MEDICAL

JURISPRUDENCE – 4.10,
4.11
 COMPETENCIES
FM 4.10 - Describe communication between doctors, public
and media

FM 4.11 - Describe and discuss euthanasia

 DOCTOR & MEDIA
 Media – Powerful tool

 Advancing healthcare issues through media

 Effective media communication is key responsibility of health

professionals
 Issues – Fear if misrepresentation, misunderstood

 Good Media coverage -> Self – monitoring, accountability, good

communication strategy
 USEFULNESS OF MEDIA
 Health Information
 Sensitization of public
 Calm worried public, reduce misinformation
 Raise awareness, Public feedback about controversial issues
 PRESS CONFERENCE
 Prepare few key messages
 Preparation is vital, don’t be caught unprepared
 Be ready to take provocative questions
 Do not digress from main issue
 Do’s & Don'ts
Do’s - Be attentive during conversation
- Before speaking distinguish humor from inappropriate
- Take turns during conversations
- Should know when to enter & exit conversation
- Have reliable source and authentic info
- Avoid controversy
- Let PRO or Media Offr handle

Don’ts - be defensive or hostile

- be overexposed to media
- pass sensational story or viewpoint
- Affirm or vouch without actual knowledge
EUTHANASIA
EUTHANASIA
 SCHEME OF LEARNING
Introduction
Definition
Classification
Methods for euthanasia
Arguments favoring euthanasia
Arguments against euthanasia
Euthanasia vs Suicide
Legal position in India
Historical Perspective
Trends in other countries
Religious Views
 INTRODUCTION
Origin of word Euthanasia – Greek

Eu - good, Thanatosis – death; ‘Good Death’, "Gentle and

Easy Death."

Used for "mercy killing”.

Coined by the great historian Suetonius, who described the way

King Augustus opted for quick, painful death without suffering
 DEFINITION
Euthanasia means producing painless death of a person suffering from hopelessly
incurable, terminal and painful disease for the purpose of ending suffering.

Terminal illness – [The Medical Treatment of Terminally ill patients (Protection of

Patients and Medical Practitioners) Bill 2016]

(i) such illness, injury or degeneration of physical or mental condition which is

causing extreme pain and suffering to the patients and which, according to
reasonable medical opinion, will inevitably cause the untimely death of the patient
concerned, or

(ii) which has caused a ‘persistent and irreversible vegetative’ condition under
which no meaningful existence of life is possible for the patient.
CLASSIFICATION
According to Physician’s act
1.Active euthanasia
2.Passive euthanasia

According to the will of the patients

1. Voluntary euthanasia
(i) Voluntary euthanasia by doctor
(ii) Physician assisted suicide
2. Involuntary Euthanasia
3. Non –voluntary euthanasia
 ACTIVE EUTHANASIA
Active or Positive: It is an act of Commission.

It means a positive merciful act to end useless sufferings and

meaningless existence.

Methods used - giving lethal doses of a drug like morphine,

cocaine, barbiturates, muscle relaxants to hasten death.

Patient would have continued to live if not euthanized.

 ACTIVE EUTHANASIA
Less acceptable in general public

Legal in Belgium, Netherlands, Colombia,

Luxembourg

Case study – Dr. Howard Martin (1935-), a

British doctor euthanized 18 patients by giving
them morphine injections.
In 2005, acquitted by court for the murder of 3 patients, because he had no motive to
kill other than euthanizing patients who were in great pain.

The General Medical Council [GMC] struck his name for life for serious professional
misconduct.
PASSIVE EUTHANASIA
Passive or Negative Euthanasia – An act of omission.

Also known as “letting die”.

“Letting die” means to give way to an ongoing inner-organismic

process of disintegration, without supporting or sustaining vital
functions.

It means discontinuing or not using extraordinary life sustaining

measures to prolong life
 PASSIVE EUTHANASIA
Methods used -
(i)failure to resuscitate a terminally ill or incapacitated patient or severely
defective newborn.
(ii)Discontinuation of IV fluids, O2, etc
(iii)Discontinuing a feeding tube, or not carrying out a life –extending
operation or not giving life extending drugs

Legal in Argentina, Chile, Finland, Germany, India, Ireland, Mexico,

Sweden , United Kingdom, Some states of US.
 VOLUNTARY
EUTHANASIA
Euthanasia practiced with the expressed desire and consent of the person
concerned.

