The Karnataka Health Department has issued an order to implement the Supreme Court’s 2023 ruling allowing terminally ill patients to die with dignity. The move, officials say, does not have any specific trigger, and is part of ongoing discussions about formalising the procedure for withdrawal of life support or what is also called passive euthanasia. It is meant to help patients with no hope of recovery or those in a persistent vegetative state, and families seeking a dignified end to their prolonged suffering.
What is the Supreme Court’s ruling?
Euthanasia, or mercy killing as it is commonly called, is legal in India in its passive form– i.e., withdrawal of life-sustaining treatment in cases of patients who have no hope of recovery. Though this has been established by the SC through cases, no dedicated legislation is in place to conduct it.
On January 24, 2023, the apex court ruled that life-sustaining treatment (such as ventilators or feeding tubes) can be withheld or withdrawn for terminally ill patients who have no hope of recovery or are in a persistent vegetative state, and where the patient has no longer benefits from life-sustaining treatment. It involves stopping medical interventions like ventilators or feeding tubes typically used to replace bodily functions critical for survival when a person’s own body can no longer perform them.
However, certain conditions under a defined framework have to be fulfilled to execute this.
Right to refuse medical treatment
The right to refuse medical treatment, even if it leads to death, has long been recognised in Common Law. It was in Aruna Shanbaug vs Union of India (2011), that the SC, for the first time, sanctioned passive euthanasia, recognising the right to die with dignity as a fundamental right envisaged within the ambit of the right to life and liberty laid down in Article 21 of the Constitution.
The case pertained to Aruna Shanbaug, a nurse at Mumbai’s King Edward Memorial Hospital, who was sexually assaulted by a sweeper in the hospital in 1973, leaving her in a persistent vegetative state for over 42 years. In 2011, Pinki Virani, a journalist and activist filed a petition seeking euthanasia for Aruna, arguing that she was living in a condition of extreme suffering with no hope of recovery.
Making a clear distinction between passive euthanasia and active euthanasia (intentionally administering lethal drugs to end a patient’s life), the court approved the former and rejected the latter.
In Common Cause vs Union of India (2018) as well, the right to die with dignity was emphasised as a fundamental right by the SC. The court also discussed the concept of a living will, in which a person can give instructions about medical care in the case of an eventuality.
When is passive euthanasia considered?
Life-sustaining treatment may be withheld or withdrawn in two scenarios:
Informed refusal by the patient: If the patient is capable of making decisions, they can choose to refuse treatment, understanding the consequences.
Advance Medical Directive (Living Will): A person can outline their treatment preferences in a living will, specifying what medical actions should be taken if they become unable to make decisions in the future.
For patients without decision-making capacity and no living will, a doctor may recommend withdrawing treatment if the patient is in a terminal or vegetative state, and further medical intervention would only prolong the dying process without hope of recovery.
The Karnataka Health Department’s order, issued on January 30, outlines the procedure for implementing the Supreme Court’s ruling. Key points include:
Withholding or Withdrawing Life-Sustaining Treatment (WLST):
> WLST can be considered for patients who are terminally ill, in a persistent vegetative state, or have no hope of recovery.
> The decision must be made in accordance with a prescribed procedure and with the approval of the treating doctor.
Medical Boards:
> Hospitals must form primary and secondary medical boards, each comprising three registered medical practitioners (e.g., neurologists, neurosurgeons, intensivists).
> The secondary board must include a medical practitioner nominated by the District Health Officer.
> These boards will assess the patient’s condition and decide on withholding or withdrawing treatment after obtaining consent from the patient’s next of kin or a person nominated in the patient’s AMD.
Judicial Oversight:
> Decisions by the medical boards must be submitted to the Judicial Magistrate of the First Class (JMFC) before implementation.
> The JMFC will forward copies of the decisions to the Registrar of the High Court for record-keeping.
Advance Medical Directive (AMD):
> Patients can create an AMD, also known as a “living will,” to specify their preferences for future medical treatment.
> The AMD allows patients to nominate two individuals to make decisions on their behalf if they lose decision-making capacity.
> The directive must be submitted to a competent officer appointed by the local government and can be maintained in the patient’s medical records (paper or digital).
Karnataka Health Minister Dinesh Gundu Rao said, “This important step will bring great relief and a dignified sense of closure to many families and individuals.” He further added, “We have also come out with an Advance Medical Directive (AMD), or a living will, in which a patient can record their wishes about their medical treatment in the future.”
What is an Advance Medical Directive (AMD)?
An AMD is a legal document that allows individuals to specify their preferences for medical treatment in advance. The order said, “Any adult patient of sound mind can execute an AMD and should send a copy of the AMD to a competent officer who is to be appointed for this purpose by the local government. AMDs can also be maintained in the paper/digital health records of the patient which are maintained by the medical establishment.”