From interviews conducted with people involved with hospice and palliative care in India, the following ethical issues were identified (Table 17):

Table 17 Identified ethical issues

In the following extracts, those involved in palliative care from across India elaborate on the ethical issues they encounter:

About 85 per cent of our patients are very, very poor. They come to us at a stage where what little resources they have have been spent on the curative treatment. As you know, almost all medical care in India is paid medical care, it’s not, there is no national health service for example, there’s very little insurance that our patients can go in for, so most of it is paid for. So by the time they come to us, when curative treatment is over, they’re absolutely drained from the financial point of view. So one of the things that funders, insensitive funders ask us is, since we’re giving an excellent set of care, why don’t we make it paid care? Why don’t we ask the patients to pay for what ... now that’s something that, it’s an ethical question.
Dr K Rao, Bangalore Hospice Trust, Karnataka, south India⁸

Disclosing has been always a problem. The tightly knit family bonds may be part of the reason for this problem that we face. We have patients coming and requesting us not to tell the prognosis to their wife and children. And we also have the other way round, the family requesting us not to disclose the truth of the patient that the fact that his life expectancy is cut short. We are being told not to disclose and I think this is the main ethical issue that we have…and so when we try to break bad news we always bear in mind that truth, although it may not be palatable, if it is done in the proper way they do understand. And if we can’t straight away break bad news or a period of time when we take them into our trust and confidence, in the midst of the family we touch hard facts and hard realities, and I think the initial road blocks are overcome when we are familiar with them and when they are familiar with us.
Dr Cherian Koshy, Trivandrum Regional Cancer Centre, Kerala, south India.⁵⁶

In fact one of the problems which is more common in India is that relatives don’t want to tell to the patient and what we realise is that the patient knows in their heart of hearts that he has cancer and they are playing a sort of a hide and seek game with each other, relatives don’t want to show to the patient that he has cancer and patient doesn’t want to reveal it because he sees the difference in them, there’s more care being done, sometimes they’re educated they can read, they can talk to other patients, they come to know about it and there is some change in their life and their attitude of relatives towards them so this hide and seek game, this is very difficult. Then another problem here is that financially they are a little bit poor.
Dr Aarti  Patel, Jawaharlal Nehru Cancer Hospital and Research Centre, Madhya Pradesh, central India.¹⁵

In a high tech hospital, sometimes when one goes and says “this patient is dying, do we have to continue IV fluids, do we have to do the blood transfusions”?  It is kind of shocking to many colleagues, because of course if a patient has a low urine output or a low haemoglobin, you should transfuse so, it takes a little bit of education to explain why death is not necessarily a medical failure, that it is something that comes to all of us and fighting to postpone it by a few hours is not necessarily a medical calling or a good thing to do.  That is one.
Dr Reena George, Christian Medical College and Hospital, Tamil Nadu, south India.⁴⁹