Dying with dignity- processes around living will still complicated

The SC recently acknowledged a person’s right to die with dignity in the Harish Rana case, by upholding that the withdrawal of life support for patients in persistent vegetative state with no recovery prospects cannot be termed as “euthanasia”.

However, for nearly 90% of ordinary citizens, whose last days might most certainly be in a hospital, there is no escaping the cumbersome processes involved in earning the right to die with dignity, regardless of whether there is an advanced medical directive (AMD/living will) or not.

“Once a person is rushed to a hospital casualty and medical interventions have been initiated, it will be difficult to withdraw these processes even if the family produces an AMD. Corporate hospitals will have protocols that would be difficult for doctors to bypass,” points out M.R Rajagopal, founder-chairman, Pallium India.

The concept of an advanced medical directive or living will is gaining popularity in Kerala. An AMD allows individuals to record their preferences about medical treatments in advance, especially if they were to become incapacitated or unable to communicate their wishes about their end-of-life care.

However, contrary to the common perception, despite being a fully legal document, an AMD does not guarantee that a person’s wishes will be automatically honoured. Apart from procedural complexities, there are ethical dilemmas, issues such as family disagreements, religious concerns and even misinterpretation of AMDs by medical professionals, which might prevent an AMD from getting executed.

“The SC upheld that merely prolonging an inevitable death through medical procedures violates a patient’s right to die with dignity and imposes significant emotional and physical suffering,” says Dr. Rajagopal. “But unless we have a legislative framework that offers doctors legal protection to withdraw artificial life support when a patient has an AMD — or when families state that a meaningless extension of life is not desired — patient autonomy will continue to be compromised.”

An important fact that SC pointed out was that “passive euthanasia” is no longer a valid terminology. SC made the distinction that henceforth, “passive euthanasia” will be replaced with “withdrawing medical treatment”.

Kerala, Dr. Rajagopal feels, is rightly poised to initiate a legislation regarding end-of-life care and right to die with dignity because there is better understanding of the concept among the public. In 2020, Kerala became the first State in the country to formulate well-defined clinical protocols for brain death certification, de-linking this process from organ donation. It also ended the ethical dilemma of doctors by stating that all life-sustaining measures may be withdrawn once brain death was pronounced.

While this could be the State’s first step towards enacting a legislation protecting a citizen’s right to die with dignity, experts emphasise that broader awareness is essential.