REVIEW OF MERCY DEATH WITH RESPECT TO SUPREME COURT OF INDIA DECIDING ARUNA SHANBAUG CASE

Dr. Mahsh Baldwa,

MBBS, M.D,D.C.H, FIAP

MBA, LL.B,LL.M , Ph. D(law)

MEDICOLEGAL SPECIALIST & ADVISOR

Formerly Assistant Professor of Pediatrics at T.N. Medical College and Nair Hospital, Mumbai-400008

Ex. Asst. Professor JJ Hosp, Grant medical college

Professor, paper setter & examiner of law to postgraduate students of University Department of Law, University of Mumbai

Baldwa Hospital, Sumer Nagar,S.V. Road,

Borivali (West)Mumbai 400 092

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In The Supreme Court Of India, Criminal Original Jurisdiction, Writ Petition (Criminal) No. 115 OF 2009 related to Aruna Ramchandra Shanbaug v/s Union of India and others Was decided by Justice Markandey Katju and justice Gyan Sudha Misra’s bench  on March 07, 2011 and summary of same is presented here with reference to euthanasia. Apex court observed that”It is alleged in the writ petition filed by Ms. Pinky Virani (claiming to be   the   next   friend   of     Aruna Shanbaug,which also was declined by apex court and said only Nurses of KEM Hospital Mumbai who are caring for her can claim to next friend)   that   in   fact   Aruna   Shanbaug   is already dead and hence by not feeding her body any more we shall not be killing her.

SUMMARY OF THE INCIDENT:

Aruna  Shanbaug   was   a   staff   Nurse   working   in   King   Edward   Memorial   Hospital, Parel, Mumbai. On the evening of 27th November, 1973 she was attacked by a   sweeper   in   the   hospital   who   wrapped   a   dog   chain   around   her   neck   and  yanked   her   back   with   it.   He   tried   to   rape   her   but   finding   that   she   was menstruating,   he   sodomized   her.   It   is   alleged   that   due   to   strangulation   by   the   dog chain the supply of oxygen to the brain stopped and the brain got damaged. Since about 36 years Aruna    Shanbaug   (60   years   of age) is permanent vegetative state (PVS).

IS ARUNA SHANBAUG IS BRAIN DEAD? 

Apex court relied on “The   Transplantation   of   Human Organs Act, 1994”, as per the definition of death in this act, it cannot be said that Aruna Shanbaug is dead. Apex court also relied on “Even from the report of Committee of Doctors which we have quoted above it appears that she has some brain activity, though very little.” From the above examination by the team of doctors, it cannot be said that   Aruna   Shanbaug   is   dead.

However, there appears little possibility of her coming out of permanent vegetative state (PVS), in which   she   is   in.    In all   probability,   she   will   continue   to be   in the   state   in which she is in till her death.  The question now is whether her life support system (which is done by feeding her) should be withdrawn, and at whose instance?

EUTHANASIA

Euthanasia is one of the most perplexing issues which the courts and legislatures all over the world are facing today.

WHEN CAN A PERSON IS SAID TO BE DEAD

The question hence arises as to when a person can be said to be dead?

Apex court observed in para 108 and observed that  “ Brain cells require regular supply of oxygen which comes through the red cells in the blood.  If oxygen supply is cut off for more than six minutes, the brain cells die and this condition is known as anoxia.  Hence, if the brain is dead a person is said to be dead.

Although   in   the   case   of Aruna Shanbhag Apex Court dealt with   passive euthanasia in case of PVS, it would be of some interest to note the legislations in certain countries permitting active euthanasia. Apex court did describe active euthanasia practice in some countries but laid down guidelines for passive euthanasia alone in India till legislators take over and pass some law on euthanasia.

BRAIN DEATH

The   term   `brain   death’   has   developed   various   meanings.   While initially,   death   could   be   defined   as   a   cessation   of   breathing,   or,   more scientifically, a cessation of heart-beat, recent medical advances have made such   definitions   obsolete. 

Brain death, may thus, be defined as “the irreversible cessation of all functions of the entire brain, including the brain stem”. 

Brain death, thus, is different from a persistent vegetative state, where the   brain   stem   continues   to   work,   and   so   some   degree   of   reactions   may occur, though the possibility of regaining consciousness is relatively remote. Even   when   a   person   is   incapable   of   any   response,   but   is   able   to   sustain respiration   circulation,   he   cannot   be   said   to   be   dead.   The   mere mechanical act of breathing, thus, would enable him or her to be “alive”. 

