Abstract
In our society, the palliative care and quality of life issues in patients with terminal illnesses like advanced cancer and AIDS have become an important concern for clinicians. Parallel to this concern has arisen another controversial issue-euthanasia or "mercy-killing" of terminally ill patients. Proponents of physician-assisted suicide (PAS) feel that an individual's right to autonomy automatically entitles him to choose a painless death. The opponents feel that a physician's role in the death of an individual violates the central tenet of the medical profession. Moreover, undiagnosed depression and possibility of social 'coercion' in people asking for euthanasia put a further question mark on the ethical principles underlying such an act. These concerns have led to strict guidelines for implementing PAS. Assessment of the mental state of the person consenting to PAS becomes mandatory and here, the role of the psychiatrist becomes pivotal. Although considered illegal in our country, PAS has several advocates in the form of voluntary organizations like "death with dignity" foundation. This has got a fillip in the recent Honourable Supreme Court Judgment in the Aruna Shaunbag case. What remains to be seen is how long it takes before this sensitive issue rattles the Indian legislature.
Introduction
The phenomenal advances in medical science and technology have not been without a significant impact on society. They have brought into forefront issues that are altering the pattern of human living and societal values. Pari passu with these changes is the upsurge of affirmation of human rights, autonomy, and freedom of choice. These issues compel us to re-evaluate our concepts of societal and medical ethics and value systems.
Amongst these issues, the palliative care and quality of life issues in patients with terminal illnesses like advanced cancer and acquired immune deficiency syndrome (AIDS) have become an important area of clinical care and investigation. Significant progress has been made in extending a palliative care/quality of life research agenda to the clinical problems of patients with cancer, including efforts that focus on mental health related issues such as neuropsychiatric syndromes and psychological symptoms in patients with terminal medical illness. However, perhaps the most compelling and clinically relevant mental health issues in palliative care today concern the desire for death and physician-assisted suicide (PAS) and their relationship to depression.
Desire for death has been postulated as a construct that is central to a number of related issues or phenomena, including suicide and suicidal ideation, interest in PAS/euthanasia, and request for PAS/euthanasia. This construct, which was initially proposed by Brown and colleagues and further developed by Chochinov et al focuses on the degree to which an individual wishes his or her life could end sooner. It ranges from suicidal intent (i.e., a desire to end one's life immediately) to a complete absence of any desire to die.
Advocates demanding autonomy for patients regarding how and when they die have been increasingly vocal during recent years, sparked by the highly publicized cases of Drs Jack Kevorkian, Timothy Quill, and Aruna Shanbaug. These cases have centered on the plight of dying patients with terminal illnesses.
What has often been overlooked, however, in the political and legal machinations, is the importance of medical, social, and psychological factors (e.g., depression) that may contribute to suicidal ideation, desire for hastened death, or requests for PAS by terminally ill patients.
Definition of euthanasia and PAS
The English philosopher Sir Francis Bacon coined the phrase "euthanasia" early in the 17th century. Euthanasia is derived from the Greek word eu, meaning "good" and thanatos meaning "death," and early on signified a "good" or "easy" death.Euthanasia is defined as the administration of a lethal agent by another person to a patient for the purpose of relieving the patient's intolerable and incurable suffering.] Typically, the physician's motive is merciful and intended to end suffering. Euthanasia is performed by physicians and has been further defined as "active" or "passive." Active euthanasia refers to a physician deliberately acting in a way to end a patient's life. Passive euthanasia pertains to withholding or withdrawing treatment necessary to maintain life. There are three types of active euthanasia. Voluntary euthanasia is one form of active euthanasia which is performed at the request of the patient. Involuntary euthanasia, also known as "mercy killing," involves taking the life of a patient who has not requested for it, with the intent of relieving his pain and suffering. In nonvoluntary euthanasia, the process is carried out even though the patient is not in a position to give consent.
PAS, on the other hand, involves a physician providing medications or advice to enable the patient to end his or her own life. While theoretical and/or ethical distinctions between euthanasia and PAS may be subtle to some, the practical distinctions may be significant. Many terminally ill patients have access to potentially lethal medications, at times even upon request from their physicians, yet do not use these medications to end their own lives.
