Why is it in the news?

• The Ministry of Health and Family Welfare has released draft guidelines aimed at facilitating the withdrawal of life support for terminally ill patients. This initiative seeks to implement the Supreme Court’s orders from 2018 and 2023, which affirm the right to die with dignity for all Indians.
• The guidelines propose the establishment of Primary and Secondary Medical Boards to determine when further medical treatment may be unnecessary for terminally ill patients.
• Doctors appointed by the district Chief Medical Officer will serve on these boards to review the decisions made by the Primary Medical Boards.

Legal Framework

• Currently, India lacks dedicated legislation regarding the withholding or withdrawal of life-sustaining treatment. However, the Supreme Court’s judgments and the new draft guidelines provide a legal framework for these actions.
• Withholding or withdrawing treatment involves stopping interventions like ventilators and feeding tubes when they no longer enhance the patient’s condition or merely prolong suffering. This approach allows for comfort care, enabling the underlying illness to progress while ensuring symptomatic relief.

Patient Rights and Advance Medical Directives

• The right to refuse medical treatment is well established in common law and is now recognized as a fundamental right under Article 21 of the Indian Constitution, following the Supreme Court’s ruling in Common Cause vs. Union of India (2018).
• Patients can withdraw life-sustaining treatment through informed refusal if they have decision-making capacity or via an advance medical directive (or “living will”), which specifies preferred actions if they become unable to make decisions in the future.
• If a patient lacks decision-making capacity and has no living will, physicians may opt to withhold treatment if the likelihood of recovery from a terminal condition is low.

Euthanasia and Misunderstandings

• Euthanasia, commonly referred to as “mercy killing,” involves the intentional ending of a terminally ill patient’s life by a doctor for the patient’s benefit. In India, “passive euthanasia” pertains to withholding or withdrawing life-sustaining treatment, which can lead to misunderstandings regarding the right to die with dignity.
• A 2018 glossary from the Indian Council of Medical Research (ICMR) noted that the term is frequently misinterpreted and lacks social acceptance.

Do-Not-Attempt-Resuscitation Orders

• The withdrawal of treatment may also involve “do-not-attempt-resuscitation” (DNAR) orders, issued by the treating physician in consultation with the patient or their family.
• It’s important to understand that a DNAR order does not mean abandoning the patient; it signifies that all efforts should continue to address the underlying condition, while resuscitation measures are withheld.

Ethical Considerations in Withholding Treatment

• Withholding or withdrawing life-sustaining treatment does not imply giving up on the patient. Instead, it recognizes situations where medical interventions are no longer effective and may only prolong suffering, leading to palliative care focused on pain management and patient comfort.
• The practice of “discharge against medical advice” can exacerbate suffering, as some doctors mistakenly believe they are unable to withhold treatment, resulting in inadequate care for patients.

Framework for Living Wills

• The Supreme Court’s 2018 judgment set forth a framework for advance medical directives, which was further streamlined in 2023.
• Living wills are legal documents created by individuals aged 18 or older with decision-making capacity, outlining their treatment preferences should they lose that capacity. These documents should name at least two surrogate decision-makers—trusted individuals who can make medical decisions on the person’s behalf if needed.
• A living will becomes legally binding when signed in the presence of an executor and two witnesses, and attested by a notary or gazetted officer.

Medical Procedure for Withholding Treatment

• The guidelines establish a procedure for withholding or withdrawing life-sustaining treatment that respects the rights and responsibilities of both doctors and patients.
• This includes the formation of a Primary Medical Board to assess the patient’s condition and recommend treatment withdrawal, consisting of the treating doctor and two subject-matter experts with a minimum of five years of experience.
• A Secondary Medical Board will review the Primary Board’s decision and will include a registered medical practitioner nominated by the district Chief Medical Officer and two additional subject-matter experts.
• Consent from the advance medical directive or surrogate decision-makers is mandatory for treatment withdrawal, and hospitals must inform local judicial magistrates of any decisions regarding life-sustaining treatment.

Conclusion

• Doctors are not expected to “play God” in these situations; assessing the appropriateness of medical treatment is a standard part of medical practice and an ethical obligation for healthcare providers.
• The established procedure prioritizes “shared decision-making,” where the treating team collaborates with the patient’s family or surrogate decision-makers on decisions regarding treatment withdrawal.
• This approach protects healthcare professionals, upholds patient autonomy, respects the wishes of family members, and provides necessary legal clarity.