In   this   connection   we   may   refer   to   the   Transplantation   of   Human Organs Act, 1994 enacted by the Indian Parliament.  Section 2(d) of  the Act states :”brain-stem death”  means  the  stage  at  which all  functions  of the brain-stem have permanently and irreversibly ceased and is so certified under sub-section (6) of section 3:” 

 Section 3(6) of the said Act states: “(6)   Where any human organ is to be removed  from the body of a person   in   the   event   of   his   brain-stem   death,   no   such   removal   shall   be undertaken unless such death is certified, in such form and in such manner and   on   satisfaction   of   such   conditions   and   requirements   as   may   be prescribed,   by   a   Board   of   medical   experts   consisting   of   the   following, namely:- (i)      the registered medical practitioner, in charge of the hospital in which brain-stem death has occurred; (ii)     an   independent   registered   medical   practitioner, being   a   specialist,   to   be   nominated   by   the registered   medical   practitioner   specified   in   clause  (i),   from   the   panel   of   names   approved   by   the Appropriate Authority; (iii)    a   neurologist   or   a   neurosurgeon   to   be   nominated by the registered  medical  practitioner  specified in clause   (i),   from   the   panel   of   names   approved   by the Appropriate Authority; and  (iv)     the   registered   medical   practitioner   treating   the person whose brain-stem death has occurred”.

LEGAL POSITION RELATED TO EUTHANASIA:

The general legal position all over the world seems to be that while active euthanasia   is illegal unless there is legislation   permitting   it; passive euthanasia is legal even without legislation provided certain conditions and safeguards are maintained. The two types are defined as below:

ACTIVE EUTHANASIA:

Active euthanasia entails the use of lethal substances or forces to kill a person e.g. a lethal injection given to a person with terminal cancer who is in terrible agony. 

PASSIVE EUTHANASIA:

Passive euthanasia entails   withholding   of   medical   treatment   for   continuance   of   life,   e.g. withholding of antibiotics where without giving it a patient is likely to die, or removing the heart lung machine, from a patient in coma.

A further categorization of euthanasia is between voluntary euthanasia and non voluntary euthanasia. 

VOLUNTARY EUTHANASIA

Voluntary euthanasia is where the consent is taken   from   the   patient. there is no legal difficulty in the case of permitting Voluntary passive euthanasia.

NON   VOLUNTARY   EUTHANASIA

Non   voluntary   euthanasia   is   where   the consent   is   unavailable   e.g.   When   the   patient   is   in   coma,   or   is   otherwise unable to give consent.   Non   voluntary   passive euthanasia poses several problems and needs to be discussed.

ACTIVE EUTHANASIA

In India active euthanasia is illegal and a crime under section 302 or at least section 304 IPC.  Physician assisted suicide is a crime under section 306 IPC (abetment to suicide)”

In para   43 the Apex court says “ A  distinction   is  sometimes  drawn between  euthanasia   and  physician assisted   dying,   the   difference   being   in  who  administers   the   lethal medication.  In euthanasia, a physician or third party administers it, while in physician assisted suicide it is the patient himself who does it, though on the advice of the doctor.   In many countries/States the latter is legal while the former is not. 

In para   44 the Apex court says “The   difference   between   “active”   and   “passive”   euthanasia   is   that   in active   euthanasia,   something   is done to   end   the   patient’s   life’   while   in passive   euthanasia,   something   is not   done that   would   have   preserved   the patient’s life. 

In para   45  the Apex court says  “An   important   idea   behind   this   distinction   is   that   in   “passive euthanasia” the doctors are not actively killing anyone; they are simply not saving him. While we usually applaud someone who saves another person’s life, we do not normally condemn someone for failing to do so. If one rushes into a burning building and carries someone out to safety, he will probably be called a hero. But if one sees a burning building and people screaming for help, and he stands on the sidelines – whether out of fear for his own safety, or   the   belief   that   an   inexperienced   and   ill-equipped   person   like   himself would only get in the way of the professional firefighters, or whatever — if one does nothing, few would judge him for his inaction. One would surely not be prosecuted for homicide. (At least, not unless one started the fire in the first place.) “

LEGISLATION   IN   SOME   COUNTRIES   RELATING   TO EUTHANASIA OR PHYSICIAN ASSISTED DEATH

ACTIVE EUTHANASIA

       Netherlands:

Termination   of   Life   on   Request   and   Assisted   Suicide   (Review Procedures) Act  took effect on April 1, 2002. It legalizes euthanasia and   physician   assisted   suicide   in   very   specific   cases,   under   very specific   circumstances.  