Patient must be competent to make this choice [i.e. must be mentally

sound].

Voluntary euthanasia is legal in:

(i) Belgium (ii) Luxembourg (iii) Netherlands (iv)Switzerland (v) U.S. - (a)
Oregon (b) Washington.

Classification – two types according to involvement of patient himself in

the dying process.
 VOLUNTARY EUTHANASIA

(i) Voluntary Euthanasia by doctor -

Patient does not participate in the dying process

(ii) Physician assisted suicide –

(a) Patient actively participates in the dying process.
(b) He actually commits suicide;
(c) Doctor provides an individual with the information, guidance, and means to
take his or her own life with the intention that they will be used for this
purpose. example – providing lethal drugs
 INVOLUNTARY
EUTHANASIA
Intentionally administering medications or other interventions to cause the patient’s
death when patient was competent but without the patient’s explicit request and/or full
informed consent; e.g. patient may not have been asked

Euthanasia practiced against the will of the person

Patient does not want to die, yet he is compulsorily killed to end his suffering.

Doctor knows patient cannot be saved

Amount to murder.
 NON-VOLUNTARY EUTHANASIA
Intentionally administering medications or other interventions to cause
the patient’s death when patient was incompetent and mentally
incapable of explicitly requesting it.

Euthanasia practiced in persons incapable of making their wishes

known.

Eg persons in irreversible coma, severely defective infants.

Case studies: (i) Karen Ann Quinlan's case (ii) Teni Schiavo s case
 METHODS OF EUTHANASIA
1) Withhold or withdraw treatment

2) Lethal injection - Injection of a lethal dose of a drug, such as a known

poison, KCl, etc.

3) Asphyxiation - The most popular gas used is Carbon monoxide (CO).

Nerve gases like sarin & tabun etc. are also added in small amounts to
fully ensure death.

4) One of the methods is also Dr. Jack Kevorkian's (Dr. Death) death
machine (mercitron, thanatron). It's a unique method in which a person
can end his life himself painlessly at the time chosen by the patient.
 THANATRON (DEATH MACHINE)
Invented by Dr Jack Kevorkian
Contain 3 bottle mount in metal frame about 6
inches wide and 18 inches high
Each bottle had a syringe that connect single
IV line in the patients arm
Normal saline, Sodium thiopental, potassium
chloride and pancuronium bromide
On pushing button, death occurred within 2-3
mins
 MERCITRON [ MERCY MACHINE]

Made by Dr Kevorkian
As could not procure drugs for thanatron on revoking of
his medical license
Mercitron employed a gas mask fed by a canister
of carbon monoxide by a tube and a makeshift handle
This method took 10 minutes or longer.
 ARGUMENTS FAVOURING
EUTHANASIA
1. Act of humanity
2. Right to die with dignity
3. Caregiver’s burden
4. Refusing treatment and care
5. Encouraging the Organ transplant
ARGUMENTS AGAINST
EUTHANASIA
1. Eliminating the Invalid
2. Symptoms of mental illness
3. Malafide intention
4. Emphasis on care
5. Lack of basic healthcare services
6. Commercialization of healthcare
7. Right to life
 Euthanasia vs Suicide
The Bombay High Court in Maruti Shripati Dubal case –
(i)The suicide by its very nature is an act of self killing or termination of one’s own life
by one’s act without assistance from others.

(ii) But euthanasia means the intervention of others human agency to end the life.
Mercy killing therefore cannot be considered in the same footing as on suicide. Mercy
killing is nothing but a homicide, whatever is the circumstance in which it is
committed.

The two concepts are both factually and legally distinct

Suicide is a sad individual act. Euthanasia is not a private act. It is facilitating of

persons death by another.
 LEGAL POSITION IN INDIA
Passive Euthanasia has been legalized but Active euthanasia is clear act of offence

S.300, IPC. Murder - There is an intention on the part of the doctor to kill the
patient. [Active euthanasia]

Exception 5 to S.300, IPC –> Voluntary Euthanasia -> S.304, IPC [ Punishment for
culpable homicide not amounting to murder]

Non-voluntary and Involuntary euthanasia - would be struck by proviso one to S.92,

IPC
 LEGAL POSITION IN INDIA
S.92, IPC - Act done in good faith for benefit of a person without consent is not an offence.

