Dr S.N. Simha
A Constitutional Bench of the Supreme Court of India delivered a landmark judgment yesterday, on the troubling issue of withdrawal of life support treatment in persons who are terminally ill. Advance directives have also been given legal sanction. The tragedy of Aruna Shanbaug brought the issue to the fore with an NGO, Common Cause, filing a petition that was supported by other organisations. The judgment took over 12 years to happen, but it is worth the wait.The five-judge bench produced a detailed decision, explaining the legal, ethical and moral issues involved. It is a worthy sequel to another landmark judgment, the Right to Privacy.
Article 21 or the right to life, has formed the basis of the judgment. So far, the withdrawal of life support has been deemed medically appropriate, a stance backed by a reference to the High Court. Hospitals were reluctant to withdraw care for fear of prosecution and resorted to Discharge Against Medical Service (DAMA). These patients are subject to unwanted medical interventions, families become distraught and an environment of deep mistrust is created. Accusations are also made against doctors using the situation for pecuniary gain. Most are incorrect.
Autonomy, beneficence, non-maleficence and justice are the four cardinal principals of care, with the first three giving the individual the right to regulate treatment, particularly when he is suffering from a terminal illness. The judgment now permits “passive euthanasia,” which implies withdrawal of treatment when there is no perceivable benefit. This has always been a sore point within the profession. The procedure has been mandated by multiple layers of oversight and committees comprising professionals, to allay fears of misuse. Still, it is a convoluted procedure, far outdoing the Organ Transplant Act, which only requires a mandate from a local committee. This decision, however, will have to be reviewed by a District Level Committee – whether it is necessary remains to be seen.
The other significant outcome is the recognition of an advance will or directive. This is a concept that has been around for many years. This document will reflect the express wishes of a person, made when he is well and in his full senses, in the event of the person being terminally ill or suffering an acute and painful episode.
Three professional organisations, Indian Society of Critical Care Medicine, Indian Academy of Neurology and Indian Association of Palliative Care formed the End of Life Care India task Force (ELICIT). This group filed two PILs on the matter. They also submitted a draft bill to the Supreme Court and it is a matter of great satisfaction that many of the procedures mandated by the Court find mention in this bill. It is now left to the Union Government to enact legislation. The Court has clarified the position of the Constitution of India. It has disagreed with the Law Commission on advance will or directive. J P Nadda and his team must not fail the country now.
Just a law won’t do. As a society, we must understand that there are limits to what we can do to keep a person alive.
Dr. S N Simha Medical Director, Karunashraya
