Opinion | Draft Guidelines On Passive Euthanasia: A Way Forward

The Union Health Ministry has released draft guidelines on passive euthanasia, titled "Guidelines for Withdrawal of Life Support in Terminally Ill Patients". The draft advises doctors to make a "considered decision" regarding the withdrawal of life support systems for terminally ill patients.

Once implemented, these draft guidelines aim to establish a legal and regulatory framework that has been absent until now, often placing doctors in a dilemma about the appropriate procedures to follow in cases involving terminally ill patients. The guidelines are intended to enhance the use of this right for terminally ill patients and their families after due diligence.

In recent years, courts and the government have recognised the right of terminally ill patients to die with dignity. However, the actual processes for facilitating this right have been so cumbersome that it has largely remained out of reach.

Main Conditions

The draft guidelines outline four conditions for passive euthanasia, emphasising the need for a "considered decision in the patient's best interests" to stop or discontinue ongoing life support in cases where the patient's condition is terminal, no longer likely to benefit from treatment, or likely to cause suffering and loss of dignity.

These conditions are based on several factors, including the patient being declared brainstem dead; a medical assessment indicating that the patient's condition is advanced and unlikely to improve with aggressive treatment; or a documented informed refusal from the patient or their family.

Compliance with procedures prescribed by the Supreme Court is also required, allowing adult patients to refuse life-sustaining treatments, even if such refusals lead to death. The guidelines clarify that life support may be lawfully withheld or withdrawn from patients who are no longer capable of making decisions, in alignment with their rights to autonomy, privacy, and dignity.

Feedback and suggestions from stakeholders and the public are invited until October 20.

Passive euthanasia involves intentionally letting a patient die by withholding artificial life support, such as a ventilator or feeding tube. Some ethicists differentiate between withholding and withdrawing life support, as defined by the School of Medicine at the University of Missouri. The draft guidelines define terminal illness as an irreversible or incurable condition from which death is expected in the foreseeable future. Severe traumatic brain injury showing no recovery after 72 hours or more is also included.

"The guidelines may come as a relief to terminally ill patients and their families, acknowledging the patient's right to die with dignity. This can alleviate emotional suffering for both patients and their loved ones," says Dr. Subrata Chatterjee, a senior physician based in Durgapur.

He adds, "Financial burdens may also decrease, as the guidelines could lead to the withdrawal of life support systems that are medically futile and costly."

According to the draft guidelines, the Primary Medical Board (PMB), which will evaluate the appropriateness of life support, should consist of the primary physician and at least two subject matter experts with a minimum of five years of experience. The decision made by the PMB must then be confirmed by the Secondary Medical Board (SMB), which will include one registered medical practitioner nominated by the Chief Medical Officer and at least two subject experts. A member of the PMB cannot also serve on the SMB. Additionally, government guidelines propose that hospitals may establish a clinical ethics committee with multi-professional members for audit, oversight, and conflict resolution.

Supportive Courts

Several cases seeking passive euthanasia have come before the courts. The Supreme Court recognised the legality of passive euthanasia in 2011 in the case of Aruna Shanbaug, a nurse at KEM Hospital in Mumbai who had been in a vegetative state for 42 years.

Pinki Virani, an activist following Shanbaug's case, petitioned the Supreme Court for passive euthanasia on Shanbaug's behalf. Nurses caring for her opposed the plea and refused to let her die. Shanbaug passed away on May 15, 2015, after being diagnosed with pneumonia.

Passive euthanasia was legalised in India by the Supreme Court in 2018, contingent upon the existence of a "living will" or a written document specifying the actions to be taken if the person is unable to make their own medical decisions in the future. If a person lacks a living will, family members may petition the High Court for permission to seek passive euthanasia.

In 2023, the Supreme Court further streamlined the procedure for passive euthanasia by modifying existing guidelines regarding living wills, as outlined in its 2018 judgment.

Recently, a petition from ageing parents for passive euthanasia for their son, who has been in a vegetative state for the last 11 years, was denied first by the Delhi High Court and then by the Supreme Court. Reports indicate that a gastrostomy tube—which has been used to feed the patient since 2013—has kept him alive. However, the courts ruled that the patient, though comatose, was not dependent on any external device for life support and that active euthanasia remains illegal.

Cautious Move

The draft guidelines have raised concerns among the medical community. Reports indicate that Dr. RV Asokan, president of the Indian Medical Association (IMA), disapproves of the guidelines, stating they could expose doctors to legal scrutiny and increase stress in their decision-making. He emphasised that clinical decisions are already made in good faith and in consultation with patients' families. The IMA plans to review the document and seek revisions.

"The guidelines may expose doctors to legal scrutiny from patients' relatives if they believe that a doctor's decision to withdraw life support was not in the patient's best interest," Dr. Chatterjee notes.

"However, these guidelines aim to provide a framework for informed decision-making, and adherence to them can help protect doctors from legal liability," he adds. The guidelines also reference Advance Medical Directives (AMD)—a written declaration by a person with decision-making capacity outlining their desired medical treatment or non-treatment in case they lose that capacity.

Once a physician determines the inappropriateness of life-sustaining measures, they will refer the case to the Primary Medical Board. If the board reaches a consensus, there will be another multidisciplinary meeting with the family, leading to a shared decision.

"From a doctor's perspective, a committee of three to five doctors should be established in each hospital (ethics committee), and the majority should agree that passive euthanasia is the only way to alleviate the patient's pain," suggests Dr Anshuman Manaswi, a consultant plastic surgeon based in Mumbai.

"This mechanism, along with the patient's wishes, relatives' consent, or input from civil society in cases with no relatives, will create a good and safe approach to prevent any misuse," Dr Manaswi adds.

No family would ever request euthanasia for a loved one unless all options for recovery have been exhausted. However, if the patient's suffering is unbearable and irreversible, doctors and families must collaboratively make a prudent decision.

(The author is Contributing Editor, NDTV)

Disclaimer: These are the personal opinions of the author