   Switzerland:

Switzerland seems to be the only country in which the law limits the circumstances   in   which   assisted   suicide   is   a   crime,   thereby decriminalizing it in other cases, without requiring the involvement of a   physician.   Consequently,   non-physicians   have   participated   in assisted   suicide.  

Belgium:

The   Belgian   law   sets   out   conditions   under   which   suicide   can   be practiced without giving doctors a licence to kill. Every mercy killing case will have to be filed at a special commission to decide if the doctors in charge are following the regulations.

Spain, Austria, Italy, Germany:

In   none   of   these   countries   is   euthanasia   or   physician   assisted   death legal. 

France:

In January 2011 the French Senate defeated by a 170-142 vote a bill seeking to legalize euthanasia.  

U.K.

In England, in May 2006 a bill allowing   physician   assisted suicide,  was  blocked,  and  never became law.

United States of America:

Active   Euthanasia   is   illegal   in   all   states   in   U.S.A.,   but   physician assisted   dying   is   legal   in   the   states   of   Oregon,   Washington   and Montana. In no other States in U.S.A. is euthanasia or physician assisted death legal.

Canada:

In Canada, physician assisted suicide is illegal vide Section 241(b) of the Criminal Code of Canada.

The   leading   decision   of   the   Canadian   Supreme   Court   in   this connection   is Sue   Rodriguez     v.     British   Columbia   (Attorney General), (1993)   3   SCR   519.     Rodriguez,   a   woman   of   43,   was diagnosed with Amyotrophic Lateral Sclerosis (ALS), and requested the Canadian Supreme Court to allow someone to aid her in ending her life. By   a   5   to   4 majority   her   plea   was   rejected.

PASSIVE EUTHANASIA

Passive   euthanasia   is   usually   defined   as   withdrawing   medical treatment   with   a   deliberate   intention     of   causing   the   patient’s   death.     For example, if a patient requires kidney dialysis to survive, not giving dialysis although   the   machine   is   available,   is   passive   euthanasia.   Similarly,   if   a patient is in coma or on a heart lung machine, withdrawing of the machine will ordinarily result in passive euthanasia.  Similarly not giving life saving medicines   like   antibiotics   in   certain   situations   may   result   in   passive euthanasia.   Denying food to a person in coma or PVS may also amount to passive euthanasia. As   already   stated   above,   euthanasia   can   be   both   voluntary   or   non voluntary.     In   voluntary   passive   euthanasia   a   person   who   is   capable   of deciding for himself decides that he would prefer to die (which may be for various reasons e.g., that he is in great pain or that the money being spent on his treatment should instead be given to his family who are in greater need, etc.), and for this purpose he consciously and of his own free will refuses to take life saving medicines.  In India, if a person consciously and voluntarily refuses to take life saving medical treatment it is not a crime.   Whether not taking food consciously and voluntarily with the aim of ending one’s life is a crime under section 309 IPC (attempt to commit suicide) is a question which need not be decided in this case. Non voluntary passive euthanasia implies that the person is not in a position to decide for himself e.g., if he is in coma or PVS.  The present is a case   where   we   have   to   consider   non   voluntary   passive   euthanasia   i.e. whether   to   allow   a   person   to   die   who   is   not   in   a   position   to   give   his/her consent. 

CERTAIN LANDMARK DECISIONS RELATED TO PASSIVE EUTHANASIA:

THE AIREDALE CASE : (Airedale NHS Trust v. Bland (1993) All E.R. 82) (H.L.) In the  Airedale  case decided by the House of Lords in the U.K., the facts were that one Anthony Bland aged about 17 went to the Hillsborough Ground on 15th  April 1989 to support the Liverpool Football Club.   In the course  of the  disaster  which  occurred  on that  day,   his  lungs  were  crushed and punctured and the supply to his brain was interrupted.   As a result, he suffered   catastrophic   and   irreversible   damage   to   the   higher   centres   of   the brain.  For three years, he was in a condition known as `persistent vegetative state (PVS). 

Lord   Keith   observed   that   although   the   decision   whether   or   not   the continued treatment and cure of a PVS patient confers any benefit on him is essentially one for the medical practitioners in charge of his case to decide, as a matter  of routine the hospital/medical practitioner  should apply to the Family   Division   of   the   High   Court   for   endorsing   or   reversing   the   said decision.  This is in the interest of the protection of the patient, protection of the doctors, and for the reassurance of the patient’s family and the public. 

