Provided this backdrop of palliative care in India, it is important to address the difficulty of imitating Western models of palliative care. In general, palliative cancer care has become a requisite for physicians while formulating a tailored plan of patient care. In the United States, the Supreme Court has voiced unequivocal support for adequate pain relief; and palliative medicine has become an area of expertise in its own right.[13
] These developments prompt a review of some of the central ethical issues particular to palliative care. These issues such as relief of pain and suffering, autonomy and consent, and multi-specialist care, are important points of consideration for all physicians caring for patients regardless of the cause of their suffering and whether or not these physicians are specialists in palliative medicine or not.[14
] At the same time, the Indian palliative care environment presents numerous challenges to these Western ethical principles of palliative care.
The first issue addresses the relief of pain and suffering. The availability, accessibility, and effectiveness of modern methods of pain control make it a moral mandate for every physician to be knowledgeable in the use of analgesics. It is estimated that less than 3% of India’s cancer patients have access to adequate pain relief.[15
] Inadequate attention to pain relief is tantamount to moral and legal malpractice and is a violation of the principle of beneficence. Despite this, many physicians still lack an integrated comprehensive approach to pain management, which culminates to a fastidious use of analgesics. One cannot have discourse on pain management and exclude the ethical dilemma that the doses of analgesics sufficient to relieve some forms of chronic pain might hasten death (which sometimes may be an intended effect). It is permissible without fear of repercussion if the conditions of the “rule of double effect” are observed.[16
] From a legal perspective, it is the physician’s obligation to provide adequate pain relief, while banning the practice of physician-assisted suicide.[17
] In this context, palliative medication ought to be a constitutional right and that there is ethical and legal sanction for the use of whatever doses of narcotics are necessary so long as death is not directly intended.
However, there are numerous barriers to the assessment of relief of pain and suffering in Indian patients although physicians may have intent to do no harm. Developing countries such as India generally view the illicit drug epidemic in Western countries with caution and fear that opioid availability in India will lead to drug abuse.[18
] The medicinal use of opioids such as morphine is highly regulated by the Indian Narcotic Drugs and Psychotropic Substances Act (NDPS), and to dispense morphine to patients the hospitals must be registered with the government and adhere to a set procedure.[10
] Despite some success at increasing availability, progress is slow and opioid accessibility continues to remain a constant problem for the providers of palliative care in India.
The second issue deals with autonomy and consent. As with any program of treatment, consent for palliative care must be obtained from competent patients and cannot be assumed. Full disclosure is requisite so that the patient realizes he or she will be cared for by a multidisciplinary team of physician specialists (i.e. oncologists), nurses, social workers, pastoral care counselors, physical therapists, pain specialists, psychologists, and psychiatrists. However, part of the problem in India arises when vulnerable patients receiving palliative care become susceptible to suggestions about unorthodox treatment. Many Indians already choose so-called alternative medicines (i.e. ayurvedic, Siddha medicine, herbal medicine, homeopathic, etc.) alongside conventional allopathic medicine.[19
] Such individuals are increasingly drawn to such treatment when conventional curative therapy fails.[20
] Vaidya et al
] state that Ayurvedic formulations have effectively controlled the side effects of chemotherapy. Siddha medicine, which supports the supernatural powers of healing, and herbal medicine are also very common elements in Indian alternative medicine. Especially in remote parts of the country, patients who live below the poverty line cannot afford palliative services and are compelled to try these alternative therapies.[6
] Physicians who consider such treatment unethical ought to be free not to participate and should respectfully explain to the patient for their reasons to continue with such methods.
The third issue deals with the ethics of being treated by a multi-specialist palliative care team. As aforementioned, palliative cancer care comprises of various specialists collectively working to meet the needs of terminally ill patients. By the nature of cancer care, physicians are frequently exposed to patients and families with multiple, concurrent issues (physical, psychological, social, spiritual, etc.). To provide a secondary level of palliative cancer care in addition to the team of general practitioners, physicians require more knowledge and skill to manage complex situations and interactions with other physicians and patients. A review by Hearn et al
] highlights that when compared to conventional care, there is evidence that specialist teams in palliative care improve satisfaction and identify and deal with more patient and family needs. Moreover, multi-professional approaches to palliative care reduce the overall cost of care by reducing the amount of time patients spend in acute hospital settings.[22
However, the primary challenge to multi-specialist treatment approaches in India is the popularity of outpatient homecare programs and services. In one study of 33 palliative care clinics across Kerala, outpatient treatment with a supportive homecare service was adopted as the main mode of palliative care.[8
] The homecare team primarily consists of trained nurses, family members, and even social workers, who travel in autorickshaws to visit terminally ill cancer patients and provide emotional support and advice for their symptom relief. Another example is the Bangalore Hospice Trust of the Indian Cancer Society, which has provided care for the terminally ill since 1994.[23
] Therefore, instead of the inpatient multi-physician-based services rooted in Western care models, the convenient and cost-effective models of Indian palliative care often revolve around medical and psychosocial support delivered directly by nurses and family members. While the autonomy of the patient is seemingly undermined once the family and community become involved as the primary body of care, for many palliative cancer patients in India, this may be the only treatment option that is both practical and cost-effective. Furthermore, by reducing a broad specialist team approach to a limited homecare setting, this should not be perceived as a weakening of healthcare ethic and patient care.
Overall, in addition to providing better clinical outcomes, palliative medicine sets up a moral foundation whose methodology can become an ideology wherein there is only one morally right way to die. In doing so, the field medicalizes and professionalizes a process that depends as much on personal commitment to a friendly interest in the patient as it does on technical expertise. In the hospital and cancer center settings, oncologists have a responsibility to recognize when the benefits of treatment with chemotherapy or radiation have reached their limit so as not to delay comfort and palliative care unnecessarily. In this respect, it would be beneficial if oncologists were to spend time during their training in hospice or palliative care. Oncologists understandably are oriented to aggressive chemotherapy, and such treatments can be detrimental and even futile to the patient’s quality of life. From the patient’s point of view, oncologists must recognize their own biases in treating fatally ill patients. Communicating with patients is a core skill of palliative medicine, so it is important for oncologists to coordinate their patients’ care because the good of the patient demands it.[14