Both euthanasia and PAS have been distinguished, legally and ethically, from the administration of high-dose pain medication meant to relieve a patient's pain that may hasten death (often referred to as the rule of double effect) or even the withdrawal of life support. The distinction between euthanasia/PAS and the administration of high-dose pain medications that may hasten death is premised on the intent behind the act. In euthanasia/PAS, the intent is to end the patient's life, while in the administration of pain medications that may also hasten death; the intent is to relieve suffering.
Distinctions between withdrawal of life support and euthanasia/PAS are, in many ways, considerably clearer. Long-standing civil case law has supported the rights of patients to refuse any unwanted treatment, even though such treatment refusals may cause death. On the other hand, patients have not had the converse right to demand treatments or interventions that they desire. This distinction has had the effect of allowing a patient on life support the ability to end his or her life on request, yet a patient who is not dependent on life support does not have such a right.
Legalization of PAS and euthanasia
Arguments supporting legalization of PAS/euthanasia
The arguments supporting legalization of euthanasia/PAS are substantial. Proponents perceive PAS as an act of humanity toward the terminally ill patient. They believe the patient and family should not be forced to suffer through a long and painful death, even if the only way to alleviate the suffering is through suicide. According to the proponents of PAS, it becomes ethical and justified when the quality of life of the terminally ill patient becomes so low that death remains the only justifiable means to relieve suffering. Lack of any justifiable means of recovery and the dying patient himself making the choice to end his life are conditions which make euthanasia more justifiable. To the advocate for PAS, legalization of PAS is a natural extension of patient's autonomy and the right to determine what treatments are accepted or refused. Arguments in favor of legalization of PAS are typically premised on the assumption that requests for PAS are "rational" decision, given the circumstances of terminal illness, pain, increased disability, and fears of becoming (or continuing to be) a burden to family and friends. Given the possibility that these symptoms and circumstances may not be relieved, even with aggressive palliative care and social services, the decision to hasten one's death may seem rational. Proponents of euthanasia also criticize the "artificial and impractical" demarcation drawn by the court and the religious organizations between active and passive euthanasia. Withdrawal of life support, the classical form of "passive" euthanasia, actually involves taking an "active" step to hasten the death of a terminally ill patient and it is the patient's consent which lends legitimacy to the act. If, following consent of a similar nature, a physician administers a lethal dose of injection, there is no reason why this act should be considered as illegal or immoral. Moreover, the desire to include one's physician in carrying out a decision to end one's life can be viewed as an extension of the natural reliance of terminally ill patients on their physicians for help with most aspects of their illness, as well as reasonable mechanism to ensure that they do not become more disabled and burdensome to their family or friends by attempting suicide unsuccessfully (causing a persistent vegetative state or increased disability).
Another argument raised by proponents of legalization is that merely knowing that one can control the timing and manner of death serves as a form of "psychologic insurance" for dying patients. In other words, knowing there can be an escape from the suffering of illness may alleviate some of the stress associated with the dying processes. It may be (as argued by some proponents of PAS) that many individuals with a terminal illness desire the option to end their lives if certain possible conditions arise, even though the likelihood that they will utilize this option is small.
Arguments opposing legalization of PAS/euthanasia
Opposition to legalization of PAS and/or euthanasia has come from numerous different perspectives. As frequently noted in the editorial pages of various medical journals, the medical profession is guided by a desire to heal and extend life. This guideline is best exemplified in the Hippocratic Oath which states, "I will prescribe regimen 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 that may cause his death." Thus, the possibility that a physician may directly hasten the death of a patient - one whom the physician has been presumably treating in an effort to extend and improve life - contradicts the central tenet of the medical profession.
From a mental health perspective, professional psychiatric and psychological training reinforces the view that suicide should be prevented at all costs. Several studies have supported this connection between mental disorder (e.g., depression) and interest in PAS, suggesting that suicidal ideation in terminally ill patients is a manifestation of undiagnosed, untreated mental illness. Consequently, physician compliance with a suffering patient's stated wish for PAS may circumvent the provision of appropriate psychiatric care. Similar arguments have been made regarding pain and physical symptoms, suggesting that requests for PAS may be evidence of inadequate palliative care. In spite of the fact that improperly managed physical and/or psychiatric symptoms may underlie a patient's wish for hastened death, physicians may unknowingly participate in PAS designed to alleviate precisely these symptoms that possibly could be managed with better palliative care, as opposed to providing proper medical management, if PAS is legalized.
