When Supreme Court First Recognised Concept Of Passive Euthanasia

Please allow withdrawal of artificial life support, the Supreme Court was urged Wednesday by the family of a 31-year-old man who has been comatose for more than a dozen years. The family's reasoning: it will restore his dignity after years of irreversible suffering.

The top court allowed passive euthasia for Harish Rana and directed the All India Institute of Medical Sciences, or AIIMS, to prepare a tailored plan for withdrawal of treatment while ensuring dignity in the process.

The Ghaziabad man has been in a permanent vegetative state since 2013 after suffering severe head injuries from a fall from the fourth floor of his rented house on August 20 that year.

Passive euthanasia in exceptional circumstances was legalised in India in the Aruna Shanbaug vs Union of India judgment in 2011.

Shanbaug, a nurse, remained in a vegetative state for over four decades after a sexual assault that left her paralysed and inflicted serious brain damage. The court had rejected a petition to remove life support after noting that medical evidence suggests she should live. The judgment, however, eased the norms for passive euthanasia, allowing it in exceptional cases.

The family said the request for withdrawal of life-sustaining treatment was based on the legal framework evolved by the Supreme Court on passive euthanasia.

In 2018, the Supreme Court recognised the right to die with dignity as a fundamental right and prescribed guidelines for terminally ill patients to enforce the right. In 2023, the Supreme Court modified the guidelines to make the right to die with dignity more accessible.

A five-judge Constitution bench delivered the 2018 decision on a petition filed by the NGO Common Cause.

A Constitution bench comprising then Chief Justice Deepak Misra, Justice AK Sikri, Justice AM Khanwilkar, Justice DY Chandrachud, and Justice Ashok Bhushan held that the right to die with dignity is part of the right to life under Article 21 of the Constitution.

The Supreme Court stated that patients suffering from a terminal illness and dependent on life-support equipment may be permitted to withdraw or stop treatment.

The court also the validity of a Living Will, which means that a person can give a written instruction in advance that if they suffer from a terminal illness in the future and are unlikely to recover, they should not receive artificial life-support treatment.

It said that keeping a person alive unnecessarily on machines could be against their dignity.

The judgment laid out a detailed process for creating a Living Will and how hospitals can decide to withdraw life-support treatment.

What Makes A Living Will?
Any adult with full mental capacity can create a living will. In this, the person can write that if they develop a terminal illness or a permanent coma in the future, they should not be placed on artificial life-support.

This document must be signed in the presence of two witnesses and must be certified by a Judicial Magistrate.

The Role Of Hospitals
The hospital must first form a medical board consisting of relevant specialist doctors. This board will assess the patient's condition. It will evaluate whether the patient is in a terminal or irreversible condition.

Second Medical Board
Following the recommendation of the first board, the hospital must form a second independent medical board. The second board will also review the patient's condition.

After the concurrence of both medical boards, the decision will be presented to a judicial magistrate. The magistrate will ensure that the process is voluntary and in accordance with the law.

What Happens if There's No Living Will?
Even if the patient has not prepared a living will, the family or close relatives can request the hospital to withdraw life-sustaining treatment.

In such a situation, the same two medical board procedures will be followed. The court held that the "right to die with dignity" is part of Article 21 of the Constitution (the right to life and personal liberty).

However, the Living Will/passive euthanasia process was later simplified by the Supreme Court in 2023. The requirement for certification from a magistrate was abolished.

Now, a Living Will must be signed in the presence of two witnesses.

Medical Board Process Simplified
Previously, there was a complex process involving two separate medical boards. Now, the first medical board will consist of hospital doctors evaluating the patient's condition. The second board will confirm the decision within 48 hours.

Clear Protocols For Hospitals
The court stated that all hospitals must establish a clear process for implementing it.

The Role Of The Family
If a Living Will exists, the family and doctors can jointly implement the decision according to its terms. The court stated that the 2018 process was too complex, and in many cases, the patient's wishes could not be implemented. Therefore, the process was made practical and less formal.

The court reiterated that the right to die with dignity is part of the fundamental right under Article 21.

What Rana's Family Told Court
In written submissions before the court, the family said Harish Rana has remained in an "irreversible and incurable permanent vegetative state" with 100 per cent disability for more than 12 years and survives only with clinically assisted nutrition and hydration administered through a percutaneous endoscopic gastrostomy tube.

They said the artificial feeding system merely sustains his biological survival and has no therapeutic benefit or possibility of reversing the severe brain injury.

The family argued that continuing such treatment would only prolong life artificially without any prospect of recovery.

Referring to the constitutional principle of the Right to Live with Dignity under Article 21, the submissions said the law permits withdrawal of life-sustaining treatment in cases where a patient is in an incurable and irreversible condition and medical intervention only prolongs suffering.

The family pleaded that passive euthanasia and the withdrawal of life-support systems are legally permissible when medical experts certify that the patient has no chance of recovery.

According to the submissions, two medical boards constituted at the direction of the Supreme Court found Rana's condition to be irreversible and confirmed that he has remained in a permanent vegetative state for more than a decade.

The secondary medical board also noted that the feeding tube being used in his case only provides sustenance for survival and cannot restore his cognitive function or reverse the underlying brain damage.

The family told the court that their request was not motivated by a desire to cause death but by the belief that it was not in Rana's best interests to continue living in such a condition.