Case Brief: Aruna Ramachandra Shanbaug v. Union of India | Important Acts and Laws for Judiciary Exams PDF Download

Brief facts of Mohd. Ahmed Khan vs Shah Bano Begum

Case Background

• The incident involves Aruna Ramachandra Shanbaug, a staff nurse at King Edward Memorial Hospital in Mumbai.
• On November 27, 1973, she was attacked by a hospital sweeper who assaulted her with a dog chain, causing severe injuries.
• The assailant attempted to rape her but sodomized her upon realizing she was menstruating.
• Due to the strangulation, she suffered brain damage, leading to long-term incapacitation.
• For 36 years, Aruna has been in a vegetative state, reliant on hospital care for basic needs.

Legal Proceedings

• Writ Petition (Criminal) No. 115 of 2009 under Article 32 of the Indian Constitution.
• Court: Supreme Court of India.
• Parties involved: Aruna Ramachandra Shanbaug (Petitioner) and Union of India (Respondent).

Request

• The plea sought permission to discontinue life support and allow Aruna to pass away peacefully.

Significance

• This case raises ethical and legal questions regarding the right to life, quality of life, and end-of-life decisions.
• It has sparked debates on euthanasia, patient autonomy, and the role of medical professionals in such scenarios.
• The judgment in this case set a precedent for future discussions on passive euthanasia in India.

Issues in Mohd. Ahmed Khan vs Shah Bano Begum

• Should withholding or withdrawal of life-sustaining therapies in a person in a permanent vegetative state be permissible or 'not unlawful'?
• If a patient has previously expressed a wish not to have life-sustaining treatments in case of futile care or a PVS, should his/her wishes be respected when the situation arises?
• If a person has not previously expressed such a wish, and their family or next of kin requests to withhold or withdraw futile life-sustaining treatments, should their wishes be respected?
• In the case of Aruna Shanbaug, who has been abandoned by her family and cared for by the staff of KEM Hospital for the last 37 years, who should make decisions on her behalf?

Analysis

• Definition of Euthanasia: Euthanasia, also known as mercy killing, is categorized into two main types: active and passive. Active euthanasia involves the use of lethal substances or forces to end a person's life, such as administering a lethal injection to a terminally ill patient suffering from unbearable pain.
• Examples of Active Euthanasia: For instance, providing a lethal injection to a cancer patient in severe agony to end their suffering.
• Passive Euthanasia: In contrast, passive euthanasia involves the withholding of medical treatment necessary to sustain life. This could include scenarios like refraining from administering antibiotics to a patient whose condition would result in death without them, or disconnecting life support devices from a patient in a coma.
• Types of Euthanasia: Euthanasia can be further classified into voluntary and non-voluntary categories. Voluntary euthanasia occurs with the explicit consent of the patient, while non-voluntary euthanasia happens when the patient is unable to provide consent, such as when they are in a coma or incapacitated.
• Legal Implications: While there are fewer legal challenges with voluntary euthanasia due to the patient's consent, non-voluntary euthanasia, especially in cases where consent is unavailable, raises significant ethical and legal concerns.
• Case Specifics: The case discussed pertains to passive non-voluntary euthanasia, shedding light on the complexities of end-of-life decisions when the patient's consent is absent.

Important Arguments (Petitioner and Respondent)

• To ensure autonomy, a patient must possess the capacity to make decisions independently. If the patient lacks this capacity, the directives outlined in a Living Will, or decisions made by surrogates through 'substituted judgment,' should be honored. Surrogates are expected to act in the best interest of the patient, either reflecting the patient's hypothetical decisions if capable or making decisions that benefit the patient without personal bias.
• In the case of Vikram Deo Singh Tomar v. State of Bihar, the court emphasized the right to a dignified life consistent with human dignity, underlining the importance of quality of life until natural death. It distinguishes between the right to die with dignity at the end of life and unnatural premature death.
• Every mentally competent adult holds the right to determine the course of their medical treatment. Medical procedures performed without the patient's consent are considered violations of personal autonomy.
• Medical professionals withdrawing life support engage in omission, not active termination of life. Contrastingly, actively terminating life, as in euthanasia, is deemed unlawful in countries like the UK, USA, and India.
• While the right to die by suicide is not recognized under Article 21 of the Constitution, individuals in terminal illness or permanent vegetative states may be permitted to end their lives with dignity in certain circumstances, as established in the Gian Kaur case.
• In India, abetment of suicide and attempted suicide are offenses. The Supreme Court has ruled that euthanasia and assisted suicide are illegal, emphasizing the role of medical experts in evaluating the potential for medical advancements to revive patients.
• The brain, as a person's vital organ, is irreplaceable. Unlike other body parts, such as limbs or organs, the brain cannot be transplanted. The brain defines one's identity, cognition, memory, sensory perception, and motor functions. Consequently, brain death signifies the end of an individual's life.