In  Airdale’s  case  another Judge on the Bench, Lord Goff of Chievely observed

In   a   Discussion   Paper   on   Treatment   of   Patients   in   Persistent Vegetative State issued in September 1992 by the Medical Ethics Committee of the British Medical Association certain safeguards were mentioned which should be observed before constituting life support for such patients:- “(1) Every effort should be made at rehabilitation for at least   six   months   after   the   injury;   (2)   The   diagnosis   of irreversible   PVS   should   not   be   considered   confirmed until   at   least   twelve   months   after   the   injury,   with   the effect   that   any   decision   to   withhold   life   prolonging treatment   will   be   delayed   for   that   period;   (3)   The diagnosis   should   be   agreed   by   two   other   independent doctors;   and   (4)   Generally,   the   wishes   of   the   patient’s immediate family will be given great weight.”

Lord   Goff   observed   that   discontinuance   of   artificial   feeding   in  such cases is not equivalent to cutting a mountaineer’s  rope, or severing the air pipe of a deep sea diver.  The true question is not whether the doctor should take a course in which he will actively kill his patient, but rather whether he should continue to provide his patient with medical treatment or care which, if continued, will prolong his life.

Lord   Browne-Wilkinson   was   of   the   view   that   removing   the nasogastric   tube   in   the   case   of   Anthony   Bland   cannot   be   regarded   as   a positive   act   causing   the   death.     The   tube   itself,   without   the   food   being supplied through it, does nothing.  Its non removal itself does not cause the death   since   by   itself,   it   does   not   sustain   life.     Hence   removal   of   the   tube would not constitute the actus reus   of murder, since such an act would not cause the death. 

Lord Mustill observed:- “Threaded   through   the   technical   arguments addressed to the House were the strands of a much wider position, that it is in the best interests of the community at large that Anthony Bland’s life should now end.   The doctors have done all they can.   Nothing will be gained by going on  and much will be lost.   The distress of the family will get steadily worse.  The strain on the devotion of   a   medical   staff   charged   with   the   care  of   a   patient whose   condition   will   never   improve,   who   may   live   for years and who does not even recognize that he is being cared for, will continue to mount.  The large resources of skill,  labour  and  money   now being  devoted  to Anthony Bland  might   in   the   opinion   of   many   be   more   fruitfully employed   in   improving   the   condition   of   other   patients, who   if   treated   may   have   useful,   healthy   and   enjoyable lives for years to come.”

 Thus all the Judges of the House of Lords in the Airedale case  were agreed that Anthony Bland should be allowed to die. Airedale (1993) decided by the House of Lords has been followed in a number of cases in U.K., and the law is now fairly well settled that in the case   of   incompetent   patients,   if   the   doctors   act   on   the   basis   of   informed medical opinion, and withdraw the artificial life support system if it is in the patient’s best interest, the said act cannot be regarded as a crime. The   question,   however,   remains   as   to   who   is   to   decide   what   is   the patient’s   best   interest   where   he   is   in   a   persistent   vegetative   state   (PVS)? Most decisions have held that the decision of the parents, spouse, or other close   relative,   should   carry   weight   if   it   is   an   informed   one,  but   it   is   not decisive  (several of these decisions have been referred to in Chapter IV of the 196th  Report of the Law Commission of India on Medical Treatment to Terminally ill Patients).

 It is ultimately for the Court to decide, as parens patriae, as to what is in the best interest of the patient, though the wishes of close relatives and next friend, and opinion of medical practitioners should be given due weight in coming to its decision.  As stated by Balcombe, J. in  In Re J  ( A Minor Wardship   :   Medical   Treatment)   1990(3)   All   E.R.   930,   the   Court   as representative   of   the   Sovereign   as   parens   patriae   will   adopt   the   same standard which a reasonable and responsible parent would do.

The   parens   patriae   (father   of   the   country)   jurisdiction   was   the jurisdiction of the Crown, which, as stated in Airedale, could be traced to the 13th Century.  This principle laid down that as the Sovereign it was the duty of the King to protect the person and property of those who were unable to protect   themselves.     The   Court,   as   a   wing   of   the   State,   has   inherited   the parens patriae jurisdiction which formerly belonged to the King U.S. decisions

The   two   most   significant   cases   of   the   U.S.   Supreme   Court   that addressed   the   issue   whether   there   was   a   federal   constitutional   right   to assisted   suicide   arose   from   challenges   to   State   laws   banning   physician assisted suicide brought by terminally ill patients and their physicians. These were  Washington    vs.    Glucksberg  521  U.S.  702  (1997)  and  Vacco   vs. Quill 521 U.S. 793 (1997).

In  Glucksberg’s  case, the U.S. Supreme Court held that the asserted right to assistance in committing suicide is not a fundamental liberty interest protected   by   the   Due   Process   Clause   of   the   Fourteenth   Amendment.   

