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Reforming End-of-Life Care with India's Draft Guidelines on Withdrawal of Life Support

Updated: Mar 29


In a significant step towards shaping the legal landscape of end-of-life care, the Union Health Ministry released a draft towards the end of last year, ‘Guidelines for withdrawal of life support in terminally Ill Patients 2024’. This move comes at a time when modern medical advancements, particularly life support systems, have transformed the way we view dying. Unlike in the past, technologies can prolong life even when recovery seems impossible, bringing the debate around euthanasia into sharper focus.


The guidelines propose a balanced approach, inferring that, under certain safeguards, passive euthanasia should not be viewed as legally or constitutionally objectionable. They reinforce the right of a competent person to refuse aggressive medical treatments, including artificial life support, if they wish. Yet, the guidelines introduce a more cautious process for patients who cannot voice decisions. In such cases, the family, close friends, or doctors must obtain approval from the High Court before discontinuing life-sustaining treatment, ensuring oversight and compliance with the Supreme Court's directives.


Several countries have established comprehensive legal frameworks governing assisted death. For instance, the Netherlands legalised voluntary euthanasia in 2002[1], allowing patients experiencing unbearable suffering to choose death under strict conditions. Similarly, Belgium[2] and Canada[3] have enacted laws permitting euthanasia and assisted suicide, emphasising patient autonomy and informed consent. These international examples offer valuable insights into potential regulatory approaches that India might consider as it navigates its legal landscape regarding end-of-life care.

 

Constitutional Validity

The right to die in India has evolved through key Supreme Court rulings. Initially, the Court interpreted Article 21's right to life as not encompassing the right to die. However, in 2018, a significant shift occurred when the Court acknowledged the right to die with dignity as a fundamental right under Article 21. This change was brought about in the Common Cause v. Union of India,[4] where the Court highlighted the evolving nature of fundamental rights. The ruling expanded the interpretation of the right to life to include a dignified death process for terminally ill or permanently vegetative patients. As a result, passive euthanasia was permitted under specific conditions, while active euthanasia continues to be prohibited.

 

Supreme Court’s Outlook

The Supreme Court clarified that if a competent patient voluntarily refuses to take life-saving medicines, it is not a crime. Following the Aruna Shanbaug case (2011)[5], the Court has approved passive euthanasia. It was the first landmark case in India in which the subject of euthanasia was deliberated at length. 


The point of distinction made by the Supreme Court between active and passive euthanasia is that in active euthanasia, something is done to end the patient’s life. In contrast, in passive euthanasia, something is not done that would have preserved the patient’s life. However, passive euthanasia is further divided into voluntary (with consent) and non-voluntary (unavailability of consent on account of the patient’s condition). 


There is no explicit law on euthanasia. The Courts and the Law Commission laid down the law concerning euthanasia, which shall continue to be the law of the land until and unless the Parliament makes a law on the subject. India has seen such structures previously in cases like Vishakha vs State of Rajasthan (1997)[6]. The Law Commission of India discussed euthanasia after the Aruna Shanbaug case and released its 241st Report in 2012.


Moreover, the inclusion of Puttaswamy v. Union of India in the ongoing discussion about the evolution of Article 21 in relation to end-of-life care is particularly significant. This case established the right to privacy as a fundamental right, which has far-reaching implications for personal autonomy and dignity. The Supreme Court's ruling highlighted that privacy is a core component of individual freedom, ensuring that individuals have the right to make personal decisions about their lives without unwarranted interference. This includes decisions about healthcare and end-of-life choices, where an individual's autonomy must be respected. The judgment further reinforced the idea that personal autonomy is a cornerstone of dignity, particularly in the context of death and dying. It set a precedent that extends the right to make deeply personal choices—such as the refusal of life-sustaining treatment or the right to pursue passive euthanasia—under the broader principle of privacy.

 

Law Commission Report

The Law Commission of India has played an instrumental role in advocating for reforms related to euthanasia and suicide laws. Initial reports from 2006 and 2008 recommended decriminalising attempted suicide and protecting terminally ill patients' rights against punitive measures.


The Commission observed that subject to certain restrictions and safeguards, passive euthanasia has been endorsed and recognised by the Supreme Court in the cases of Aruna Shanbaug[7] and Gian Kaur vs State of Punjab[8]. This proves the matter has sufficient propriety and legality to justify legalising euthanasia. The Commission proposed various changes in the draft bill regarding the definition of an incompetent patient and, most importantly, the procedure for obtaining permission from the High Court. Also, the task of preparing panels of medical experts does not rest with the High Court, rather with the highest medical body of the Centre of State. 


