© 2008 American Thoracic Society
Challenges to the Withdrawal of Care in Critically Ill Patients in IndiaTo the Editor:I read with interest the critical care perspective by John M. Luce and Douglas B. White, wherein the authors have discussed the factors responsible for pressure to limit life support for critically ill patients in the United States (1). However, there are certain points that merit attention regarding factors responsible for limiting the end-of-life decisions in developing countries like India. First, apart from the educational, social, and cultural differences, the health care system in India differs substantially from that in the United States. The government contributes only 17.8% of the total health care expenditure in India compared with 44.3% in the United States (2). Although insurance and social security account for 33.7% of the health care expenditure in the United States, this is almost nonexistent in India, and 82.2% of the total health care bill is paid out of pocket by patients or their relatives (3). Second, India has less than one hospital bed per 1,000 people and an even lower number of ICU beds. Most of these beds are provided by the private health care sector and are a source of good income for them (3). The scarcity of resources coupled with a high demand from the higher income class, i.e., businessmen, industrialists, and bureaucrats, creates a unique challenge to the delivery of intensive care in general and to end-of-life decisions in particular. Third, the ethical and legal status of withholding and withdrawal of life-sustaining therapy from critically ill patients in India is ambiguous. The Indian constitution provides for the right to life for all subjects of the state. Concepts like autonomy and death with dignity have not been explored in any meaningful or pragmatic way by the constitution or the courts. Euthanasia and physician-assisted suicide are not legal. Many brain-dead patients are mechanically ventilated until cardiac arrest occurs. Last, there is no clarity on the legality of standard palliative techniques (4), and palliative end-of-life care is totally ignored. Given the scarcity of resources and growing needs in India, it is the right time for physicians and allied health care societies to educate the government and public about the magnitude of the problem of life support for the critically ill, and to start a healthy dialog to reach a constitutional and legal directive in regard to withholding and withdrawal of care for these patients.
Christian Medical College and Hospital FOOTNOTES Conflict of Interest Statement: A.S. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. REFERENCES
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
