New Delhi, March 11 Aruna Shanbaug and Harish Rana. The Mumbai nurse who died in 2015 after 42 years in a coma and the 32-year-old Ghaziabad man waiting to die with dignity, highlight the long-standing debate about passive euthanasia.
This complex issue, which involves morality, compassion, and dignity, has been extensively discussed in various forums over the years. The Supreme Court finally settled the matter on Wednesday by allowing Rana, who has been in a coma since 2013, to have his life support withdrawn.
"If there is dignity in life, and if there is meaning in life, then you should continue," said Vipul Mudgal, director of the NGO Common Cause, which petitioned the Supreme Court in 2018.
Dr. Surendra Dhelia of the Society for the Right to Die with Dignity, one of the earliest advocates for euthanasia in India, hailed the verdict as a "very good step."
Passive euthanasia involves intentionally allowing a patient to die by withholding or withdrawing life support or treatment necessary to keep him alive.
While urging the Union government to enact comprehensive legislation on passive euthanasia, a bench of Justices J B Pardiwala and K V Viswanathan also directed AIIMS-Delhi to ensure that life support for Rana is withdrawn in a way that maintains his dignity.
The bench allowed the plea filed by Rana through his father, Ashok Rana, and said that AIIMS-Delhi should admit Rana to palliative care so that medical treatment can be withdrawn in a "humane manner".
"This is a very good verdict and it's probably the first time that passive euthanasia will be carried out under the supervision of the court," said Dhelia. "In 2011, when Aruna Shanbaug's case was decided, passive euthanasia was legalized, but the guidelines and procedures were so lengthy that nobody could implement it as the Supreme Court described."
In 2011, the top court rejected a euthanasia plea on behalf of Aruna Shanbaug, who had been in a vegetative state in a Mumbai hospital since a brutal sexual assault in 1973. The court also allowed passive euthanasia in cases of permanent vegetative state. Shanbaug eventually died in 2015 of pneumonia.
Three years later, the apex court in the Common Cause v Union of India recognized the "right to die with dignity" as a fundamental right under Article 21. It legalized passive euthanasia and "living wills," or "Advance Medical Directive" and laid down strict procedures for implementation.
According to Mudgal, the Harish Rana verdict vindicates the Common Cause position. He noted that by legalizing a "living will" in 2018, the Supreme Court gave everyone the right to decide their fate when they are terminally ill.
"We also said that everyone should be allowed to write their own (living) will, specifying that if they are in a vegetative state or terminally ill, they should not be subjected to things like ventilators or artificial resuscitation," said Mudgal.
On January 24, 2023, a five-judge Constitution bench modified the 2018 guidelines to ease the process of granting passive euthanasia to terminally ill patients. The guidelines stated that a primary and a secondary medical board would have to be formed for an expert opinion on the withdrawal of artificial life support for a patient in a vegetative state.
Mudgal also noted that the apex court's verdict in Rana's case also implies that "one does not need to go to the courts every time."
"If a person writes an advanced medical directive, they should not be subjected to unwanted medical intrusion... If the hospital is following the protocol, which is very simple, that you have a two-tier medical review. First is just a subject expert and your physician... they will first give a medical opinion and they will also certify the chances of survival."
"And then there is a secondary medical board, which has a doctor nominated by the chief medical officer of the district. They give an opinion in 48 hours. So, I think today's judgment is very important for many reasons. One is it gives a message to the hospitals that look, just follow the guidelines,” he said.
Dhelia, who said passive euthanasia is a practice often carried out in hospitals, added that the process needs to be simplified further in the best interest of a terminally ill patient.
“The legal framework as of now takes too long. Primary board and then secondary board and what have you. I think hospitals and doctors are more practical. If the patient is beyond hope of recovery, they would come, they would talk to the relatives, if the relatives agree, they would quietly withdraw the life support system. It has been happening for decades,” Dhelia said.
“…but passive euthanasia needs to be simplified further, so that a patient is not kept suffering unnecessarily to get consent of the courts. It's probably only a matter of time that we will have voluntary active euthanasia, we will have involuntary euthanasia, we may have physician assisted suicide,” he added.
On Wednesday, the apex court noted that Rana survived only through clinically administered nutrition via 'percutaneous endoscopic gastrostomy' tubes, and medical boards had unanimously concluded that continuation of treatment merely prolonged biological existence without any possibility of recovery.
When primary and secondary boards have certified withdrawal of life support, there is no need for judicial intervention, the apex court said.
Not far away from the Supreme Court premises in Delhi, crowds started building up outside the Rana home in Ghaziabad. As media crews started gathering, security personnel at the Brahm Raj Empire residential complex limited access and prevented outsiders from entering the premises.
The family was not in a position to comment, said their lawyer Rashmi Nandakumar.
Local residents told their story instead. One neighbour said Ashok Rana and his wife Nirmala Rana had sold their house in Delhi to meet the medical expenses of their son, a football enthusiast who was pursuing a B.Tech degree at Panjab University in 2013 when he fell from the fourth floor of his paying guest accommodation and sustained a brain injury leading to coma.
The court made special mention of Rana's devoted parents, expressing its appreciation to them for showing their immense love and care for their son. "His family never left his side," the bench said.
Passive euthanasia is legal in many countries, including the Netherlands, Belgium, Spain, Canada, New Zealand, Australia, Germany, France, Italy, the UK, Columbia and the US.