In Vacco’s case  the U.S. Supreme Court again recognized the

distinction between refusing life saving medical treatment and giving lethal medication.   

In  Cruzan  v.  Director,   MDH,  497   U.S.  261(1990)   decided   by   the U.S. Supreme Court the majority opinion was delivered by the Chief Justice Rehnquist, while delivering the opinion of the Court (in which Justices White, O’Connor, Scalia, and Kennedy, joined) in his judgment first noted  the facts:-

“On  the  night of January 11, 1983, Nancy  Cruzan lost control   of   her   car   as   she   traveled   down   Elm   Road   in Jasper   County,   Missouri.   The   vehicle   overturned,   and Cruzan   was   discovered   lying   face   down   in   a   ditch without   detectable   respiratory   or   cardiac   function. The   Missouri   trial   court   in   this   case found that permanent brain damage generally results after 6 minutes in an anoxic state; it was estimated that Cruzan was   deprived   of   oxygen   from   12   to   14   minutes. In   order   to   ease feeding   and   further   the   recovery,   surgeons   implanted   a gastrostomy   feeding   and   hydration   tube   in   Cruzan   with the   consent   of   her   then   husband.  She now lies in a Missouri state hospital in what is commonly  referred to as a persistent vegetative state. The State of Missouri is bearing the cost of her care.  All   agree that   such   removal   would   cause her   death.   The   employees   refused   to   honor   the   request without   court   approval.   The   parents   then   sought   and received   authorization   from   the   state   trial   court   for termination.” While the trial Court allowed the petition the State Supreme Court of Missouri reversed.  The US Supreme Court by majority affirmed the verdict of the State Supreme Court.

As observed by Justice Cardozo, while on the Court of Appeals of New York “Every human being of adult years and sound mind has a right to   determine   what   shall   be   done   with   his   own   body,   and   a   surgeon   who performs an operation without his patient’s consent commits an assault, for which   he   is   liable   in   damages.”   vide  Schloendorff    vs.    Society   of   New York Hospital, 211 N.Y. 125, 129-30, 105 N.E. 92, 93 (1914).     Thus the informed consent doctrine has become firmly entrenched in American Tort Law.  

The logical corollary   of the doctrine of informed consent is that the patient   generally   possesses   the   right   not   to   consent,   that   is   to   refuse treatment.  The question, however, arises in cases where the patient is unable to decide whether the treatment should continue or not e.g. if he is in coma or PVS.  Who is to give consent to terminate the treatment in such a case?  The learned   Chief  Justice   referred   to   a  large   number   of  decisions   of  Courts   in U.S.A. in this connection, often taking diverse approaches.

 In   re   Quinlan  70   N.J.10,   355   A.   2d   647,   Karen   Quinlan   suffered severe brain damage as a result of anoxia, and entered into PVS.  Her father sought   judicial   approval   to   disconnect   her   respirator.     The   New   Jersey Supreme Court granted the prayer, holding that Karen had a right of privacy grounded   in   the   U.S.   Constitution   to   terminate   treatment.     The   Court concluded that the way Karen’s right to privacy could be exercised would be to allow her guardian and family to decide whether she would exercise it in the circumstances.  

In re Conroy  98 NJ 321, 486 A.2d 1209 (1985), however, the New Jersey Supreme Court, in a case of an 84 year old incompetent nursing home resident   who   had   suffered   irreversible   mental   and   physical   ailments, contrary to its decision in Quinlan’s case, decided to base its decision on the common  law right  to self determination  and informed consent.    This  right can   be   exercised   by   a   surrogate   decision   maker   when   there   was   a   clear evidence that the incompetent person would have exercised it.  Where such evidence was lacking the Court held that an individual’s right could still be invoked   in   certain   circumstances   under   objective   `best   interest’   standards. Where   no   trustworthy   evidence   existed   that   the   individual   would   have wanted   to   terminate   treatment,   and   a   person’s   suffering   would   make   the administration   of   life   sustaining   treatment   inhumane,   a   pure   objective standard   could   be   used   to   terminate   the   treatment.       If   none   of   these conditions obtained, it was best to err in favour of preserving life.

 What is important to note in Cruzan’s case  is that there was a statute of the State of Missouri, unlike in  Airedale’s  case (where there was none), which required clear and convincing evidence that while the patient was   competent   she   had   desired   that   if   she   becomes   incompetent   and   in   a PVS her life support should be withdrawn.

