In India, the right to refuse life support is legally recognized through what is known as an advance medical directive (AMD), often referred to as a "living will". This allows individuals to make informed decisions about their medical treatment, especially when they are unable to communicate their wishes due to severe illness or incapacity. The Supreme Court has affirmed the right to refuse medical treatment as part of the fundamental right to life under Article 21 of the Constitution.
Advance Medical Directives Explained
An AMD is a legal document where a person can specify their preferences for medical treatment, including the refusal or withdrawal of life-sustaining measures like ventilators, dialysis, feeding tubes, and cardiopulmonary resuscitation (CPR). It comes into effect only when the person loses the capacity to make healthcare decisions. The AMD should clearly state treatment preferences and appoint a healthcare proxy, a trusted individual who can make decisions on the patient's behalf.
Creating a Valid Advance Medical Directive
To create a legally sound AMD in India:
- Start Advance Care Planning: Discuss your wishes with family, a trusted doctor, and a legal advisor.
- Draft a Living Will: Clearly state the treatments you want to receive or refuse in case of serious illness.
- Appoint a Healthcare Proxy: Choose a trusted person with good judgment to act on your behalf.
- Consult a Lawyer: Ensure the document meets the legal requirements outlined by the Supreme Court.
- Attestation: The AMD must be signed in the presence of two witnesses and attested by a notary public or gazetted officer.
- Communicate: Share copies with family members, relevant hospitals, and your attending physician to ensure it's accessible when needed.
The Legal and Ethical Landscape
The Supreme Court's 2018 ruling in Common Cause v. Union of India recognized the right to die with dignity as a fundamental right, encompassing the right to refuse life-sustaining treatment. Subsequent amendments in 2023 have simplified the process for executing AMDs and withdrawing life support.
Withholding or withdrawing life-sustaining treatment is different from euthanasia, which involves intentionally ending a patient's life. Indian law permits passive euthanasia, which is the withdrawal of life support, under strict guidelines, but it does not allow active euthanasia.
The Role of Medical Boards
When a patient requires the withdrawal of life support and cannot make decisions, the hospital must constitute a primary medical board of at least three doctors, including the treating physician and subject experts, to review the case. If the primary board approves the withdrawal, the case is referred to a secondary medical board, which includes doctors nominated by government authorities. The secondary board must make a decision within 48 hours.
Safeguards and Considerations
It's important to note that the decision to refuse life support is not considered an attempt to suicide but rather an exercise of the right to live with dignity and to avoid prolonged suffering. Palliative care should always be offered to manage pain and ensure the patient's comfort.
While AMDs are legally recognized, cultural and systemic factors in India can sometimes make their implementation challenging. Families may find it emotionally difficult to discuss end-of-life wishes, and there can be misunderstandings about the intent of an AMD. Therefore, open communication and advance care planning are essential to ensure that a patient's wishes are respected.
