On 11th March (Wednesday), the Supreme Court authorised passive euthanasia for 32-year-old Harish Rana, who had been in a vegetative condition since August 2013 after falling from a building in Chandigarh. The decision, which was produced by a bench of Justices JB Pardiwala and KV Viswanathan, allowed this method for the first time in the country.
Which regulations oversee passive euthanasia in India
No law in India tackles passive euthanasia, but the Union Health Ministry published “Draft Guidelines for Withdrawal of Life Support in Terminally Ill Patients” in September 2024, which was founded by specialists from All India Institute of Medical Sciences (AIIMS). The stakeholders were asked to provide feedback and recommendations on the draft by 20th October of that year.
The instructions outlined the procedure hospitals must follow to withhold or withdraw treatment. They were based on directives from the Supreme Court in 2023. It outlined 4 parameters for a “considered decision in a patient’s best interests, to stop or discontinue ongoing life support in a terminally ill disease that is no longer likely to benefit the patient or is likely to harm in terms of causing suffering and loss of dignity.”
The criteria included the declaration of brainstem death in line with Transplantation of Human Organs Act, a medical prognosis and expert opinion indicating that the disease is in an advanced stage and cannot be expected to improve with aggressive treatment, recorded informed refusal by the patient or surrogate following an understanding of the prognosis, to maintain life support and adherence to the procedures mandated by the top court.
The doctor must decide whether the individual has a probability of recovering or living a happy life if treatment is continued. Afterwards, a primary medical board must evaluate the situation and come to a decision. The doctor and two experts on the subject with five or more years of experience constitute the panel.
The family must then be informed of the prognosis and asked if they would like any additional therapy. It must explain the sickness, available medical routes, alternate modes of care and the repercussions of both undergoing and not getting treatment. The medical team must reach a consensus and develop a coherent treatment plan.
The doctors and the family must lodge a request to a secondary medical board whenever they conclude that the measures should be terminated. It should consist of two subject matter experts with at least 5 years of expertise and a physician appointed by a district’s chief medical officer (CMO). A decision must be made by the board within 48 hours. While their consent is not necessary, hospitals must notify magistrates prior to ceasing treatment.
The key provisions in the draft
According to the document, a terminal illness is an incurable or irreversible condition that would inevitably result in death in the near future. This also included a severe traumatic brain injury that failed to display any signs of recovery following 72 hours.
The paperwork pointed out that life-sustaining treatments (LST) such as mechanical ventilation, vasopressors, dialysis, surgery, transfusions, parenteral nutrition, or extracorporeal membrane oxygenation are not anticipated to be beneficial for many of the hospice patients in the Intensive Care Unit (ICU).
It read, “In such circumstances, LSTs are non-beneficial and increase avoidable burdens and suffering to patients and therefore, are considered excessive and inappropriate. Additionally, they increase emotional stress and economic hardship to the family and moral distress to professional caregivers.”
The regulations outlined, “Withdrawal of LST in such patients is regarded as a standard of ICU care worldwide and upheld by several jurisdictions. Such decisions have medical, ethical and legal considerations. It may be considered that the above-mentioned also applies at the time of initiating Life support treatments to individuals with.”
They recommended reaching an informed decision not to undertake cardiopulmonary resuscitation in the case of an ensuing cardiac arrest if there is no reasonable chance of survival or substantial recovery. The draft noted that even if LST causes mortality, an adult who is capable of making healthcare choices might refuse it under the legal standards pronounced by the Supreme Court.
These principles emphasised that LST could be lawfully withheld or withdrawn from patients who cannot decide under certain circumstances, based on the fundamental rights to autonomy, privacy and dignity, alongside an Advance Medical Directive (AMD) that satisfies relevant conditions with legal binding.
AMD is a written statement that people with the potential to arrive at decisions prepare, outlining their preferences for medical treatment, or lack thereof, should they lose that capacity.
The reaction from the medical fraternity
The medical community did not approve of the effort, and Dr RV Asokan, the national president of the Indian Medical Association (IMA) contesded that it placed them under pressure and exposed them to legal scrutiny.
He asserted, “Such clinical decisions have always been taken in good faith by doctors. The patient’s relatives are explained and given all information, taken into confidence in a given case and a decision is taken on merit in every single case. Putting it down in sort of guidelines and also alleging that inappropriate decisions have been taken or they have been prolonged is a misunderstanding of the situation.”