Opponents of PAS additionally posit that individuals of lower socioeconomic classes or other disenfranchised groups will be "coerced," either directly or indirectly, into requesting PAS as a means of resolving the difficulties posed by their illness. Family members may subtly suggest that death, since inevitable, would be preferable if it occurred sooner rather than later because of the social and financial burdens involved in caring for terminally ill family members. Physicians may view PAS, perhaps because of their own unrecognized feelings (countertransference), as the appropriate and preferable response to a terminal illness and resulting disability. Thus, physicians may be particularly poor at recognizing "irrational" requests for PAS because of their belief that they would not want to live in a condition similar to that of their patients. An even more frightening possibility is that physicians or other health care providers might recommend PAS as an option because the alternative - providing adequate palliative care - is too expensive or difficult to obtain. Thus, patients with poor health insurance or limited financial resources may be "coerced" into requesting PAS by poorly managed or untreated physical and psychological symptoms, perceiving their only options to be either continued suffering or death. Several studies have demonstrated inadequate recognition and treatment of both psychological and physical symptoms, with symptoms such as depression and anxiety going largely unrecognized in many medically ill patients. According to a recent review of palliative care in Canada, only 5 per cent of dying patients in Canada receive adequate palliative care. These and related studies are often cited by opponents of legalization for PAS/euthanasia as evidence that legalization is premature until all dying patients and their families have access to skilled and effective palliative care service.
In response to these concerns, legislators proposing guidelines for PAS have incorporated several mechanisms to minimize the risk that PAS, if legalized, will be misused. These guidelines include (1) a voluntarily request for assistance in dying on the part of the patient, (2) evidence of a terminal illness, and (3) documentation by the primary physician of the reason for the request and efforts made to optimize the patient's care. Opponents, however, suggest that these limitations are more arbitrary than scientific, and they argue that the legal and medical communities will eventually end up on a "slippery slope," where euthanasia is ultimately legalized as an acceptable practice for a wider patient population, including non-terminal, nonvoluntary patients. Opponents point to a similar evolution of euthanasia use in The Netherlands where regulations regarding PAS have gradually weakened over the 13 years since this practice was decriminalized. For example, in 1994, the Dutch Supreme Court accepted the argument that a chronic disease is an acceptable basis for euthanasia, even if not terminal, and more recent cases have extended this "right" even to patients without a physical illness.
Attitudes toward hastened death and PAS: importance of psychiatric issues
Public interest has been spurred by media attention devoted to Drs. Kevorkian, Quill, Aruna Shanbaug, and others, as well as legal decision, state referenda, and the growing availability of life-extending medical treatments. As a result, both the public and the medical community have openly debated ethical issues relating to end-of-life options. While the US Supreme Court upheld the rights of individual states to prohibit PAS, its decision simultaneously opened the door for professionals to "experiment" with legalization of PAS, as has recently occurred in the state of Oregon. In part spurred by this increased attention, a number of researchers have surveyed attitudes toward euthanasia and PAS among the lay public, medical professionals, and medically ill patients. These surveys have demonstrated high rates of public support for legalization of PAS, as well as relatively significant rates of endorsement and even performance of PAS among medical professionals. The proposed guidelines offered to date have all suggested that psychiatric evaluation must comprise critical components of any assessment of a patient's request for PAS. Clearly, if PAS is legalized, mental health professionals must play an important role in the evaluation of patients at the end of life who request PAS. Despite the apparent importance of a mental professional's evaluation in assessing requests for PAS, little research has been conducted that has focused on the basis for patients′ interest in hastened death. In their study of physician response to request for PAS/euthanasia, Meier et al. found that physicians sought mental health consultation for only 2 per cent of their patients who requested PAS or euthanasia. Furthermore, a study by Ganzini et al indicated that only 6 per cent of Oregon psychiatrists felt "confident" in their ability to assess whether a psychiatric disorder was impairing the judgment of a patient requesting PAS, despite overwhelming support from psychiatrists for legalization.
