In a historic decision, the Supreme Court on Friday allowed passive euthanasia with certain guidelines saying a person has the "right to die with dignity" and can make an advance "living will" authorising the withdrawal of life support system if in medical view he or she has reached an irreversible stage of terminal illness.
The top court also said right to lead a healthy life also includes "leaving the world in a peaceful and dignified manner" and an adult "has right to refuse medical treatment including withdrawal from life saving devices".
While allowing adults "who are of a sound and healthy state of mind" to make the advance directive or living will, a five-judge Constitution Bench, headed by Chief Justice Dipak Misra, however, attached strict conditions and framed guidelines to be followed for executing these.
A living will is a written document by way of which a patient can give instructions that his or her life should not be prolonged with an artificial support system when he or she has reached an irreversible stage of terminal illness.
The bench, also including judges AK Sikri, AM Khanwilkar, DY Chandrachud and Ashok Bhushan, laid down guidelines on who would execute the will and how the nod for passive euthanasia would be granted by the medical board.
"To deprive an individual of dignity towards the end of life is to deprive the individual of a meaningful existence," Justice Chandrachud said.
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He said the reason which has impelled the court to recognise passive euthanasia and advance directives is that both bear a close association to the human urge to "live with dignity".
"The right to a dignified existence, the liberty to make decisions and choices and the autonomy of the individual are central to the quest to live a meaningful life. Liberty, dignity and autonomy are essential to the pursuit of happiness and to find meaning in human existence."
Passive euthanasia is a condition where there is withdrawal of medical treatment with the deliberate intention to hasten the death of a terminally-ill patient.
The court said the life support can be removed only after the statutory medical board declares the patient to be incurable.
The bench said its guidelines and directives should remain in force till Parliament makes legislation on this issue.
The bench clearly specified that for executing the living will, the person has to be in a position to communicate, relate and comprehend the purpose and consequences of executing the document.
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It "must be voluntarily executed" and "without any coercion or inducement or compulsion and after having full knowledge or information".
The living will shall be "clearly stating as to when medical treatment may be withdrawn" or no specific medical treatment shall be given which will only have the effect of delaying the process of death that may otherwise cause him or her pain, anguish and suffering and further put him or her in a state of indignity, said the bench.
The bench said it should also mention that the "executor may revoke the instructions or authority at any time".
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The living will should be signed by the executor in the presence of two attesting witnesses, preferably independent, and countersigned by the jurisdictional Judicial Magistrate of First Class (JMFC) so designated by the concerned District Judge.
The witnesses and the jurisdictional JMFC shall record their satisfaction that the document has been executed voluntarily and without any coercion or inducement or compulsion and with full understanding of all the relevant information and consequences.
On when and by whom can the living will be given effect to, the bench, in its 538-page judgement, said in such a case the treating physician, when made aware about the advance directive, shall ascertain the genuineness and authenticity thereof from the jurisdictional JMFC before acting upon it.
"The physician or hospital shall then constitute a medical board consisting of the head of the treating department and at least three experts... who shall visit the patient in the presence of his or her guardian or close relative" and then take a call, the verdict read.
"This decision shall be regarded as a preliminary opinion,"
The bench said if permission to withdraw treatment is refused by the medical board, it would be open to the executor or his family members or even the treating doctor or the hospital staff to approach the high court.
The apex court also laid down similar guidelines for the cases where there is no advance directive.
Chief Justice Misra said a competent person who has come of age "has the right to refuse specific treatment or all treatment or opt for an alternative treatment, even if such decision entails a risk of death".
Quoting the philosophy of Swamy Vivekananda on life and death, Justice Misra said Vivekananda expects one to understand that life is the lamp that is constantly burning out and suggests that if one wants to have life, one has to die every moment for it.
The judges pronounced four separate but concurring judgements.
Justice Chandrachud, in a separate judgement, said: "Life and death are inseparable. Every moment of our lives, our bodies are involved in a process of continuous change... Life is not disconnected from death. To be is to die. From a philosophical perspective, there is no antithesis between life and death. Both constitute essential elements in the inexorable cycle of existence."
The court's verdict came on a plea filed in 2005 by an NGO Common Cause seeking the right to make a living will authorising the withdrawal of life support system in the event of the will-makers reaching an irreversible vegetative state.
Advocate Prashant Bhushan, appearing for the NGO, had said since a patient under coma cannot express his or her wish, law should allow him or her to put it down in writing in advance that he or she should not be tortured.
In the absence of a law authorising doctors to do so, they keep incurable patients on life support, he said.
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Health experts welcome euthanasia verdict
Health experts welcomed the Supreme Court verdict upholding passive euthanasia.
The Indian Medical Association (IMA) said the judgement was long overdue and would pave the way in ensuring that everybody is granted the "right to die with dignity".
AIIMS' assiastant professor in the geriatrics department and founder president of Healthy Aging India, Dr Prasoon Chatterjee said recognising the concept of 'living will' would give an opportunity to the elderly to opt for 'do not resuscitate (DNR)', a concept already established in developed nations.
"It is a landmark decision in a resource-constraint country and would save a lot of salvageable patients by giving them opportunity to avail ventilatory support," Dr Chatterjee, who is also joint editor of Indian Academy Geriatrics, said.
Dr R N Tandon, Secretary General of the Indian Medical Association(IMA), said, "Just as every person has the right to life, they also have the right to die with dignity."
Dr K K Aggarwal, Vice President of Confederation of Medical Associations in Asia and Oceania, and former IMA president, however, said strict guidelines should be put in place to ensure that there is no abuse of the 'living will' by relatives of the terminally ill patient.
Dr Anupam Sibal, the Group Medical Director and Senior Pediatric Gastroenterologist and Hepatologist in Apollo Hospitals Group, said 'living will' or advanced directive (as it is called in some countries) allows a citizen the ability to exercise a fundamental right -- to decide in advance what should be done to his or her body when he or she is not in a position to make that decision.
"This is a step that several countries have taken in the last 10-15 years. The Supreme Court has laid out the framework for a 'living will' and also prescribed the procedure for partial euthanasia which needs to be welcomed. The safeguards that the court has built in should allay fears that some people may have," he said.
