Imagine an 85-year-old woman with an advanced stage of lung disease who has told her family that she does not wish to spend her last days in the hospital and certainly does not wish to die on a ventilator. However, one day, her condition worsened at home. A combination of guilt and helplessness then prompts her family to bring her to the hospital, where the machinery of critical care kicks in, with its objective of saving life at all costs. The woman is put on a ventilator.
After a week, due to mounting costs and lack of improvement in the woman’s condition, the family wishes to take her home. But the ventilator becomes an insurmountable hurdle.
If you were a doctor, how would you approach this situation in an ethically and legally sound manner?
Countless patients, when nearing their end, suffer due to medical interventions that no longer benefit them. This suffering arguably falls under the broad ambit of violence against patients in the health system as it is inflicted needlessly on patients who should have otherwise been cared for.
However, the ethical and legal ambiguity pushes even those who want to care to pursue a cure. Doctors often wonder if it is legal to withdraw life-supporting interventions for terminally ill patients in India.
Since they are reluctant to do so in hospital settings, they frequently discharge patients against medical advice and let the family withdraw support outside the hospital, allowing death, but not on their watch. The ethical and legal validity of this latter act or omission is also suspect, but doctors often believe that it is the only option available to them.
The legal and ethical dilemma
When doctors grapple with the treatment of our hypothetical 85-year old patient, the real question they are asking themselves is this: ‘I know that this ventilator isn’t helping the patient anymore. I know that the family doesn’t want her to continue with it. Is it lawful for me to leave this patient and her family to their own devices in an ambulance, where the patient will pass away in agony without comfort care? Or should I continue all medical interventions, even when futile, to prolong life that might add to both the physical and financial suffering of the patient?’
Any right-thinking person would think that doctors should not continue to provide treatment that no longer benefits their patients. Doctors have a fiduciary duty to relieve the suffering of their patients and to respect their autonomy. However, at the same time, medical training also teaches doctors that they are expected to save every life and do their best to prolong it.
Why is it then that doctors believe that they are legally compelled to discharge patients against medical advice, thereby committing a form of violence against the patient and their family and are so flagrantly at odds with the most fundamental tenets of medical ethics?
The legal journey to a dignified death
The answer to this requires a thorough examination of the complex legal history surrounding the right to die with dignity in India. The ethically responsible principle of withholding potentially inappropriate and unnecessary medical treatment has come up against weightier legal prohibitions on suicide (before the Mental Healthcare Act, 2017) and murder.
If a terminally ill person refuses medical treatment and dies as a consequence, does that amount to suicide? If a doctor discontinues life support when it is no longer benefiting the patient, does that amount to murder? The answer to both these questions is NO, although in both instances, it required a pronouncement from the Supreme Court of India.
The Supreme Court’s recent intervention has added to the conceptual clarity. As a direct result of its judgment in Common Cause v Union of India, every person in India has the right to die with dignity, which, if applied to our hypothetical 85-year-old patient, would practically mean that-
One, she would have been able to formalize her wishes about hospitalization and ventilation in a document called an advance medical directive, which the Court recognized and which her treating team and family would have had to respect.
Two, her treating team would have been free to discontinue the ventilator in the hospital without fear of legal liability and then refer her to palliative care.
Three, even if she had not made an advance medical directive, her treating team and family, through a process of mutual discussion, could have jointly agreed that discontinuing the ventilator was in her best interests.
Procedural uncertainty blocking access to a dignified death
This principled clarity, as welcome as it is, has been accompanied by procedural uncertainty. The Court ventured to lay down guidelines to govern the implementation of advance medical directives and the withholding/withdrawal of life-sustaining treatment.
Very briefly, the 2023 guidelines require two different sets of medical experts - two Medical Boards, Primary and Secondary, each comprising three doctors - to determine whether withholding or withdrawing life-sustaining treatment would be in the patient’s best interests.
This applies only when the patient no longer has decision-making capacity, regardless of whether they have executed an advance medical directive or not. The Court’s guidelines require State Governments to take steps to operationalise them in at least two specific ways-
First, the Secondary Medical Board must comprise one registered medical practitioner who is nominated by the district Chief Medical Officer or equivalent.
Second, there must be an officer of the local government who is nominated to act as ‘custodian’ of all advance medical directives.