In essence, these legal and ethical arguments underscore the significance of respecting patient autonomy, ensuring dignity in end-of-life care, and the limitations surrounding euthanasia and assisted suicide. It also highlights the crucial role of medical practitioners in making decisions regarding a patient's medical treatment and end-of-life care.

Withdrawal of Life Support of a Patient in Permanent Vegetative State (PVS)

• No specific legal procedure exists in the country for withdrawing life support from a person in PVS or someone incapable of decision-making in this regard.
• Passive euthanasia could be allowed in certain circumstances, as opposed to the view that it should never be permitted.
• A decision to discontinue life support can be made by the patient's parents, spouse, close relatives, a next friend, or the attending doctors, always in the patient's best interest.
• The High Court's approval should be sought before discontinuing life support, considering the views of close relatives, next friend, and doctors.

Court Approval for Withdrawing Life Support

• The High Court under Article 226 of the Constitution can grant approval for withdrawing life support from an incompetent person.
• Article 226(1) empowers High Courts to issue directions, orders, or writs for enforcing rights conferred by Part III of the Constitution.

Procedure for High Court Approval

• Upon receiving an application, the Chief Justice should form a Bench of at least two Judges to decide on granting approval.
• A committee of three doctors, including a neurologist, psychiatrist, and physician, should provide their opinion on the case.
• The High Court may maintain a panel of doctors in each city for consultation on such matters.

Judgment: Mohd. Ahmed Khan vs Shah Bano Begum

• The Supreme Court of India, through Justices Markandey Katju and Gyan Sudha Mishra, issued a landmark ruling on March 7, 2011.
• The court determined that Aruna, despite being in a Persistent Vegetative State (PVS), did not meet the criteria for brain death according to medical reports and the Transplantation of Human Organs Act, 1994.
• It was established that Aruna could breathe unaided, had sensations, and showed responses, indicating she was not brain dead.
• Her sustenance relied on a life-saving technique involving mashed food, which the court deemed crucial for her survival.

Decision Making Authority

• The court affirmed that decisions regarding Aruna's care lay with the KEM Hospital management and staff, not Pinki Virani.
• The court emphasized the distinction between removing life support like ventilators and ceasing essential sustenance like food, asserting that withholding food was not permissible under Indian law.

Passive Euthanasia Guidelines

• The court introduced guidelines for passive euthanasia to prevent potential misuse, entrusting the High Court with the authority to approve life termination in specific circumstances.
• Applications for passive euthanasia required a High Court Bench comprising at least two judges and a committee of three doctors to assess the case and offer their opinions.
• The High Court had to notify the State and the patient's close relatives, seeking their input before making a final decision.
• The prescribed procedure for passive euthanasia was mandated to be followed nationwide until legislation was enacted by Parliament on the matter.

Outcome for Aruna Shanbaug

• Aruna Shanbaug was not granted euthanasia, as the court deemed her case unsuitable for such a measure.
• The court specified that if in the future the hospital staff or management deemed it necessary, they could seek approval from the High Court following the established procedure.

Significance and Recommendations

• This case provided clarity on euthanasia matters and outlined protocols for passive euthanasia.
• The court suggested the repeal of Section 309 of the Indian Penal Code and recommended guidelines for end-of-life decisions in the absence of specific legislation.
• Overall, this case set a precedent for addressing unlegislated areas and established a framework for handling similar cases in the future.

Status of the Judgement

• Passive euthanasia has been legalized in India under specific conditions set by medical boards.
• The Supreme Court defined passive euthanasia as the withdrawal of medical treatment to hasten a terminally ill patient's death.
• A bench of justices laid down guidelines for executing the will and granting approval for passive euthanasia by the medical board.
• The Supreme Court's landmark judgment recognized passive euthanasia, also known as mercy killing.

Meaning of Euthanasia: Defined

• Euthanasia is a contentious issue globally, allowing individuals of sound mind to decide their medical treatment.
• The distinction between passive euthanasia (refusing life-saving treatment) and active euthanasia is crucial, especially in cases like Permanently Vegetative State (PVS).
• The court, acting in the best interest of the patient, determines whether to terminate treatment.
• Passive euthanasia involves withholding treatment with the intention of causing the patient's death, such as withdrawing life support or essential medication.
• Euthanasia can be voluntary (with the patient's consent), non-voluntary (without consent), or physician-assisted, depending on the circumstances.
• Physician-assisted suicide involves the patient self-administering the intervention under medical advice.