Euthanasia and PAS in clinical practice
A number of surveys have been published documenting the practice of euthanasia and PAS among health care professionals. For example, an anonymous survey of Washington physicians conducted in 1995 found that 26 per cent of responding physicians had received at least one request for PAS and two-thirds of those physicians had granted such requests. These statistics suggest that PAS is not a rare event, despite the illegal status (it is also possible that despite the anonymous nature of the survey, some physicians who had in fact carried out these requests were unwilling to acknowledge their actions for fear of repercussions). Even more striking results were reported in a survey of San Francisco area physicians looking after AIDS patients. Slome et al found that 98 per cent of respondents had received requests for PAS and that more than half of all responding physicians reported having granted requests for PAS, with some physicians fulfilling dozens of such requests. Moreover, in response to a hypothetical vignette, nearly half of the sample (48 per cent) indicated that they would be likely to grant a hypothetical patient's initial request for PAS.
Perhaps the most striking research to date regarding the use of PAS and euthanasia was a study of critical care nurses conducted by Asch. This study, based on the results of an anonymous survey, found that 17 per cent of respondents reported having received at least one request for PAS and 11 per cent had granted such a request. Approximately 5 per cent responding nurses acknowledged having hastened a patient's death at the request of the physician, but without the request of the patient or the family (termed "nonvoluntary euthanasia" by some writers). Moreover, 4.7 per cent of the sample indicated that they had hastened a patient's death without the knowledge of or request by the physician. Respondents described having stopped oxygen therapy or increased pain medication in order to hasten death. Asch suggested that based on the reports of respondent nurses, these actions were done in order to ease the suffering of the patients. The traditional role of nursing in palliative care was cited as the basis for these results. It should also be noted that Asch's controversial study generated considerable response, including many suggestions that methodological issues such as vague wording of questions may make these data unreliable. Nevertheless, while these data may not accurately indicate the true prevalence of PAS or euthanasia, requests for assistance in dying are clearly not rare events and physicians occasionally grant such requests despite legal prohibitions. Furthermore, because legal restrictions limit the ability of physicians to consult with colleagues regarding how to react to a request for PAS, the appropriateness of patient requests and physician responses is unknown.
In The Netherlands, however, where PAS and euthanasia have been practiced regularly for more than 20 years, data are available regarding the frequency of requests for assistance in dying and the proportion of terminally ill patients whose lives end in this manner. Euthanasia was granted its current status in 1984 after a Dutch Supreme Court decision authorized this practice, provided a number of conditions were met. Specifically, the patient's request for PAS must be considered free, conscious, explicit, and persistent. Both the physician and patient must agree that the patient's suffering is intolerable, and other measures for relief must have been exhausted. A second physician must be consulted and must concur with the decision to assist in ending the patient's life. Finally, all of these conditions must be adequately documented and reported to the governmental body supervising the practice of euthanasia. Because of the availability of such records, several studies have documented the proportion of deaths in The Netherlands in which euthanasia and PAS are implicated (these estimates were adjusted to account for underreporting of euthanasia acknowledged by many Dutch physicians). While reporting on euthanasia and PAS practices in The Netherlands from 1990 to 1995, van der Maas et al incorporated both official reports of euthanasia as well as responses to anonymous surveys to estimate the rates of euthanasia and PAS. They concluded that euthanasia and PAS were involved in roughly 4.7 per cent of all deaths in The Netherlands during 1995, a substantial increase over the 2.7 per cent of deaths involving medical assistance reported in a 1991 study.
Supporters of PAS point to data from The Netherlands as evidence that legalization has not led to widespread abuse or overuse of euthanasia or PAS. However, critics suggest that the 75 per cent increase in deaths involving euthanasia or PAS (from 2.7 to 4.7 per cent) demonstrates a growing tendency toward their more frequent use and thus a greater number of potentially inappropriate cases of euthanasia. Such concerns are clearly reflected in a 1994 Dutch Supreme Court decision in which the right to euthanasia/PAS was extended to include patients′ suffering from chronic illnesses that are not terminal, including mental disorders such as depression, provided the illness is refractory to treatment and causes intolerable suffering. Although the vast majority of requests for PAS from mentally ill individuals have been denied, isolated cases have occurred in which mentally ill Dutch adults have been allowed to receive PAS or euthanasia as a result of this court ruling. This experience has been identified as evidence of the "slippery slope" argument, in which legalization of PAS is presumed to lead to a gradual widening of the group of patients eligible for this "intervention," many of whom may not be appropriate candidates (e.g., physically healthy but clinically depressed individuals).