In Cruzan’s case  the learned Chief Justice observed : “Not   all   incompetent   patients   will   have   loved   ones available   to   serve   as   surrogate   decision   makers.     And even where family members are present, there will be, of course,   some   unfortunate   situations   in   which   family members   will   not   act   to   protect   a   patient.     A   State   is entitled   to   guard   against   potential   abuses   in   such

situations.”  

 The learned Chief Justice further observed : “An   erroneous   decision   not   to   terminate   results   in maintenance   of   the   status   quo;   the   possibility   subsequent   developments   such   as   advancements   in medical science, the discovery of new evidence regarding the   patient’s   intent,   changes   in   the   law,   or   simply   the unexpected death of the patient despite the administration of   life-sustaining   treatment,   at   least   create   the   potential that a wrong decision will eventually be corrected or its

impact   mitigated.     An   erroneous   decision   to   withdraw life-sustaining   treatment,   however,   is   not   susceptible   of correction.”

          No   doubt   Mr.   Justice   Brennan   (with   whom   Justices   Marshall   Blackmun   joined)   wrote   a   powerful   dissenting   opinion,   but   it   is   not necessary   for   us   to   go   into   the   question   whether   the   view   of   the   learned Chief Justice or that of Justice Brennan, is correct.

 Apex court of India observed that Cruzan’s case  can be distinguished on the simple ground that there was a  statute  in the State of Missouri, whereas there was none in the Airedale’s case nor in the present case before us.  We are, therefore, of the opinion that the Airedale’s case is more apposite as a precedent for us.  No doubt foreign decisions are not binding on us, but they certainly have persuasive value.

LAW IN INDIA

In   India   abetment   of   suicide   (Section   306   Indian   Penal   Code)   and attempt   to   suicide   (Section   309   of   Indian   Penal   Code)   are   both   criminal offences.  This is in contrast to many countries such as USA where attempt to suicide is not a crime.

 The Constitution Bench of the Indian Supreme Court in  Gian Kaur vs.    State   of   Punjab,   1996(2)   SCC   648   held   that   both   euthanasia   and assisted suicide are not lawful in India.   That decision overruled the earlier two Judge Bench decision of the Supreme Court in P. Rathinam  vs.  Union of   India,   1994(3)   SCC   394.     The   Court   held   that   the   right   to   life   under Article 21 of the Constitution does not include the right to die (vide para 33). In Gian Kaur’s case  the Supreme Court approved of the decision of the House of Lords in Airedale’s case , and observed that euthanasia could be made lawful only by legislation.

 Sections 306 and 309 IPC read as under  “306. Abetment of suicide –  If   any   person   commits suicide,   whoever   abets   the   commission   of  such   suicide, shall be punished with imprisonment of either description for a term which may extend to ten years, and shall also be liable to fine.

309.    Attempt to commit suicide – Whoever attempts to commit suicide and does any act towards the commission   of   such   offence,   shall   be   punished   with simple imprisonment for a term which may extend to one year or with fine, or with both.” 

Apex court said “We  are  of the opinion that although Section  309 Indian  Penal Code (attempt   to   commit   suicide)   has   been   held   to   be   constitutionally   valid   in Gian Kaur’s  case , the time has come when it should be deleted by Parliament as it has become anachronistic.   A person attempts suicide in a depression, and hence he needs help, rather than punishment.  We therefore recommend to Parliament to consider the feasibility of deleting Section 309 from the Indian Penal Code.” 

Apex court further said” It   may   be   noted   that   in  Gian   Kaur’s  case      although   the Supreme Court has quoted with approval the view of the House of Lords in Airedale’s  case ,   it   has   not   clarified   who   can   decide   whether   life support should be discontinued in the case of an incompetent person e.g. a person in coma or PVS.  This vexed question has been arising often in India because there are a large number of cases where persons go into coma (due to an accident or some other reason) or for some other reason are unable to give consent, and then the question arises as to who should give consent for withdrawal of life support. This   is   an   extremely   important   question   in   India   because   of   the unfortunate   low   level   of   ethical   standards   to   which   our   society   has descended,   its   raw   and   widespread   commercialization,   and   the   rampant corruption, and hence, the Court has to be very cautious that unscrupulous persons   who   wish   to   inherit   the   property   of   someone   may   not   get   him eliminated by some crooked method. Also,   since   medical   science   is   advancing   fast,   doctors   must   not declare   a   patient   to   be   a   hopeless   case   unless   there   appears   to   be   no reasonable   possibility   of   any   improvement   by   some   newly   discovered medical   method   in   the   near   future.     In   this   connection   we   may   refer   to   a recent news item which we have come across on the internet of an Arkansas man Terry Wallis, who was 19 years of age and newly married with a baby daughter   when   in   1984   his   truck   plunged   through   a   guard   rail,   falling   25 feet.     He   went   into   coma   in   the   crash   in   1984,   but   after   24   years   he   has regained consciousness.   This was perhaps because his brain spontaneously rewired   itself   by   growing   tiny   new   nerve   connections   to   replace   the   ones sheared apart in the car crash.  Probably the nerve fibers from Terry Wallis’ cells   were   severed   but   the   cells   themselves   remained   intact,   unlike   Terri Schiavo, whose brain cells had died (see Terri Schiavo’s case on Google). 

