- Frank J. Leavitt, Ph.D.,

Faculty of Health Sciences, Ben Gurion University of the Negev, P.O.B. 653, 84105 Beer-Sheva, Israel

In a world where we are taught to define the meaning of life in terms of material pleasures and achievements and the acquisition of high-tech toys, it is not surprising that people who can no longer enjoy these things will find life no longer worth living. Movements for active euthanasia and physician assisted suicide have swept the West. And now Dr. Tharien has called our attention to the rise of this movement in India (1).

We should not be so presumptuous as to think that we know the meaning of our lives. We may be here for purposes for which we are not aware. For this reason there really can be no "informed consent" to end one's life because we have no way to become informed of the implications of dying or what will happen to us after we leave this life. So Tharien is right to discuss God's purposes from a Christian point of view. His views ought to be examined by bioethicists of other faiths as well as secular and strictly scientific bioethicists.

Tharien accepts the concept of "cerebral death". But really this concept is not well-defined. In the years since the U.S. President's Commission's 1981 attempt to define death (references in (2)) studies of patients clinically declared "brain dead" have revealed that numbers of them "maintain hypothalamic-endocrine function", "maintain cerebral electrical activity", "retain evidence of environmental responsiveness" and "retain central nervous system activity in the form of spinal reflexes" (3).

Some authors have proposed that we no longer wait for total brain death or for "brain stem death" but that we declare a patient dead upon "irreversible cessation of conscious functioning". (2, 3) But such a decision in arbitrary and has no more justification than the view of some important Israeli rabbis who do not agree with the Chief Rabbinate's acceptance of brain death, and suggest continuing to regard "brain dead" patients as alive so long as the heart is beating (4). This raises serious questions for heart, lung and liver transplants.

Tharien correctly emphasizes love, which should be the response to patient depression rather than even considering euthanasia. It should be added that one of the best ways to show love, when non-pharmaceutical methods fail, is by giving anti-depressant drugs. Not enough physicians are aware that antidepressants can be effective even when the depression is an understandable reaction to some life event (5). A patient's request for euthanasia may also be because of pain, and physicians may be insufficiently aware of proper use of narcotic analgesics (6-8). And there are many gradations between acceding to a patient's refusal of treatment letting him die, and imposing coercive treatment. Sometimes a patient will refuse treatment because he wants a second opinion from another physician, or prefers complementary medicine, or chooses to rely on faith and prayer. Often such decisions ought to be respected. But when the patient's refusal is clearly and dangerously wrong it does not follow that forceful treatment is in order. The love of which Dr. Tharien has written may be the better way to bring the patient around. And if love can reduce somewhat the need for drugs against pain and depression, what a blessing this will be!

Tharien's Christian approach is extremely important. But I hope our journal doesn't become too heavily Jewish and Christian. Teaching the Buddhist meditative concept of life is another loving alternative to euthanasia (9). And I hope we shall be hearing more from bioethicists with Hindu, Shinto, Muslim, secular and other Asian approaches so that our journal will serve as forum for a truly pan-Asian multilogue.

References

(1) Tharien, A.K. "Euthanasia in India", EJAIB 1: 33-35.
(2) Halevy A., Brody B (1993) "Brain death: reconciling definitions, criteria and tests", Annals of Internal Medicine 119: 519-525.
(3) Truog R.D., Fackler J.C. (1992) "Rethinking brain death", Critical Care Medicine 20: 1705-1713.
(4) Aurbach S.Z. et al. (1994) "Brain death in halacha", Assia: Halacha and Medicine 14: 21-23 (In Hebrew).
(5) White P.D. (1994) "Clinical depression can be understandable and treatable", BMJ 309: 721.
(6) Marks R.M., Sachar E.J. (1973) "Undertreatment of medical in patients with narcotic analgesics", Annals of Internal Medicine 78: 173-181.
(7) Angell M. (1982) "The quality of mercy (Editorial)", NEJM 306: 98-99.
(8) Glick S.M. "The empathic physician: nature and nurture", pp. 85-102 in: Spiro H.M.et al. eds., Empathy and the Practice of Medicine (Yale University Press, New Haven and London, 1993).
(9) Ratanakul P. Bioethics (Bangkok, Mahidol University, 1986). (Appendix III: "The Buddhist concept of life, suffering and death and their meaning for health policy."