Reasons for seeking hastened death/PAS
A growing body of literature has emerged indicating the types of physical and psychological concerns that may give rise to a desire for hastened death and requests for PAS. Although this literature has not always been consistent, a growing consensus has supported many of the assumptions put forth by the initial advocates and opponents of legalization. Specifically, the issues that have received the broadest empirical support are pain, depression, social support, and cognitive dysfunction.
Suicide among the medically ill
Not all patients who seek a hastened death request assistance from their physicians. Rates of suicide among medically ill populations have been a topic of clinical concern and empirical research for many years prior to the emergence of the PAS debate. This research has generally concluded that depression and suicide among patients with medical illnesses are not particularly common but rather occur more often than in physically healthy populations. These suicide vulnerability factors in cancer and AIDS patients include poor prognosis and advanced disease, depression, hopelessness, loss of control, a sense of helplessness, delirium, fatigue and exhaustion of resources, pre-existing psychopathology, and previous suicide attempts. The role of psychiatric and psychosocial assessment and intervention has been well accepted as a critically important aspect of the care of patients with advanced cancer or AIDS.
Hinduism - Suicide, Euthanasia, and PAS
It has been pointed out that in Hinduism, the word for suicide, atma-gatha, has also the elements of intentionality.
The intention to voluntarily kill oneself for selfish motives was condemned in Hinduism. Subjectively, the evil sprang from a product of ignorance and passion; objectively, the evil encompassed the karmic consequences which impeded the progress of liberation. It was in this context that the Dharmasutras vehemently prohibited suicide.
Nevertheless, Hinduism venerated enlightened people who voluntarily decided their mode of death. Thus, the Pandavas eulogized "Mahaparasthana" or the great journey through their Himalayan sojourn when they walked in pilgrimage, thriving on air and water till they left their bodies one after another. Crawford lists fasting, self-immolation, and drowning at holy places as other examples of such venerated deaths. Such deaths by enlightened persons have never been equated with the popular notion of suicide in the Indian tradition. It has been always considered that suicide increases the difficulties in subsequent lives.
Can the Hindu stance as mentioned above be extended to the question of euthanasia? Here, the Indian attitude toward life and death needs special mention.
In the Hindu tradition, death acts as a prefiguration and model, through which the ties that bind man's self or soul to cosmic impermanence can be completely broken and through which ultimate goals of immortality and freedom can be finally and definitely attained. Crawford considers "spiritual death" in the Indian context to be synonymous with a "good death," i.e., the individual must be in a state of calm and equipoise. Crawford surmises that to ensure such a noble death, the concept of active euthanasia would not be unacceptable to the Indian psyche. However, this view has been criticized by authors who claim that "spiritual death" or "iccha mrtu" can only be possible when the evolved soul chooses to abandon the body at will. It is also claimed that the evolving soul cannot be equated with mental tranquility as it is at a higher level of consciousness. Thus, though less dogmatic than other religions, Hindus would traditionally remain skeptic in their view about euthanasia. It has been proposed that a strong objection to euthanasia might arise from the Indian concept of Ahimsa. However, even in the Gandhian framework of Ahimsa, violence that is inevitable is not considered as sin. This emphasizes flexibility of the Indian mind. Hence, though a little skeptic, the Indian mind would not consider the thought of euthanasia and PAS as a sacrilege.
Attitudes of psychiatrists toward voluntary euthanasia in India
A major concern that has been expressed is that the wish of the terminally ill patient requesting PAS may be colored by depression. Hence, psychiatrist's role becomes important for assessing depression in these patients. It is in fact a legal requirement in some places that psychiatric assessment should be mandatory before a patient is granted the permission to undergo PAS. It is claimed that after being allotted this crucial role, the psychiatrists would act as a gatekeeper in this highly controversial issue. It has also been proposed that since very few psychiatrists would feel confident in detecting depression in the terminally ill, their attitude might color their judgment.
