The document provides an extensive overview of euthanasia, including its definitions, historical context, types, and legal status across various jurisdictions, with a focus on Indian law. It outlines debates surrounding euthanasia's morality, religious perspectives, and the legal framework regarding the right to die and advance directives in India as of 2023. Additionally, it discusses the conditions under which euthanasia and assisted suicide are permissible and the processes involved in decision-making for patients unable to consent.

1. Dr Sumit Kumar
Assistant professor
NEIGRIHMS, Shillong

2. OUTLINES
INTRODUCTION HISTORY RELIGIONS INDIAN LAW
LAW

3. Introduction
• Euthanasia comes from the Greek words: Eu (good) and thanatosis (death)
and it means ”good death”, “gentle and easy death”. This word has come to be
used for “mercy killing”.
• It is the act or practice of ending a life of a person either by a lethal injection
or suspension of medical treatment.
• The word “euthanasia was first used in a medical context by Francis bacon in
the 17 th century, to refer to an easy , painless, happy death, during which it
was a physian’s responsibility to alleviate the “physical suffering ”of the body

10. Type of euthanasia
Active
Passive
Voluntary
involuntary
Assisted
Indirect

11. Active euthanasia
• It is when death is brought by an act for example taking a high dose of
drugs
• To end a person’s life by the use of drugs, either by oneself or by the
aid of a physician.

12. Passive euthanasia
• When death is brought by an omission e.g.:
When someone lets the person die, this can be done by withdrawing or
withholding treatment.
Withdrawal treatment : for example switching off a machine that keeps the person alive
Withholding treatment : for example not carrying out a surgery that will extend life of
the patient for a short time.

13. Voluntary euthanasia
• Is committed with the willing or autonomous cooperation of the subject.
This means that the subject is free from direct or indirect pressure from
others.

14. Non voluntary euthanasia
• Occurs when the patient is unconscious or unable to make a meaningful
choice between living and dying, and an appropriate person takes that
decision for him/her.
• This is usually called murder, but it is possible to imagine cases where the
killing would count as a favor for the patient.

15. Assisted suicide
• This usually refers to cases where the persons who are going to die
need help to kill themselves and ask for it.
• It may be something as simple as getting drugs for the person, and
putting those drugs within their reach.

16. Indirect euthanasia
• This means providing treatments- mainly to reduce pain-that has a
side effect of shortening the patient’s life.
• Since the primary intent wasn’t to kill, it is morally accepted by some
people.

17. History
• It is believed that euthanasia started in ancient Greece and Rome
around the fifth century B.C.
• Some did this by abortions, and every now and then performed a
mercy killing even though doctors were supposed to follow the
• HIPPOCRATIC Oath:
-”I will give no deadly medicine to any one if asked, nor suggest any such counsel”.

18. • Euthanasia was essentially unthinkable in the middle times.
• It was illegal in Europe to bury a suicide victim's body in the streets or to
fastened it to a barrel and let it float downstream.
• The practice of assisted suicide was discussed in the seventeenth and
eighteenth century. Assisted suicide and euthanasia, however, were still
frowned upon.
• In his novel Utopia, written between 1478 and 1535, the Utopian priest
advocates for euthanasia when a patient is terminally sick and in pain. Sir
Thomas More is frequently cited as the first well-known Christian to
advocate for euthanasia.
History

19. History
1828: The first law
against assisted
killing, known as
anti-euthanasia
was passed in
new York.
1870: The use of morphine and
analgesic medications for assisting quick
and painless death was suggested.
1885: The American Medical
Association strongly denied the use of
analgesic for euthanasia.
1994: Netherlands become the 1ª
country where euthanasia has
been allowed.
2001: The euthanasia law was adopted
in Belgium -this law defines conditions
for doctors to avoid penal punishment.
2008: U.S.state of
Washington legalizes
assisted suicide

21. Laws
• In Europe, euthanasia is only legal in Netherlands and Belgium,
provided certain conditions are met.
• For example, the patient's request must be voluntary and well considered;
the patient must be suffering unbearable physical or mental suffering, with
no prospect of relief the patient must be informed about their situation and
prospects, at least one other, independent, doctor must be consulted.
• However, in Netherlands euthanasia is allowed for children aged
between 12 and 16 years of age, with the consent of their
parents/guardians and for individuals aged 16 years and over.