Verdict

• In a significant ruling on 7th March 2011, the Supreme Court, led by justices Markandey Katju and Gyan Sudha Mishra, made a landmark decision regarding mercy killing in the case of Aruna Shanbaug.
• The court permitted "passive euthanasia," which involves withdrawing life support from patients in Persistent Vegetative State (PVS). However, it categorically rejected the notion of active euthanasia, which entails ending life through the administration of lethal substances.
• The Supreme Court laid down guidelines for passive euthanasia, declaring that these guidelines would stand as the law of the land until the Parliament formulates appropriate legislation on the matter.
• Justices Markandey Katju and Gyan Sudha Mishra also called for the removal of Section 309 IPC, which pertains to the criminalization of attempted suicide. They deemed this section outdated and suggested that individuals attempting suicide need assistance rather than punishment.
• While acknowledging the absence of a legal provision for discontinuing life support for individuals in PVS, the court acknowledged the permissibility of passive euthanasia in certain circumstances. It entrusted the responsibility to the high courts to adjudicate on requests for mercy killings.

Euthanasia in Other Countries

• United States: Active Euthanasia is illegal in all states in the U.S., but physician-assisted dying is legal in Oregon, Washington, and Montana.
• Canada: In Canada, Physician-Assisted Suicide is illegal under Section 241(b) of the Criminal Code of Canada.
• Netherlands: Euthanasia in the Netherlands is governed by the "Termination of Life on Request and Assisted Suicide (Review Procedures) Act" of 2002. According to this act, euthanasia and physician-assisted suicide are not punishable if the attending physician adheres to specific criteria of due care. These criteria include the patient's request, the patient's unbearable and hopeless suffering, information provided to the patient, the presence of reasonable alternatives, consultation with another physician, and the method of ending life.
• Switzerland: Switzerland has a unique stance on assisted suicide; it is legally permitted and can be carried out by non-physicians. Euthanasia, however, is illegal. The key distinction between assisted suicide and euthanasia lies in the fact that in assisted suicide, the patient self-administers the lethal injection, while in euthanasia, a doctor or another individual administers it.
• Belgium: Belgium became the second European country after the Netherlands to legalize euthanasia in September 2002. Patients who wish to end their lives must be conscious when making the request and must repeat their plea for euthanasia. They must be experiencing constant and unbearable physical or psychological pain due to an accident or an incurable illness.

Passive Euthanasia Legalization in India

Legal Status in India

• Abetment of suicide (Section 306 Indian Penal Code) and attempt to suicide (Section 309 of Indian Penal Code) are considered criminal offenses in India.
• This differs from countries like the USA, where attempting suicide is not a criminal act.

Supreme Court Rulings

• In the case of Gian Kaur vs. State of Punjab, the Indian Supreme Court's Constitution Bench determined that euthanasia and assisted suicide are illegal in India.
• The decision overturned a previous ruling in P. Rathinam vs. Union of India.
• The Court clarified that Article 21 of the Constitution, the right to life, does not encompass the right to die.
• Referencing the House of Lords' decision in Airedale's case, the court emphasized that euthanasia could only be legalized through legislation.

Conclusion

• The Aruna Ramachandra Shanbaug case was significant as it led to several key outcomes:
• The Supreme Court of India suggested to the Indian Parliament to consider removing Section 309 from the Indian Penal Code.
• In Gian Kaur's case, the Court acknowledged the ambiguity surrounding the decision-maker for discontinuing life support for incompetent individuals like those in a coma or Persistent Vegetative State (PVS).
• Permission for "passive euthanasia," allowing the withdrawal of life support for patients in PVS.
• Establishing strict procedural guidelines for "passive euthanasia" to prevent misuse.
• Rejection of "active euthanasia," which involves ending life through the administration of lethal substances, due to ethical concerns, commercialization, and corruption in Indian society.
• Given the rapid advancements in medical science, doctors should not deem a patient as beyond hope unless there is no foreseeable chance of improvement through new medical techniques.

Referred Cases

• State of Maharashtra v. Maruty Shripati Dubal:
  • The Bombay High Court deemed Section 309 of the Indian Penal Code unconstitutional, asserting that it violated Articles 19 and 21.
  • The court ruled that the 'right to life' encompasses the 'right to die', leading to the striking down of Section 309.
  • It was clarified that the right to die is not unnatural but rather uncommon and abnormal.
• P. Rathinam v. Union of India:
  • Highlighted that Article 21 includes the 'right to die' within its scope.
  • Emphasized that Article 21 has both a positive and negative aspect, not solely negative.
• Gian Kaur v. State of Punjab:
  • Examined the validity of Section 306 of the IPC, which addressed abetment of suicide.
  • Overturned the decision in P. Rathinam but acknowledged that in specific cases like terminally ill patients, the right to die is about accelerating the natural process of death.
  • Argued that the right to live with dignity encompasses the right to die with dignity.
• Airedale NHS Trust v. Bland:
  • In this landmark judgment, the English courts permitted the withdrawal of life support systems, including food and water, granting individuals the right to die.
  • Established the court's authority in determining cases fit for euthanasia.
• Mckay v. Bergsted:
  • The Supreme Court of Nevada permitted the removal of a respirator after evaluating state interests and patient well-being.
  • Distinct from the Aruna case, as the patient in Mckay required external assistance to breathe.