Proviso 1 to S.92,IPC - this exception shall not extend to the intentional causing of death, or the attempting to cause
death.

Right to suicide is not an available “right” in India.

S.305, IPC - Abetment of suicide of child or insane person

S.306, IPC - Abetment of suicide. [Physician assisted suicide]

 LEGAL POSITION IN INDIA
S.309, IPC - Attempt to commit suicide. [Decriminalized]

Article 21 - No person shall be deprived of his life or personal liberty except

according to procedure established by law

Article 21 is a provision guaranteeing protection of life and personal liberty

and by no stretch of imagination can imply ‘EXTINCTION OF LIFE’.

Right to Die with dignity ’ is now included in the ‘Right to Life’ under
Article 21 of Indian constitution. [ After SC judgment on 09 March 2018]
 SC GUIDELINES PASSIVE
EUTHANASIA
Aruna Shanbaug case - on 7 Mar 2011, the Supreme Court, in a landmark judgment, issued a set of
broad guidelines legalizing passive euthanasia by means of withdrawal of life support to patients in a
permanent vegetative state.

Guidelines for Passive Euthanasia

(1)A decision to discontinue life support can be taken by :
(i)Parents, (ii) Spouse, (iii) Other close relatives, (iv) Friend
[in case none of earlier 3 available], (v) Doctors attending
the patient.

(2) The decision should be taken bona fide in the best interest of the patient,
(3) Such a decision always requires approval from the High Court
[ Doctrine of parens patriae]

(4) When such an application is filed - the Chief Justice of the High
Court will constitute a Bench of at least two Judges who should
decide to grant approval or not.

(5) A committee of three reputed doctors to be nominated by the

Bench, who will give report regarding the condition of the
patient

(6) Before giving the verdict a notice regarding the report should be
given to the close relatives and the State

(7) After hearing the parties, the High Court can give its verdict.
On 25 February 2014, while hearing a PIL filed by NGO
Common Cause, a three-judge bench of Supreme Court of
India termed the judgment in the Aruna Shanbaug case to be
'inconsistent in itself' and referred the issue of euthanasia to its
five-judge Constitution bench.

Opinion was internally inconsistent because although it held

that euthanasia can be allowed only by an act of the legislature,
it then proceeded to judicially establish euthanasia guidelines.
On 23 December 2014, Government of India endorsed
and re-validated the Passive Euthanasia judgement-law in
a Press Release stating that these guidelines should be
followed and treated as law in such cases.
 PASSIVE EUTHANASIA LEGALISED IN
INDIA
On 9 March 2018, the Supreme Court of India, in a
historic judgment-law made Passive Euthanasia legal
under strict guidelines.

Supreme court in its conclusion mentioned :-

All adults with capacity to consent have the right of self-
determination and autonomy.
A competent person has the right to refuse specific treatment or all
treatment or opt for an alternative treatment, even if such decision
entails a risk of death
Court has expanded the spectrum of Article 21 to include within it the right
to live with dignity as component of right to life and liberty.

The right to live with dignity also includes the smoothening of the process
of dying in case of a terminally ill patient or a person in PVS with no hope
of recovery.

Advance Directives have gained lawful recognition in several other

jurisdictions by way of legislation and in certain countries through judicial
pronouncements.

The sanctity of life has to be kept on the high pedestal yet in cases of
terminally ill persons or PVS patients without hope for revival, priority shall
be given to the Advance Directive and the right of self-determination.
PASSIVE EUTHANASIA LEGALISED
IN INDIA

Patients must consent through a living will, and must be either

terminally ill or in a vegetative state.

Living will - a document prepared by a person in their

healthy/sound state of mind under which they can specify in
advance whether or not they would like to opt for artificial life
support, if he/she is in a vegetative state due to an irreversible
terminal illness in the future.
 ADVANCE MEDICAL
DIRECTIVE
The five-judge Constitution bench of SC prefers term ‘Advance
Medical Directive’ and not ‘living will’.

