By Dr K Madan Gopal & Prof Dr Suneela Garg
The topic of passive euthanasia, or the withdrawal of life-sustaining treatments from terminally ill patients, has been the subject of much debate in India. Following the Supreme Court’s recognition of passive euthanasia as a fundamental right under Article 21, the Indian government has introduced new draft guidelines through the Directorate General of Health Services (DGHS) to streamline the process. These updates build on the 2018 guidelines and address the concerns of medical professionals, patients, and families alike. This article explores the global context of euthanasia practices, India’s evolving legal landscape, the details of the DGHS’s new guidelines, and the potential benefits and challenges these changes bring.
Global Perspectives on Euthanasia and Assisted Dying
Globally, euthanasia and assisted dying laws reflect diverse cultural, religious, and ethical considerations. In the Netherlands, Belgium, and Luxembourg, both active euthanasia and physician-assisted suicide are legal under stringent regulations. Patients must demonstrate unbearable suffering with no chance of recovery, and they must undergo multiple medical evaluations. The law in the Netherlands, for instance, even allows minors aged 12-17 to request euthanasia with parental consent.
In Switzerland, physician-assisted suicide is legal, with services provided by organisations like Dignitas. The Swiss model is unique in that it permits non-residents to seek assisted dying, a practice that has drawn both criticism and admiration globally. Canada introduced Medical Assistance in Dying (MAID) in 2016, allowing physician-assisted suicide and euthanasia under strict conditions. Canadian law mandates a waiting period, multiple assessments, and procedural safeguards to ensure that the patient’s request is fully informed and voluntary(
In the United States, states like Oregon, Washington, and California have enacted “Death with Dignity” laws that permit physician-assisted suicide for terminally ill patients. However, these laws do not allow active euthanasia, where a doctor directly administers the means to cause death. The variability across U.S. states reflects the complex interplay between state rights, individual autonomy, and ethical considerations, mirroring some of the challenges India faces as it implements its passive euthanasia guidelines.
The Supreme Court of India’s landmark 2018 judgment in Common Cause v. Union of India recognised the right to die with dignity, establishing a legal framework for passive euthanasia. The ruling allowed patients to create Advance Medical Directives (AMDs) detailing their preferences for end-of-life care, including instructions for withdrawing life support if they become incapacitated. The 2018 guidelines required judicial oversight and multiple layers of medical scrutiny, which some stakeholders, including the Indian Society for Critical Care Medicine (ISCCM), criticised as overly cumbersome.
The DGHS recently introduced updated draft guidelines to streamline this process. These modifications reflect a concerted effort to balance patient autonomy with the practical realities of India’s healthcare system and the ethical concerns of healthcare providers.
Key Provisions of the DGHS Guidelines
The DGHS guidelines outline specific criteria and procedures for implementing passive euthanasia. These updates aim to make the process more accessible and legally sound, addressing some of the shortcomings of the 2018 framework. The main provisions include:
- Conditions for Withdrawal of Life Support: The guidelines specify that passive euthanasia may be considered when:
- A patient has been declared brainstem dead according to the Transplantation of Human Organs Act (THOA).
- Medical prognostication indicates no benefit from continued treatment, as in cases of advanced, incurable diseases.
- An informed refusal has been documented by the patient or their surrogate, indicating a desire to forgo life-sustaining measures.
- All procedures comply with the Supreme Court’s protocols, safeguarding the legality of these decisions(
- Streamlined Medical Board Requirements: The original 2018 guidelines required a two-stage medical board review, with doctors having at least 20 years of experience. The DGHS has reduced this experience requirement to five years and has decreased the size of each board to three members. This change reflects the practical need for flexibility in assembling qualified boards, particularly in smaller hospitals.
- Time Limits and Verification Processes: The DGHS has also introduced a preferable 48-hour time limit for both the primary and secondary medical boards to provide their opinions. This ensures that terminally ill patients receive timely decisions regarding their care, minimising prolonged suffering and uncertainty.
