Indian court says it may sanction euthanasia in the future

India’s Supreme Court has declared that withdrawing life support to patients may be permitted in certain situations through a legal procedure, in a landmark ruling that the country’s medical community believes will provide guidance for care at the end of life.

On 7 March the court rejected a petition filed two years ago to withdraw feeding support from Aruna Shanbaug, a former nurse at the King Edward Memorial Hospital in Mumbai (Bombay), who has been in a persistent vegetative state since she was sexually attacked by a hospital cleaner in November 1973. But the court signalled that it would not rule out sanctioning some cases of euthanasia in the future if doctors approached the courts to request permission.

When she was attacked, Ms Shanbaug had a dog chain wrapped around her neck to immobilise her, causing hypoxia and irreversible brain damage. Her brain stem is active, and she can breathe on her own, make sounds, blink, and eat food that is placed in her mouth, court documents said. The hospital nurses feed her, bathe her, and change her position every few hours.

In an affidavit Sanjay Oak, dean of the King Edward Memorial Hospital, said that the hospital staff and nurses are determined to take care of Ms Shanbaug, who is now in her 60s, “until her last breath by natural process.”

“In the history of medicine there would not be another single case where a patient has been cared for and nurtured in bed for [over three decades] and yet has not developed a single bed sore,” Dr Oak said. “This speaks volumes for the excellence of nursing care.”

The court noted that Ms Shanbaug’s relatives had abandoned her and that hospital staff now make up her “real family.” However, the court said that if the hospital did change its stance in the future it could approach the Mumbai High Court to allow withdrawal of feeding.

In its ruling the court cited the case of Anthony Bland, the UK man who was injured in the April 1989 Hillsborough football stadium disaster and who was the first patient in British legal history to be allowed to die (in March 1993) after permission by a court to withdraw life prolonging treatment. Mr Bland’s case was strikingly appropriate, the court said.

The Supreme Court has outlined a procedure by which India’s high courts will consult panels of independent doctors before delivering verdicts on requests for withdrawal of life support made by families of patients in permanent vegetative states.

The Indian Society for Critical Care Medicine has said that although the ruling deals only with the specific situation of patients in a chronic persistent vegetative state it is still a “crucial positive step” in the development of appropriate guidelines for the care of dying people in India.

Raj Kumar Mani, director of critical care medicine at Artemis Hospital, who helped develop the society’s guidelines on limiting life support for terminally ill people, said, “In the absence of clear guidelines, doctors were afraid of doing the ethically appropriate things.”

Doctors say that the legal environment in India has discouraged the transition of terminally ill patients from critical care to palliative care. Narendra Rungta, a critical care specialist in Jaipur and the president elect of the Indian Society for Critical Care Medicine, said, “For reasons of dignity, ethics, and finance terminally ill patients do move into palliative care after families consult with doctors.

“We’re hoping that this judgment will lead to greater acceptance of the idea of limiting life support to the terminally ill in situations where doctors and patients’ families agree that that is the best option for the patient.”