Apex court in par 104 said “ However, we make it clear that it is experts like medical practitioners who can decide whether there is any reasonable possibility of a new medical discovery which could enable such a patient to revive in the near future.”

WITHDRAWAL   OF   LIFE   SUPPORT   OF   A   PATIENT   IN

PERMANENT VEGETATIVE STATE (PVS)

Apex court observed “There is no statutory provision in our country as to the legal procedure for   withdrawing   life   support   to   a   person   in   PVS   or   who   is   otherwise incompetent   to   take   a   decision   in   this   connection.”

     We   agree   with  Mr. Andhyarujina that passive euthanasia should be permitted in our country in certain situations, and we disagree with the learned Attorney General that it should   never   be   permitted.

          We   are   laying   down   the   law   in   this   connection which   will   continue   to   be   the   law   until   Parliament   makes   a   law   on   the subject.

 (i)     A   decision   has   to   be   taken   to   discontinue   life   support either   by   the   parents   or   the   spouse   or   other   close relatives,   or   in   the   absence   of   any   of   them,   such   a decision   can   be   taken   even   by   a   person   or   a   body   of persons acting as a next friend.   It can also be taken by the doctors attending the patient However, the decision should   be   taken   bona   fide   in   the   best   interest   of   the patient. 

(ii)    Hence, even if a decision is taken by the near relatives or doctors   or   next   friend   to   withdraw   life   support,   such   a decision   requires   approval   from   the   High   Court concerned as laid down in Airedale’s case .    In our opinion, this is even more necessary in our country as we cannot rule out the possibility of mischief being done by relatives or others for inheriting the property of the patient.

Apex court observed “In our opinion, if we leave it solely to the patient’s relatives or to the doctors or next friend to decide whether to withdraw the life support of an incompetent   person   there   is   always   a   risk   in   our   country   that   this   may   be misused   by   some   unscrupulous   persons   who   wish   to   inherit   or   otherwise grab   the   property   of   the   patient.     Considering   the   low   ethical   levels prevailing   in   our   society   today   and   the   rampant   commercialization   and corruption, we cannot rule out the possibility that unscrupulous persons with the help of some unscrupulous doctors may fabricate material to show that it is   a   terminal   case   with   no   chance   of   recovery.     There   are   doctors   and doctors.     While   many   doctors   are   upright,   there   are   others   who   can   do anything   for   money   (see   George   Bernard   Shaw’s   play   `The   Doctors Dilemma’).     The   commercialization   of   our   society   has   crossed   all   limits. Hence we have to guard against the potential of misuse (see Robin Cook’s novel `Coma’).   In our opinion, while giving great weight to the wishes of the parents, spouse, or other close relatives or next friend of the incompetent patient and also giving due weight to the opinion of the attending doctors, we cannot leave it entirely to their discretion whether to discontinue the life support or not.  We agree with the decision of the Lord Keith in Airedale’s case      that   the   approval   of   the   High   Court   should   be   taken   in   this connection.  This is in the interest of the protection of the patient, protection of the doctors, relative and next friend, and for reassurance of the patient’s family as well as the public.  This is also in consonance with the doctrine of parens patriae which is a well known principle of law.   

In our opinion, in the case of an incompetent person who is unable to take a decision whether to withdraw life support or not, it is the Court alone, as   parens   patriae,   which   ultimately   must   take   this   decision,   though,   no doubt, the views of the near relatives, next friend and doctors must be given due weight.

UNDER   WHICH   PROVISION   OF   THE   LAW   CAN   THE   COURT GRANT APPROVAL FOR WITHDRAWING LIFE SUPPORT TO AN INCOMPETENT PERSON

In   Apex Court’s opinion,   it   is   the   High   Court   under   Article   226   of   the Constitution which can grant approval for withdrawal of life support to such an incompetent person.  Article 226(1) of the Constitution states :”Notwithstanding   anything   in   article   32,   every   High Court   shall   have   power,   throughout   the   territories   in relation to which it exercises jurisdiction, to issue to any person   or   authority,   including   in   appropriate   cases,   any Government, within those territories directions, orders or writs,   including   writs   in   the   nature   of  habeas   corpus, mandamus,  prohibition,  quo warranto  and  certiorari,  or any   of   them,   for   the   enforcement   of   any   of   the   rights conferred by Part III and for any other purpose”.