“First, the perception and assumption that unnecessary machines are used and lives are prolonged is wrong. It exposes the doctors to legal scrutiny. More so, what is left of a doctor-patient relationship, trying to define it in four corners of black and white documentation, which is legally scrutinised, is nothing but exposing the doctors to further stress,” Asokan argued.
He insisted that some things need to be reserved for family members, patients and doctors, depending on the circumstances and science. He further conveyed that the IMA would review the text and submit its opinions to have the rules revised.
The continuous challenges
Dhvani Mehta expressed that problems have persisted despite the apex court streamlining the procedure in 2023, reported The Indian Express. She is the co-founder of the Vidhi Centre for Legal Policy and one of the attorneys representing Harish Rana’s family. “It is still difficult to find doctors with a sufficient level of expertise and experience in all hospitals. And, when it comes to the secondary medical board, the process requires the CMO to send in the list of nominated doctors,” she added.
Mehta highlighted that very few states, including Goa, Karnataka and Maharashtra, have started the process of compiling this list of physicians who have been nominated for the secondary medical board.
“It is easier to withdraw such life-sustaining measures after thoroughly counselling the family members in a government hospital. Many private hospitals, however, are afraid of litigation,” observed Dr Sushma Bhatnagar, former chief of the palliative care team at AIIMS, New Delhi. She currently works at the Indraprastha Apollo Hospital in the national capital and has established a similar procedure there.
Bhatnagar mentioned, “Patients and their family members understand the pain of prolonging life through such measures. What is required is clear communication that can help them understand that they have done everything. There is a lot of guilt that families face over such a decision.”
However, the process has been made easier by understanding the patient’s intentions through a living will. These enable such persons to prepare a legal document specifying the steps they want or would rather not have executed on them when they are no longer capable of making judgments.
The first living will clinic in a private hospital in northern India was established by Bhatnagar at Indraprastha Apollo Hospital. It gives patients the option to select the particular type of care they prefer, the gender they want to be recognised as and the ability to designate someone other than their family to handle medical choices on their behalf.
Supreme Court urges the centre to frame a law on euthanasia
The Supreme Court encouraged the government to introduce a law regarding the practice of euthanasia and/or the withdrawal of medical treatment because it is pertinent to the right to live with dignity, during the recent hearing. It brought attention to the delay on the critical subject of passive euthanasia despite its “pious hope” for the centre to make such a move 8 years ago.
The court charged that no rules had been formed and there was no protracted discussion on the matter, although two law commission studies and numerous bills were presented by private members in Parliament. It was remarked that the intervention was only meant to serve as a temporary constitutional bridge until Parliament fulfilled its obligation, not to replace legislative wisdom.
The bench stressed, “The prolonged absence of a comprehensive legislation on end-of-life care has compelled this Court, time and again, to step in to fill the vacuum, out of constitutional necessity rather than institutional choice. While the guidelines as laid down in Common Cause (supra) have served as an important interim safeguard to protect the right to live and die with dignity, they were never intended to operate as a permanent substitute for legislation.”
“Therefore, we urge the Union Government to consider enacting a comprehensive legislation on the subject in consonance with the vision of the Constitution Bench in Common Cause 2018 (supra). Such a legislation would provide more clarity, coherence and certainty to these pertinent, practical and emotionally charged issues,” the court announced.
A draft bill titled “Medical Treatment of Terminally-Ill Patients (Protection of Patients and Medical Practitioners Bill)” was released by the Ministry of Health and Family Welfare in 2016. The public had been asked to provide input. However, no steps were taken upon completion of the consultative phase.
The right to die with dignity was acknowledged by the Supreme Court in 2018 as a fundamental right under Article 21 in the ongoing Common Cause petition. It devised thorough norms for the withdrawal and withholding of medical care in the absence of a statutory framework. On the other hand, former justice AK Sikri had voiced hope for the government to pass an appropriate statute at the time.
What is euthanasia
Euthanasia is the intentional taking of a patient’s life to stop their suffering. It has multiple different forms and is classified as voluntary, non-voluntary or involuntary. Active euthanasia is the practice of a doctor prescribing a deadly medication or injection to end the agony of a patient who has a minimal likelihood of survival. It is permitted in the United States, Canada, Australia and several regions of Europe, but not in India.
Passive euthanasia involves enabling a person to die spontaneously by withdrawing life-sustaining medical care. Treatments including cardiopulmonary resuscitation, ventilator support, chemotherapy, radiation, dialysis, or specialist diet could be refused by patients or their families.