However, these orders have proved to be challenging to implement in practice. Decisions about withholding or withdrawing life-sustaining treatment often need to be made within a matter of hours. Bringing together six different medical experts during this period is a challenge, especially in non-urban settings.
It is also impractical to approach the district Chief Medical Officer to nominate someone to a Secondary Medical Board every time such a decision has to be taken, given the heavy load of administrative duties they already have.
The Karnataka government orders
The Karnataka government orders fulfil the State Government’s obligations under the Supreme Court order. They do not establish a new legal principle, confer a new legal right, or in any way advance the law beyond the Court’s pronouncement in Common Cause.
The first circular, dated 30 January 2025, summarises the key features of the Court’s judgment in Common Cause and the modified guidelines in 2023, and conveys them to all the stakeholders who are responsible for implementing them--deputy commissioners, district health and family welfare officers, district surgeons, deans and directors of medical colleges, medical superintendents, municipal commissioners, among others.
The second order, also dated 30 January 2025, provides a practical way to fulfill the obligation of the District Chief Medical Officer or their equivalent to nominate a registered medical practitioner to the Secondary Medical Board. It allows hospitals to use experts who have already been approved to certify brain stem death under the Transplantation of Human Organs and Tissues Act. Under this Act, the Appropriate Authority (a state government-appointed officer) approves specialists to serve on a Board of Medical Experts to certify brainstem death.
This order states that intensivists, surgeons, anaesthetists, neurologists, and neurosurgeons who the Appropriate Authority has approved should automatically be considered to be nominees of the district Health Officer to serve on the Secondary Medical Board and make decisions about withholding or withdrawing life-sustaining treatment.
The third order, dated 14 February 2025, is issued by the Rural Development and Panchayati Raj Department and appoints the Executive Officer of the Taluk Panchayath for Rural Areas as the competent officer to receive advance medical directives.
Of these, the second order is the most significant in operationalising the Supreme Court judgement. It means that there are no longer any barriers, at least in hospitals that certify brain-stem death, to setting up Secondary Medical Boards that can confirm whether or not to withhold or withdraw life-sustaining treatment.
Such hospitals in Karnataka can no longer say that they cannot set up Secondary Medical Boards, that they cannot take lawful decisions to withhold or withdraw life-sustaining treatment, that their only option is to discharge patients against medical advice, and let them suffer an agonising death.
Has euthanasia been legalized in Karnataka?
What the Karnataka orders do not do, however, despite news coverage to the contrary, is legalise euthanasia, which is more commonly referred to as assisted suicide or assisted dying in countries where it is legal. This typically involves the administration of a lethal injection to bring about the death of a terminally ill person whose suffering is deemed to be unbearable.
There are news reports of an 85-year-old woman, HB Karibasamma (not a hypothetical example this time), who hopes to be the ‘first beneficiary’ of the Karnataka orders. However, from all accounts, it appears that what she hopes to avail of is euthanasia rather than the withholding or withdrawal of any life support. This is not legally permissible in India.
The unaddressed gaps
There are, of course, still gaps to fill. It will be harder to find experts like this in healthcare settings that do not have the expertise to certify brain stem death. In these settings, other solutions will have to be found for the nomination of medical practitioners to Secondary Medical Boards by the District Chief Medical Officer.
Nevertheless, this order certainly removes barriers to withholding or withdrawing life-sustaining treatment in metropolitan, tertiary care settings, which are also more likely to subject patients to disproportionate medical treatment at the end of life.
While euthanasia is still illegal in India, people like Karibasamma might feel that their suffering has been left unaddressed. However, the real solution to addressing unmitigated suffering is palliative care. As a patient with cancer who has also endured a slipped disc for 30 years, she should have had access to palliative care that would have eased her pain and precluded her current plea for euthanasia. However, this is a far cry in a country where less than 4 percent of the people who need palliative care receive it.
The Karnataka orders and the attention they have received serve as a reminder that indignity can stem from both excessive medical treatment and inadequate care. If implemented appropriately and adopted by other States as well, they offer the medical profession a chance at redemption—the law and its perverse logic should no longer prevent medical professionals from doing what ethics have always demanded.
(To understand what an Advance Medical Directive is and how you can create one, WATCH THIS. CLICK HERE to download a template of an Advance Medical Directive. For any doubts, write to advancecareplanindia@gmail.com )
Edited by Parth Sharma
Image by Gayatri