LAW IN INDIA HAVING IMPLICATION IN MERCY DEATH

Laws/judgmentsMain themePunishment /improvement
Section   306   IPCabetment   of   suicide  If   any   person   commits suicide,   whoever   abets   the   commission   of such   suicide, shall be punished with imprisonment of either description for a term which may extend to ten years, and shall also be liable to fine.  
Section   309   of   IPCattempt   to   suicide  Attempt to commit suicide – Whoever attempts to commit suicide and does any act towards the commission   of   such   offence,   shall   be   punished   with simple imprisonment for a term which may extend to one year or with fine, or with both.”   
P.Rathinam  vs.  Union of   India,   1994(3)   SCC   394.    right   to   life   under Article 21 of the Constitution does not include the right to dieSuicide and its abetment illegal
Gian Kaur vs.    State   of   Punjab,   1996(2)   SCC   648  Both   euthanasia   and assisted suicide are not lawful in India.  In Gian Kaur’s case  the Supreme Court approved of the decision of the House of Lords in Airedale’s case , and observed that euthanasia could be made lawful only by legislation.  
Aruna Shanbaug caseThe time has come when s. 309 should be deleted by Parliament as it has become anachronistic.  A person attempts suicide in a depression, and hence he needs help, rather than punishment.  We therefore recommend to Parliament to consider the feasibility of deleting Section 309 from the Indian Penal Code
Medical council ethics 2002, rule 6.7Practicing euthanasia shall constitute unethical conduct.Erasure of name from medical council

PASSIVE EUTHANASIA PROCEDURE AS LAIN DOWN IN ARUNA SHANBAUG CASE

PROCEDURE   TO   BE ADOPTED   BY   THE   HIGH   COURT   WHEN SUCH AN APPLICATION IS FILED  A   decision   has   to   be   taken   to   discontinue   life   support either   by   the   parents   or   the   spouse   or   other   close relatives,   or   in   the   absence   of   any   of   them,   such   a decision   can   be   taken   even   by   a   person   or   a   body   of persons acting as a next friend.   It can also be taken by the doctors attending the patient However, the decision should   be   taken   bona   fide   in   the   best   interest   of   the patient.  Hence, even if a decision is taken by the near relatives or doctors   or   next   friend   to   withdraw   life   support,   such   a decision   requires   approval   from   the   High   Court concerned as laid down in Airedale’s case .    In our opinion, this is even more necessary in our country as we cannot rule out the possibility of mischief being done by relatives or others for inheriting the property of the patient.When such an application is filed the Chief Justice of the High Court should   forthwith   constitute   a   Bench   of   at   least   two   Judges   who   should decide to grant approval or not.  Before doing so the Bench should seek the opinion   of   a   committee   of   three   reputed   doctors   to   be   nominated   by   the Bench   after   consulting   such   medical   authorities/medical   practitioners   as   it may deem fit.   Preferably one of the three doctors should be a neurologist; one should be a psychiatrist, and the third a physician.   For this purpose a panel   of   doctors   in   every   city   may   be   prepared   by   the   High   Court   in consultation   with   the State Government /Union   Territory   and their   fees for this purpose may be fixed.   The   committee   of   three   doctors   nominated   by   the   Bench   should carefully   examine the patient and also consult   the   record  of  the  patient   as well   as   taking   the   views   of   the   hospital   staff   and   submit   its   report   to   the High Court Bench. Simultaneously   with   appointing   the   committee   of   doctors,   the   High Court   Bench   shall   also   issue   notice   to   the   State   and   close   relatives   e.g. parents,   spouse,   brothers/sisters   etc.   of   the   patient,   and   in   their   absence his/her next friend, and supply a copy of the report of the doctor’s committee to them as soon as it is available.  After hearing them, the High Court bench should give its verdict.     The above procedure should be followed all over India until Parliament makes legislation on this subject. The High Court should give its decision speedily at the earliest, since delay in the matter may result in causing great mental agony to the relatives and persons close to the patient.The High Court should give its decision assigning specific reasons in accordance with the principle of `best interest of the patient’ laid down by the   House   of   Lords   in  Airedale’s  case. The   views   of   the   near relatives and committee of doctors should be given due weight by the High Court   before   pronouncing   a   final   verdict   which   shall   not   be   summary   in nature.  
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