The media debate on the Supreme Court’s verdict in the Aruna Shanbaug case has proceeded along predictable lines — the same as in the rest of the world. These are decadeold questions —the right of terminally ill patients and their families to seek a dignified end to the suffering; the distinction between active and passive euthanasia. Most countries have debated these issues, rejected the idea of active euthanasia and very few have legalized it.

The Supreme Court has also played safe by suggesting that ‘passive’ euthanasia can be looked at on a case-bycase basis. There is, however, a critical linkage which most discussions fail to make, ie, the economic and social dimension. Any debate on euthanasia, which does not take into account the heavily privatized structure of Indian healthcare, is in a sense, incomplete and perhaps, elitist. Let me begin by saying that many Indian doctors in India have been practicing a form of passive euthanasia for many years, although few are likely to admit it.This may not have ‘legal’ sanction , but it is a practical approach when it involves a terminally ill patient. In some cases, this is based purely on an assessment of the futility of treatment. But often, there is a critical additional factor, which influences the decision of the team treating the patient.

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This is the cost of treatment. Put differently, one of the reasons for ‘passive’ euthanasia is that the patient or his family could be running out of money. In some cases, this overlaps with the incurability of the disease.

In others , it may not.Costly medication and intervention is often withdrawn as the first step of this passive euthanasia process. Sometimes patients are ‘transferred’ to smaller (read cheaper) institutions or even their homes, with the tacit understanding that this will hasten the inevitable. If a third party is funding the patient’s treatment , chances are that the intervention and support will continue. Shocking and arbitrary as this may sound, this is the reality that needs flagging because it is relevant to the proposed legitimization of passive euthanasia.In a system where out-of pocket payment is the norm and healthcare costs are booming, there has to be a way of differentiating a plea made on genuine medical grounds from one that might be an attempt to avoid financial ruin. This may not be easy for any court or institution. The state and judiciary, which are proactive in granting such permission, will also need to look at vested interests that are forcing futile but costly treatment in a healthcare system that aims to profit through any means.

On the day of the Aruna Shanbaug judgment, a television show anchor asked, “Do you think we can adopt the Netherlands model which legalizes active euthanasia ? ” The answer I managed was “it is inappropriate to compare the Netherlands healthcare system to India. ” One would have liked to point out that in the Netherlands (as in many other countries, including some in the developing world) healthcare is provided by the state in an organized and subsidized fashion. Families don’t go bankrupt or become indebted while paying for healthcare.Healthcare is practiced as a social need and a right to be fulfilled by the state. Doctors aren’t constantly grappling with the problem of the increasing cost burden of a patient. In such countries, the state provides high quality palliative care and nursing services to those in need. However, the issue of euthanasia is very real for a significant number of people stricken with a terminal or debilitating disease.

But let’s be clear that given the Indian healthcare scenario, it could become an instrument of cost containment.Equally worrying is that it could be a hindrance in the development of quality and humane palliative care services that are so utterly lacking in India. Not so long ago, a mental health facility for young girls in Pune planned mass hysterectomies with the declared motive of ‘protecting’ them from unwanted pregnancies. The argument advanced by both state officials and medical professionals was that a hysterectomy was much simpler and cheaper than the complex task of ‘protecting’ or ‘educating’ these girls.They retracted when there was an outcry against this bizarre logic. In the context of euthanasia, the “shortcut” subtext may be more subtle and difficult to discern. While we cannot trivialize the plight of those who would benefit from an early end to their suffering, we must not detract from a more urgent issue —the financial and social devastation faced by families because the state doesn’t acknowledge that supportive care towards the end of life is the right of a citizen.