Though legalization of PAS is still not a very important prerogative for the Indian legislature, we designed a study at the Central Institute of Psychiatry, Ranchi, to see the attitude of Indian psychiatrists about euthanasia, as they might have to act as gatekeepers in PAS issues in the future. Certain interesting findings emerged in this study. Out of the 165 psychiatrists who participated in the study, 99 completed the questionnaire. More than 55 per cent of the subjects favored PAS and believed that it should be legalized, whereas only 28 per cent opposed the idea. The major factors that determined the attitude included deeply held moral values like role of physician is to preserve life, PAS would pressurize for improved palliative care, religious beliefs, and diversion of resources from palliative care. 60 per cent believed that they would consider PAS on themselves in case of terminal suffering. The factors determining their decision to consider PAS would be pain in 70 per cent cases, no hope of recovery in 50 per cent cases, loss of mental faculties in 49 per cent cases, inability to take care of self and poor quality of life in 35 per cent cases each. 60 per cent of the respondents believed that they would not be confident in diagnosing depression in the terminally ill patients during a single interview with the patients if they were called for giving an expert opinion. This is a surprising finding as it implies that more than expert knowledge, the moral principles and previous attitude regarding PAS may influence the judgments of the psychiatrists if they were act as a gatekeeper in the future.
Another sample survey of 200 doctors carried out by the Society for the Right to Die with Dignity in Bombay also gave a glimpse of what views health professionals in our country held regarding euthanasia and PAS: Ninety percent stated they had the topic in mind and were concerned, while 78 per cent argued that patients should have the right to choose in case of terminal illness; 74 per cent believed that artificial life supports should not be extended when death is imminent, but only 65 per cent stated that they would withdraw life supports; 41 per cent argued that Living Will should be respected, and 31 per cent had reservations about the issue.
The Indian reality
It can be argued that in a country where the basic human rights of individuals are often left unaddressed, illiteracy is rampant, more than half the population is not having access to potable water, people die every day due to infections, and where medical assistance and care is less, for the few people, issues related to euthanasia and PAS are irrelevant. However, India is a country of diversities across religious groups, educational status, and cultures. In this background, the debate on euthanasia in India is more confusing as there is also a law in this land that punishes individuals who even try to commit suicide.
The Medical Council of India, in a meeting of its ethics committee in February 2008 in relation to euthanasia opined: Practicing euthanasia shall constitute unethical conduct. However, on specific occasions, the question of withdrawing supporting devices to sustain cardio-pulmonary function even after brain death shall be decided only by a team of doctors and not merely by the treating physician alone. A team of doctors shall declare withdrawal of support system. Such team shall consist of the doctor in-charge of the patient, Chief Medical Officer / Medical Officer in-charge of the hospital, and a doctor nominated by the in-charge of the hospital from the hospital staff or in accordance with the provisions of the Transplantation of Human Organ Act, 1994.
In India, euthanasia is a crime. Section 309 of the Indian Penal Code (IPC) deals with the attempt to commit suicide and Section 306 of the IPC deals with abetment of suicide - both actions are punishable. Only those who are brain dead can be taken off life support with the help of family members. Likewise, the Honorable Supreme Court is also of the view that that the right to life guaranteed by Article 21 of the constitution does not include the right to die. The court held that Article 21 is a provision guaranteeing protection of life and personal liberty and by no stretch of imagination can extinction of life be read into it. However, various pro-euthanasia organizations, the most prominent among them being the Death with Dignity Foundation, keep on fighting for legalization of an individual's right to choose his own death.
A major development took place in this field on 7 March 2011. The Supreme Court, in a landmark judgment, allowed passive euthanasia. Refusing mercy killing of Aruna Shaunbag, lying in a vegetative state in a Mumbai Hospital for 37 years, a two-judge bench laid down a set of tough guidelines under which passive euthanasia can be legalized through a high-court monitored mechanism. The court further stated that parents, spouses, or close relatives of the patient can make such a plea to the high court. The chief justices of the high courts, on receipt of such a plea, would constitute a bench to decide it. The bench in turn would appoint a committee of at least three renowned doctors to advise them on the matter.
Conclusion
Medical science is progressing in India as in the rest of the world, and hence currently we are having devises that can prolong life by artificial means. This may indirectly prolong terminal suffering and may also prove to be very costly for the families of the subject in question. Hence, end-of-life issues are becoming major ethical considerations in the modern-day medical science in India. The proponents and the opponents of euthanasia and PAS are as active in India as in the rest of the world. However, the Indian legislature does not seem to be sensitive to these. The landmark Supreme Court judgment has provided a major boost to pro-euthanasia activists though it is a long way to go before it becomes a law in the parliament. Moreover, concerns for its misuse remain a major issue which ought to be addressed before it becomes a law in our country.
Disclaimer: This article, written by Vinod K Sinha, S Basu and S Sarkhel, was published in the Indian Journal of Psychiatry
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