NEW DELHI, Aug 04 (IPS)  - If a terminally ill patient, with scant hope of recovery, pleads for his death to be facilitated, should the doctors comply? Or, if the family of a patient who has been declared brain-dead requests that her life-support system be withdrawn, should their will be respected?

These and many other such fraught questions are currently roiling India as the country debates the moral and legal dimensions of legalising euthanasia or ‘mercy killing', defined as the painless termination of an incurably sick person's life in order to relieve them of their suffering, or end a long-term coma.

In response to a petition filed by the New Delhi-based NGO Common Cause, which wants both the right to refuse treatment and the right to die with dignity to be incorporated into law, the Supreme Court has ordered a public debate on the contentious issue after decades of eschewing adjudicating on it.

At the heart of the debate is the case of Aruna Shanbaug, a rape victim who has been lying in a vegetative state in Mumbai's KEM Hospital since 1973, virtually brain dead.

In March 2011, Shanbaug's friend, journalist Pinki Virani, filed a plea to the Supreme Court to free Shanbaug from the agony of a barely conscious existence, but the apex court denied the petition.

The ruling National Democratic Alliance (NDA) government helmed by Narendra Modi – which came to power this May – has also been firmly opposed to legalising euthanasia.

"The government doesn't accept euthanasia as a principle," Attorney General Mukul Rohatgi told the press. "Our stand on euthanasia, in whichever form, is that the court has no jurisdiction to decide this. It's for Parliament and the legislature to take a call after a thorough debate and taking into account multifarious views."

Experts say complexities are amplified further by the absence of agreement between lawmakers and public, as well as medical, opinions about the right to life granted by the Indian Constitution.

"Will legalising euthanasia require a Constitutional amendment?" asked Samta Khanna, a Delhi-based legal activist. "And suppose a terminally ill or comatose patient has no close relatives or next of kin, who will take the decision whether or not life support should be withdrawn?"

The lawyer told IPS there were "so many dimensions to this sensitive issue" that it needed to be discussed in close detail before the drafting of a law.

Still, it is not rare for Indian families to opt for euthanasia with full cooperation from physicians. Prohibitive costs of protracted treatment, as well as a desire to end the suffering of a family member, both play a catalytic role in these decisions.

"Even with insurance cover, private hospital care in India burns a deep hole in the pockets of middle-class Indian families," Dr. Dineshwar Sharma, CEO of the Apollo Hospital in Noida, a city in the northern state of Uttar Pradesh, told IPS.

"And for the poor, for whom life is a daily struggle for survival, treatment costs of a long-suffering patient can be ruinous."

Stories of small farmers being forced to sell their meager landholdings for treatment are not uncommon. Nor are tales of terminally ill patients from villages being abandoned by their relatives in big hospitals.

The cost of life

Passive euthanasia, defined as the withholding of life-saving medicines or treatment, is also a frequent occurrence, particularly among the poor.

Thirty-six-year-old Naina, the wife of Manik Ram, a farmer whose family withdrew life support for him after two years of brain hemorrhaging and confinement to the bed, told IPS, "In the beginning, we were hopeful that my husband would recover. So we sold our small agricultural plot. Then went the household furniture followed by all my jewelry.

"But gradually, we realised the futility of spending money on my comatose husband as doctors were clear he wouldn't ever recover. I asked the doctors to release my husband so we could take him home. After all, I had four young kids to look after as well."

Ram was then brought home where he breathed his last after three weeks. "I'm still under a heavy debt but as we don't have to pay hefty hospital bills any more, I'm hoping things will gradually get back to normal," she said.

Such tales are not unique in this country of 1.2 billion people.

Sarita, 35, whose young brother Mukesh was paralysed from the neck downwards in a motorcycle crash in 2011 in New Delhi, recounts the days of horror the family lived through after he was hospitalised.

"My mother had to sell off all her gold ornaments. My wedding was also put on hold because the hospital bills for my brother were phenomenal," she told IPS.

"It was unbearable to see an athlete like him live in a vegetative state. One fine day my father made a decision. He went to the hospital and brought my brother home. He died within a month."

Still, the Indian medical fraternity's views over the matter are splintered.

While some doctors oppose it, calling it "murder", others believe that extenuating circumstances make a case for passive euthanasia.

"Family members should be at liberty to decide whether to withdraw the life-support system from a patient if there is no hope of revival," Dr. Rajendra Prasad, medical director of the Indian Head Injury Foundation, told IPS.

"Several patients die because of a lack of such systems," he said. "However, active euthanasia, in which the terminally ill are killed [by lethal injection] should be prohibited."

The anti-euthanasia lobby contends that doctors have a moral responsibility to keep their patients alive, as enshrined in the Hippocratic Oath.

"The line dividing euthanasia from murder is a fine one, and legalising euthanasia might result in an abuse of law, unfairly targeting the poor and disabled, and create incentives for insurance companies to terminate lives in order to save money," according to Dr. Sanjay Dheer, an oncologist at Max Healthcare in New Delhi.

"There should be a system of checks and balances to review such situations on a case-to-case basis so that both doctors and families can take an informed decision," added Dr. Sumit Ray, vice chairperson of critical care medicine at the Sir Ganga Ram Hospital in New Delhi.

"Just like most hospitals have a panel to certify whether a person is brain dead or not, a similar panel for euthanasia should be in place," he told IPS.

Doctors say there is mounting pressure on them as most big hospitals are getting at least three to four such requests from families per week.

Worsening the situation is the crisis in the Indian health sector where a dearth of doctors and hospital beds is forcing the medical community to reconsider huge investment in patients who are unlikely to live.

According to the 12th Five-Year Plan, the doctor-patient ratio is 45 per 100,000, against the desirable ratio of 85 per 100,0000.

Similarly, the number of nurses and midwives is only 75 per 100,000, compared to the goal of 255 per 100,000 patients. The crisis is worse in rural areas, which are especially poorly served.

Euthanasia as a concept isn't new to India. Seers and sages have for centuries practiced yogic concepts like samadhi, nirvana and santhara, voluntarily opting for death at a particular stage in life, or to escape terminal illness. But successive governments of ‘modern' India have been reluctant to draft these ancient practices into law.

Until Indian courts make a firm decision on the issue, those forced to make life-or-death choices for their loved ones say they will be plagued by confusion and guilt.