The procedure established is made in confidence by the Supreme Court and the Law Commission. The High Court will follow the procedure, considering the opinion of the Committee of three medical experts. The doctrine of parens patriae has been conferred to the High Court in cases where the patient is not competent enough to voluntarily and consciously make such a decision. This makes the approval of the High Court a condition precedent for stopping the life-supporting measures.


Relying on a UK case Airedale[9], the Commission laid down that withholding of life support to a dying patient amounts to allowing the patient to die a natural death and that where death in the normal course of action is certain, such withholding is not an offence. 


The Commission considered the doctor’s duty and the contents of Article 21 to preclude the doctor and the patient from facilitating passive euthanasia. Moreover, one pressing issue to deal with was the proper approach to the case of an incompetent patient who may be in an irreversible coma or permanent vegetative state (PVS).

 

Guidelines for withdrawal of life support in Terminally ill Patients 2024

Successfully implementing these guidelines will require a comprehensive strategy that engages both healthcare institutions and legal authorities. Hospitals should establish ethics committees responsible for evaluating cases involving the withdrawal of life support, ensuring decisions are made in accordance with medical standards and the patient's preferences. In addition, training programs for healthcare professionals are crucial to effectively addressing the ethical challenges that arise in end-of-life care. Moreover, alongside these guidelines, there is an urgent need to strengthen and incorporate palliative care within India's healthcare framework. Palliative care focuses on enhancing the quality of life for terminally ill patients by providing pain relief and emotional support, helping them live their final days with dignity and comfort.


The latest guidelines clarify key terms that are central to the directives on passive euthanasia, including 'withdrawal,' 'withholding,' and 'surrogate.' They also explicitly state that active euthanasia remains illegal.

  • ‘Withdrawal’

While defining ‘withdrawal’, the broad four conditions have been described that conclusively determine –

                                     i.          Individuals declared brainstem dead [10]

                                    ii.          Prognostication that intervention is not likely to benefit

                                  iii.          Documented informed refusal from patient/surrogate

                                   iv.          Compliance with Supreme Court Directives

 

  • Procedural Guidelines and Safeguards

The Supreme Court has established clear guidelines for passive euthanasia in India, which, together with the draft from the commissions, are now set to be formalised into policy. These guidelines include the provision for a living will or advance medical directive from an adult with the legal capacity to make such decisions. Instead of requiring approval from a judicial magistrate, the directive must be certified by a notary or a gazetted officer. Once attested, the directive will be stored in the National Health Digital Record, allowing medical professionals easy access when necessary. In cases where a hospital's medical board refuses to approve the withdrawal of treatment, family members have the option to approach the High Court. The Court may then convene a new expert panel to reach a final decision. These guidelines ensure a dignified death while incorporating protections to prevent misuse.

 

Conclusion

Life, as defined under Article 21, is more than mere animal existence, as per Maneka Gandhi vs Union of India[11]. The law could then deal with a person's life and liberty by or under a fair, just and reasonable procedure. Moreover, the state looks upon palliative care for terminally ill patients beyond the stage of recovery, which is currently a neglected area.

That being said, apprehensions regarding the socio-economic conditions of the country, wherein greedy relatives interested in the wealth of the critically ill stoop to malpractices with a nefarious design to hasten the process of death, shall also be considered to protect the incompetent patients. Other than this, there are concerns from the medical fraternity that such guidelines ought to put a greater onus on them and expose them to legal scrutiny.

The public will be keen to see how the guidelines will be enforced to prevent abuse and ensure ethical practices. What remains to be seen is whether the system can balance compassion with vigilance, protecting patients' rights while addressing concerns from families and medical professionals.

 

 

 

[1] Termination of Life on Request and Assisted Suicide (Review Procedures) Act 2002 - https://www.government.nl/topics/euthanasia

[4] Common Cause vs Union of India AIR 2018 SC 1660

[5] Aruna Ramchandra Shanbaug vs Union of India (2011) 4 SCC 454

[6] Vishaka vs State of Rajasthan (1997) AIR SCW 3043

[7] supra

[8] Gian Kaur vs the State of Punjab AIR 1996 SCC 1257

[9] Airedale NHS Trust vs Bland 919930 AC 789

[10] Under the Transplantation of Human Organs and Tissues Act 1994

[11] Maneka Gandhi vs. Union of India 1978 AIR 597

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