- Do-Not-Attempt-Resuscitation (DNAR) Orders: The guidelines explicitly address DNAR orders for the first time, allowing doctors to refrain from CPR in cases where there is no realistic chance of survival. This addition underscores the broader aim of minimising unnecessary interventions that may only prolong suffering(
- Legal and Ethical Safeguards: The guidelines reinforce the importance of patient autonomy, affirming that patients with decision-making capacity may refuse life-sustaining treatment. For patients without such capacity, a consensus among physicians on the primary medical board (PMB) is required, with the decision further validated by a secondary medical board (SMB). This layered approach provides ethical oversight while maintaining legal accountability.
Potential Benefits of the DGHS Guidelines
- Enhancing Patient Autonomy: The guidelines empower individuals to make choices that align with their values by enabling patients to express their end-of-life preferences through AMDs. This aspect of the guidelines reassures the audience about respecting individual rights in India’s context of end-of-life care.
- Reducing Financial and Emotional Burden on Families: The guidelines provide significant relief to families by allowing the withdrawal of expensive, life-sustaining treatments when there is no hope for recovery. This provision can significantly alleviate the financial burden on families, fostering empathy among the audience towards the challenges families face in such situations.
- Alleviating Pressure on Healthcare Infrastructure: Passive euthanasia, as outlined in the guidelines, allows healthcare facilities to allocate resources more efficiently, particularly in intensive care units. This could lead to better availability of critical care resources for patients with treatable conditions, fostering optimism among the audience about the future of healthcare in India.
- Providing Clarity for Medical Practitioners: The guidelines offer a structured framework that helps doctors navigate end-of-life care decisions ethically and legally. The detailed criteria reduce ambiguity, allowing healthcare providers to make decisions in good faith without fear of legal repercussions, provided they comply with the outlined procedures(
Challenges and Criticisms
- Risk of Misuse and Legal Exposure: While the DGHS guidelines aim to protect doctors, some fear they could lead to legal challenges if families dispute the withdrawal of life support. The Indian Medical Association has expressed concerns that healthcare providers may face litigation if disagreements arise, highlighting the need for additional legal safeguards.
- Cultural and Religious Sensitivities: In a culturally diverse country like India, where beliefs about the sanctity of life vary widely, passive euthanasia may face resistance. Many religious communities may view the withdrawal of life support as morally unacceptable, presenting ethical conflicts for healthcare providers and families alike(
- Ensuring Informed Consent: Health literacy is inconsistent across India, and ensuring that patients and families fully comprehend the implications of passive euthanasia is crucial. The guidelines must be accompanied by public education initiatives to improve awareness and understanding of end-of-life options, especially in rural and underserved areas(
- Emotional and Psychological Impact on Families: Making decisions about withdrawing life support can be emotionally distressing for families. In India, where family bonds are often deeply intertwined with caregiving responsibilities, the psychological toll of these decisions can be profound. Enhanced support systems, including counselling and palliative care services, are essential to help families navigate these difficult choices(
Moving Forward: The Path to Compassionate End-of-Life Care
The DGHS’s updated guidelines on passive euthanasia represent a significant step towards compassionate and ethical end-of-life care in India. However, successful implementation will require ongoing efforts to:
- Expand Palliative Care: Strengthening palliative care services can offer alternatives to passive euthanasia, providing patients with comprehensive pain management and emotional support.
- Clarify Legal Protections: To ensure that healthcare providers feel protected, the government may need to establish additional legal frameworks that protect doctors from potential litigation when they comply with these guidelines.
- Promote Health Literacy and Public Awareness: By investing in public education campaigns, the government can improve awareness of passive euthanasia and the options available for end-of-life care. This will empower patients and families to make informed choices based on clearly understanding their rights.
In conclusion, passive euthanasia represents a shift toward patient-centred care, offering dignity and choice at the end of life. As India considers these guidelines, balancing ethical considerations, cultural values, and legal protections will be essential to creating a compassionate, transparent, and sustainable approach to end-of-life care.
(Dr K Madan Gopal works as Advisor Public Health Administration, NHSRC, and Dr Suneela Garg is Chair of the Program Advisory Committee NIHFW, MoHFW GOI. Views expressed are personal and do not reflect the official position or policy of the FinancialExpress.com.)
