For more than two decades, veterinary surgeon Ashok Singhal has been putting dogs to sleep in his clinics in Gurgaon and Delhi, on an average two a month. Yet each time he injects the death liquid into a dog he experiences a stab of conscience: Is it the right thing to do? Is it really the end of the road for the dog on the operating table?

If putting dogs to sleep can trigger such emotional distress in a veteran vet, injecting a lethal concoction into a human patient or prescribing a fatal dose to him or her can also lead to considerable anxiety.

Indeed, Singhal’s experience suggests that the ongoing debate on euthanasia in this country, sparked off by a Supreme Court directive earlier this month to the government to come up with legislation for this medical practice, is largely one-sided. By focusing almost entirely on patients it has underplayed the dilemma that euthanasia poses for doctors and the psychological toll it can take on them.

From the patient's point of view, one can certainly ask whether it makes sense to keep alive those experiencing acute suffering because of an incurable disease and deny them the chance to die with dignity. From a patient's perspective it doesn’t make sense, particularly if he or she has expressed a prior wish to die. However, this answer presumes that the patient is the only actor in euthanasia.

To look at the issue from the viewpoint of the other actor, namely the doctor, we first need to distinguish between passive and active euthanasia. The first entails withdrawing a line of treatment by, for instance, switching off the life-support system that keeps a person alive who has a negligible chance of staging a recovery. Passive euthanasia is practised widely, even in India.

By contrast, active euthanasia demands that the doctor either administer a lethal injection or prescribe a fatal dose of medicine to a patient who has explicitly expressed the wish to die. This form of euthanasia is often referred to as physician-assisted suicide, or just assisted suicidewhich is not legal in India.

For the terminally ill patient, euthanasia is an escape from needless suffering, a relief. For the doctor, the act of euthanasia can be tantamount to participating in killing a person, even though many would call him or her  a "beneficent executioner." The debate on euthanasia over the past few weeks in this country conveys the impression that a beneficent executioner is a badge most doctors sport willingly.

But that is not necessarily true. Ashok Bakaya, who heads the cardiology department of ASCOM Hospital in Jammu, says he would get emotionally distressed if a patient on whom he has done a procedure dies subsequently.

While he wouldn’t have qualms withdrawing the life-support system from a patient who is medically determined beyond the stage of recovery, he feels differently about active euthanasia. "A doctor will think ten times before performing it," Bakaya said over the phone.  "I won’t even then. It’s killing a person, plain and simple."

The experience abroad
Those who believe that assisted suicide does not pose an ethical dilemma for doctors may cite the example of Jack Kevorkian. Popularly known as Dr Death, he claimed in the 1990s to have assisted 130 terminally ill people in the US to end their lives. He invented a suicide machine, Mercitron, which injected a lethal dose in those who sought his assistance in dying. One such suicide was shown live on TV, and Dr Kevorkian was sent to prison for eight years.

But there are numerous accounts of the negative impact of euthanasia on doctors. One of the most detailed is the essay, Emotional and Psychological Effects of Physician-Assisted Suicide on Participating Physicians, which Dr Kenneth R Stevens Jr wrote for Law and Medicine in 2006.

After poring through hundreds of articles in medical journals, dozens of books, documents generated by legislative investigations and stories in the press, Dr Stevens, who is the vice-president of Physicians for Compassionate Care, concluded: "Many doctors who have participated in euthanasia and/or PAS are adversely affected emotionally and psychologically by their experiences."

Perhaps the most compelling evidence in support of this assertion comes from the Netherlands, which has had a long tradition of euthanasia. For instance, PJ van der Mas wrote in the Lancet in 1991, "Many physicians who had practiced euthanasia mentioned that they would be most reluctant to do so again."

Then the American Medical News quoted Pieter Admiraal, a leader of Holland's euthanasia movement, as saying. "You will never get accustomed to killing somebody… With euthanasia, your nightmare comes true."

