Context: The Ministry of Health and Family Welfare has released draft Guidelines for the Withdrawal of Life Support in Terminally ill Patients to operationalize the Supreme Court’s 2018 and 2023 orders in Common Cause vs Union of India on the right to die with dignity for all Indians.
Till now, there was no dedicated legislation in India on withholding/ withdrawing life-sustaining treatment. The Supreme Court’s judgment in Common Cause vs Union of India 2023, and the subsequent draft guidelines published by the Ministry of Health and Family Welfare (MoHFW) have made it clear that withholding/ withdrawing life-sustaining treatment is legal in India under a defined framework.
What is withholding or withdrawing of life sustaining treatment?
- It refers to discontinuing life-sustaining medical interventions such as ventilators and feeding tubes, etc., when these no longer help the condition of the patient or prolong their suffering.
- Life-sustaining treatments are medical treatments that artificially replace bodily functions essential to the life of the person. These interventions are withheld or withdrawn with the intention of providing comfort care, allowing the underlying illness to take its course, while providing symptomatic relief.
- The right to refuse medical treatment has previously existed in common law, even if it might result in death. After the Supreme Court’s decision in Common Cause vs Union of India (2018), it is also recognized as a fundamental right under Article 21 (Right to life and personal liberty) of the Indian Constitution.
- The withholding/ withdrawal of life-sustaining treatment takes place through two ways:
- informed refusal by a patient with decision-making capacity or
- through an advance medical directive (or a ‘living will’, which is a document that specifies what actions should be taken if the person is unable to make their own medical decisions in the future).
- In case a person is left without decision-making capacity who also does not have a living will, the decision to withhold or withdraw treatment can be considered when the treating physician determines that there is no reasonable medical probability of recovery from a terminal or end-stage condition, or vegetative state — and that any further medical intervention or course of treatment would only artificially prolong the process of dying.
Advanced medical directive (or living will):
- To enforce the right to die with dignity, the Supreme Court in its 2018 judgment laid down the framework for making advance medical directives or living wills. Since the process was complex, the court simplified it in its 2023 judgment.
- Living wills are written documents made by a person of age 18 years or older (just like wills on how one’s property is to be distributed) with decision-making capacity, expressing their will on how they would wish to be treated if they lose capacity of decision making.
- The document should detail at least two surrogate decision-makers- anyone whom the person trusts, from family to neighbours, who can make decisions on behalf of the person if they lose decision-making capacity.
- The document becomes legal when it is signed in the presence of an executor and two witnesses and attested before a notary or gazetted officer.
Guidelines published by the MoHFW for withdrawal of life support in Terminally ill patients:
- Setting up of Primary and Secondary Medical Boards at the level of the hospital, which will determine when further medical treatment may not be beneficial to a terminally ill patient.
- Nomination of doctors by the district Chief Medical Officer or equivalent to hospital-level Secondary Medical Boards, which will confirm or reject the opinion of the Primary Medical Boards.
Legal principles outlined by the Supreme Court in common cause vs Union of India 2018:
- An adult patient capable of taking healthcare decisions may refuse Life Sustaining Treatment (LST) even if it results in death.
- LST may be withheld or withdrawn lawfully under certain conditions from persons who no longer retain decision-making capacity, based on the fundamental right to Autonomy, Privacy and Dignity.
- Advanced Medical Directive that meets specified requirements is a legally valid document.
- For a patient without capacity, Foregoing of Life Support (FLST) proposals should be made by consensus among a group of at least 3 physicians who form the Primary Medical Board (PMB).
- The PMB must explain the illness, the medical treatment available, alternative forms of treatment, and the consequences of remaining treated and untreated to fully inform the surrogate.
- A Secondary Medical Board (SMB) of 3 physicians with one appointee by the Chief Medical Officer (CMO) of the district must validate the decision by the PMB.
- Active Euthanasia is not lawful.
Medical procedure for withholding/ withdrawing life-sustaining treatment as laid down by the SC and reaffirmed by the guidelines:
The legal framework recognizes the rights and duties of both doctors and patients and allows for extensive independent expert opinion and the informed consent of next-of-kin/ surrogate decision-makers.
- The treating hospital constitutes a Primary Medical Board to assess the patient’s condition, and to recommend the appropriateness of withholding/ withdrawing life-sustaining treatment. The board is composed of the treating doctor and two subject-matter experts with at least five years of experience.
- A Secondary Medical Board, to ensure another level of check is also set up by the hospital, reviews the decision of the Primary Medical Board. The Secondary Medical Board comprises a registered medical practitioner nominated by the district Chief Medical Officer, along with two subject-matter experts with at least five years of experience. All these members must be different from those on the Primary Medical Board.
- The persons nominated by the patient in the advance medical directive or surrogate decision-makers (where there is no directive) must consent to the withholding or withdrawal of treatment.
- The hospital must notify decisions on withholding/ withdrawing life-sustaining treatment to the local judicial magistrate.
Medical procedure for withholding/ withdrawing life-sustaining treatment, Procedure flow chart as per MohFW:
Difference between Euthanasia and Withdrawal of life support in terminally ill patients:
| Aspect | Euthanasia | Withdrawal of life support |
| Definition | Actively intervening to end a patient’s life to relieve suffering | Ceasing medical interventions that are keeping a patient alive like critical life support. |
| Method | Administration of lethal substances | Removal of life-sustaining treatments (e.g., ventilators, dialysis) |
| Intent | To end life directly and relieve suffering | To allow natural death by stopping artificial prolongation |
| Types | Voluntary, Non-voluntary, Involuntary | Generally, not categorized by types |
| Legal status | Illegal in many countries including India; legally restricted wherever allowed | Generally legal, especially when further treatment is futile, legalized in India after Common Cause vs Union of India 2018 case. |
| Ethical aspect | Raises debates on sanctity of life, doctor’s role, and autonomy | Seen as respecting patient autonomy and informed consent |
| Patient consent | Often requires explicit consent (in voluntary euthanasia) | Typically requires patient or family consent, or a living will or medical board. |
| Examples | Administering lethal injection | Turning off a ventilator in a terminally ill patient. |