SC opine that Advance Medical Directive would serve as a fruitful

means to facilitate the fructification of the sacrosanct right to life
with dignity.

It will strengthen the mind of the treating doctors as they will be in a

position to ensure, after being satisfied, that they are acting in a
lawful manner
WHO CAN EXECUTE ADVANCE
DIRECTIVE & HOW
1. Only by an adult of a sound and healthy state of mind and in a
position to communicate, relate and comprehend the purpose and
consequences.

2. Voluntarily executed without any coercion or inducement or

compulsion.

3. Informed consent

4. In writing clearly stating as to when medical treatment may be

withdrawn or no specific medical treatment shall be given.
 WHAT IT SHOULD CONTAIN?
1. Clearly indicate the decision relating to the circumstances in which Rx to be
withheld or withdrawn.
2. Should be in specific terms and absolutely clear and unambiguous
instructions.
3. Executor may revoke the instructions/ authority any time.
4. Disclose that the executor has understood the consequences of executing such
a document.
5. Specify the name of a guardian or close relative who will be authorized to
give consent to refuse or withdraw medical treatment if required.
6. If more than one valid Advance Directive, the most recently signed will be
considered
 HOW SHOULD IT BE RECORDED AND
PRESERVED?
1. Signed by - executor, 2 attesting witnesses, and countersigned by the
jurisdictional Judicial Magistrate of First Class (JMFC) so designated by
the concerned District Judge .

2. The witnesses and the jurisdictional JMFC shall record their satisfaction
that document is executed as required.

3. The JMFC shall preserve one copy in his office & also keep it in digital
format.

4. The JMFC shall forward one copy of document along with digital copy to
the Registry of the jurisdictional District Court for preservation.

5. The JMFC shall cause to inform the immediate

family members of the executor.
6. A copy shall be handed over to the competent officer of the local
Government or the Municipal Corporation or Municipality or
Panchayat. A nominated competent official shall be the custodian
of the document.

7.The JMFC shall cause to handover copy to the family

physician, if any.
 WHEN AND BY WHOM CAN IT BE GIVEN
EFFECT TO?
1. The treating physician ascertains authenticity of advance medical directive
from the jurisdictional JMFC.

2. Treating physician satisfied -> Directive to be implemented.

3. Executor or close relative informed -> opinion taken -> withdrawal or

refusal of medical treatment is the best choice.

4. Preliminary opinion by medical board consisting of HOD of treating dept

& 3 medical experts from the fields of general medicine, cardiology,
neurology, nephrology, psychiatry or oncology.
5.The jurisdictional Collector informed. Medical Board constituted with Chief
District Medical Officer as the Chairman and three expert doctors from the fields
of general medicine, cardiology, neurology, nephrology, psychiatry or oncology
with 20 year overall standing to certify for implementing directives.

6.Medical board ascertains and again confirms the wish of executor or close
relatives.

7.Medical board informs jurisdictional JMFC. He visits patient and after

confirming will authorize implementation of directive.
 WHAT IF PERMISSION IS REFUSED BY
THE MEDICAL BOARD?

Executor or family members or even the treating doctor or the hospital staff can
approach the High Court by way of writ petition under Article 226 of the Constitution.

High court constitute medical board to examine patient and submit report.

High court shall render its decision at the earliest keeping in mind the principles of
"best interests of the patient".
 REVOCATION OR INAPPLICABILITY
OF ADVANCE DIRECTIVE

An individual may withdraw or alter the Advance Directive at

any time when he/she has the capacity to do so and by
following the same procedure as provided for recording of
Advance Directive in writing.

If the advance directive is not clear or ambiguous then medical

board shall not give effect to it and guidelines meant for
patients without advance directive made applicable

When hospital decides not to follow advance directive during

treatment, an application to medical board by jurisdictional
JMFC be made for their direction.
WHEN THERE IS NO ADVANCE
DIRECTIVE
The treating physician may inform hosp.

Hosp makes a medical board which discusses with family members

and minutes are recorded.

Hosp medical board opinion is treated as preliminary opinion.

It is forwarded to jurisdictional JMFC