These observations had its echo in the depositions of several Dutch doctors to the British House of Lords Select Committee on the Terminally Ill Bill in 2005. Asked what he felt about performing euthanasia for the first time, Dr Van Coevorden replied, "Awful." The Committee also learned that it was common among Dutch doctors to take a day off after performing euthanasia because it temporarily rendered them incapable of taking clinical decisions.

The experience of doctors was not any different in Oregon, the American state that implemented the Death with Dignity Act in 1998. In that year, 14 physicians wrote lethal medications for 15 patients who opted for assisted suicide.

The annual report of the Oregon Health Department observed: "For some of these physicians, the process of participating in physician-assisted suicide exacted a large emotional toll, as reflected by such comments as, 'It was an excruciating thing to do . . .It made me rethink life's priorities', 'This was really hard on me, especially being there when he took the pills' and 'This had a tremendous emotional impact.'"

The overwhelming experience of participating in assisted suicide is evident in the account of Oregon physician, Dr Peter Reagan, who assisted a woman called Helen to die. He wrote in the Lancet medical journal: "I wrote the prescription for the 90 secobarbital. I hesitated at the signature… I tried to imagine deciding to die… Whenever I tried, I experienced a sadness much more profound than what I saw in her." In the same piece, he wrote, "Gerrit Kimsma, a Dutch family physician and medical ethicist, writes with colleagues that some professionals (in the Netherland) become dysfunctional and may require a lot of time to recover."

But the death of Helen continued to haunt Dr Reagan for another three years. In an interview to the Oregonian in 2001, he said if he were dying, he wouldn’t ask for assisted suicide. Why? "Because it’s a lot to ask."

Experiences such as that of Reagan's prompted euthanasia critic Leon Cass to write, "The psychological burden of the licence to kill (not to speak of the brutalisation of the physician-killers) could very well be an intolerably high price to pay for physician-assisted euthanasia."

Perhaps this also explains the growing reluctance of physicians in Oregon to be present at the time patients take the lethal dose they prescribed to them. Between 1998 and 2002, 52% of all physicians who agreed to perform assisted suicide watched their patients die. In 2004, this number dwindled to just 16%

Also, the number of doctors participating in active euthanasia is very small – barely one per cent of all Oregon physicians. In a 2010 article, Dr Stevens wrote, "Sixty-one percent of the 271 lethal prescriptions from 2001 to 2007 were written by 20 physicians. Even more significant is that 23% of the 271 prescriptions came from only three physicians."

Ideological battle
Behind these figures is an ideological battle, a battle between those opposed to euthanasia and others like Compassion & Choices, a non-profit organisation that aims to enhance the end-of-life choices for patients. Citing medical records, Dr Stevens says Compassion & Choices was involved in 88% (53 of 60) of assisted-suicide deaths in 2008, and 97% (57 of 59) in 2009. He noted sarcastically, "Compassion & Choices has the corner on the market for physician-assisted suicide."

Indeed, new entrants in the medical profession are reluctant to voice their opposition to assisted suicide because they fear they will be denied employment opportunities. Dr Henk Jochemsen said as much to the House of Lords Select Committee, "I know from physicians who are opposed to performing euthanasia that they are afraid of saying so when applying for jobs and trying to find a post as a physician. In certain circumstances, that will make it much more difficult for them to get a job."

Not only is there unsaid pressure from hospitals to perform euthanasia, several doctors have reported feeling intimidated by patients and their relatives to prescribe lethal drugs.

Palliative care
It is only fair to recognise that euthanasia, whether passive or active, could skew the system of palliative care. In other words, it could reduce the incentive to improve the quality of health care focusing on relieving pain and suffering.

"Providing euthanasia as a solution to every difficult problem in palliative care would completely change our knowledge and practice, and also the possibilities that we have," Dr Ben Zylicz told the House of Lords Committee. "My biggest concern in setting a norm of euthanasia in medicine (is) that it will inhibit the development of our learning from patients, because we will solve everything with euthanasia."

Suicide is not the problem here. Seeking the help of another person for inflicting death on oneself is. This is a point that the current debate on euthanasia has missed.

(A Delhi-based journalist, Ajaz Ashraf is the author of  The Hour Before Dawn, HarperCollins India, releasing September 2014.)