year-old Oakland University student who had been bed-ridden for thirteen months, opted for PAS in 1998 and thus is a beneficiary of euthanasia.

3. Aruna Shanbaug, a former nurse at King Edward Memorial Hospital, suffered serious brain damage consequent upon rape related atrocity. Although she has been in persistent vegetative state since 1973, she has not been allowed to die.

4. ‘PVS is a state in which there is generally extensive damage to the cerebral neocortex. The brain stem, which is responsible for the vegetative functions such as respiratory movement and the regulation of heart rate and rhythm, is more or less intact. Patients therefore breathe spontaneously, have normally functioning hearts, and require no support other than nursing care (turning, toileting etc), feeding and the provision of fluids. Feeding and hydration are generally done through nasogastric tubes, intravenous lines or stomas going directly into the stomach.’ <>

5. The relevant Hippocratic oath reads: ‘I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone. To please no one will I prescribe a deadly drug, nor give advice which may cause his death.’ <>.

6. ‘Some doctors estimate that about 5% of patients don't have their pain properly relieved during the terminal phase of their illness, despite good palliative and hospice care’. ‘When Palliative Care is Not Enough’. <>

7. A promising young Indian dentist, Savita Halappanavar developed septicemia out of accidental miscarriage, but she was not helped with an abortion, for MTP is illegal in Ireland where she lived at that time. Subsequently, due to multiple organ failure Savita died on 28 October 2012.

8. M. Henwood in The Future of Health and Care of Older People: The Best is Yet to Come mentions the following twelve conditions of good death:

·        To know when death is coming, and to understand what can be expected

·        To be able to retain control of what happens

·        To be afforded dignity and privacy

·        To have control over pain relief and other symptom control

·        To have choice and control over where death occurs (at home or elsewhere)

·        To have access to information and expertise of whatever kind is necessary

·        To have access to any spiritual or emotional support required

·        To have access to hospice care in any location, not only in hospital

·        To have control over who is present and who shares the end

·        To be able to issue advance directives which ensure wishes are respected

·        To have time to say goodbye, and control over other aspects of timing

·        To be able to leave when it is time to go, and not to have life prolonged pointlessly

9.  ‘Medical advances have altered the physiological conditions of death in ways that may be alarming; highly invasive treatment may perpetuate a human existence through a merger of body and machine that some might reasonably regard as an insult to life rather than its continuation’ (p. 17) < >

10. Seema Sood, a gold-medalist from BITS Pilani crippled by rheumatoid arthritis since 1993, first appealed for mercy-killing, but finally changed her mind and chose to survive with all her handicaps.

Works Cited:
1. Flaubert, Gustave. Madame Bovary. Trans. Eleanor Marx-Aveling. Retrieved on August 5, 2013. <>

2. Girsh, Faye.A Personal Tribute to Jack Kevorkian’. Hemlocksocietysandiego. N.p. Retrieved March 29, 2013. <>

3. Green, David (ed.) The Winged Word. Calcutta: Macmillan, 1974.

4. Good News Bible: Today’s English Version. Bangalore: The Bible Society of India, 1977.

5. Hewett, R. P. (ed.) A Choice of Poets. London; George G. Harrap & Co., 1968

6. Horsley, Sebastian. Dandy in the Underworld: An Unauthorized Autobiography. Retrieved on August 5, 2013 from <>

7.  Huxley, Aldous. Brave New World. N. p. Retrieved on August 4, 2013. <>

8. Lawrence, D. H. ‘The Ship of Death’. Retrieved on August 9, 2013.  <>

9. More, Sir Thomas. Utopia. Book II. N.p.  August 4, 2013. <>

10. Paul II, John.  ‘Apostolic Letter Salvifici Doloris’. N. p. August 4, 2013. <>

11. Synge, J. M. Riders to the Sea. Ed. B. N.  Chowdhury & B.  Banerjee. New Book Stall, Calcutta 1992.

12. Udwadia, F. E. The Forgotten Art of Healing and Other Essays. New Delhi: O.U. P., 2009

13. Wharton, Edith. The House of Mirth. The Electronic Classics Series. August 4, 2013. <>

14. Wilke. J. ‘Abortion Questions and Answers’. August 5, 2013. <>

Dr Sukriti Ghosal, MA in English, has done Ph. D. on the literary criticism of Oscar Wilde. He started his teaching career as a Lecturer in English and is now the Principal at MUC Women’s College, Burdwan. Dr Ghosal has published over a dozen research papers in journals of repute, prepared study materials for university courses and edited a commemorative volume on the famous Bengali poet Jibanananda Das. He has also published many essays and poems and translated stories in Bengali.

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