22. Laws
• Assisted suicide is legal in the Netherlands, Switzerland and the
state of Oregon in the US but have certain conditions eg: the patient
must be considered competent and aware of their situation.
• In Japan: Only "passive" euthanasia is permitted for patients who
have been in a Coma for more than 3 months.
• While in Egypt, or in Islamic countries in general, the popular
Egyptian's Scholar Sheikh, recently issued a fatwa. Equating
euthanasia with murder but allowing the with-holding of treatment
that is deemed useless.

23. Religions
• Those in favour of euthanasia argue that a civilized society should
allow people to die in dignity and without pain.
• They add that as suicide is not a crime, euthanasia should not be a
crime.
• Most religions disapproved of euthanasia for number of reasons:
God has forbidden it (that says "You must not kill)
Human life is sacred.
Human beings are made in God's image.
God gives people life, so only God has the right to take it away.

24. Hinduism
• Hinduism holds diverse views on euthanasia: Some see it as a compassionate act to end
suffering, while others believe it disrupts the natural cycle of death and rebirth.
• Euthanasia may transfer the patient's remaining karma to those involved, as it interferes
with the timing of death.
• Death is considered a natural process in Hinduism, with interfering in it having spiritual
consequences.
• Euthanasia isn't inherently sinful, but attachment to worldly desires may taint its
perception. It can even be considered by spiritual seekers as a means to attain liberation
(moksha).
Religious views on euthanasia

25. Religious views on euthanasia
• Buddhism
• An important value of Buddhism teaching is compassion.
Compassion is used by some Buddhists as a justification for
euthanasia because the person suffering is relieved of pain.
• However, it is still immoral "to embark on any course of action
whose aim is to destroy human life, irrespective of the quality of
the individual's motive."

26. Jainism
• In Jainism, the principle of non-violence (ahimsa) is paramount. The
practice of sallekhana, or voluntary death, is recommended for both
ascetics and householders at the end of life. Sallekhana involves
fasting until death, undertaken with full consciousness and without
desire for life or death. It's not considered suicide but a conscious
thinning out of passions and the body. Practitioners must refrain from
recollecting past pleasures or desiring future ones. Though
controversial, with annual estimates of 100 to 240 deaths, preventing
sallekhana may result in social ostracism.
Religious views on euthanasia

27. Religious views on euthanasia
• Islam
Euthanasia is forbidden by Islam. Because human life is a gift from Allah,
who also determines each person's lifespan, we hold that all human life
is precious. Turning off life support for someone who is considered to be
in a chronic vegetative state is allowed, according to IMANA (the Islamic
Medical Association of America). This is because they consider all
mechanical life support procedures as temporary measures.

28. Christianity
Most Christians oppose euthanasia. The arguments typically rest
on the convictions that humans are created in God's image and
that God bestows life. Some religious institutions also stress how
crucial it is to respect death's natural course. Christianity teaches
us to respect all people, believing that life is a gift from God.
Religious views on euthanasia

29. Religious views on euthanasia
• Judaism
Jewish medical ethics have become divided, over euthanasia and end of
life treatment since the 1970s. Generally, Jewish thinkers oppose
voluntary euthanasia, often vigorously passive euthanasia in limited
circumstances.
• Shinto
In Japan, where the dominant religion is Shinto, 69% of the religious
organizations agree with the act of voluntary passive euthanasia. In
Shinto, the prolongation of life using artificial means is a disgraceful act
against life.

30. Euthanasia: Indian law
• Right to Life vs Right to Die
• Article 21 guarantees Right to Life and Personal Liberty. ~
• Right to Life means Right to Live with Dignity and not mere
physical existence.-
Maneka Gandhi v. Union of India
• But do we have Right to Die as a Fundamental Right???????

31. • State of Maharashtra v. Maruti Sripati Dubal-
• Bombay High Court held that the right to life guaranteed under Article
21 includes right to die,
• Section 309 IPC- punishment for attempt to commit suicide by a
person was held unconstitutional.
• In P Rathinam v. Union of India Division Bench of the Supreme
Court upheld Maruti Sripati Dubal
• held that right to life, Article 21 also include right to die and laid down
that section 309 of Indian Penal Court which deals with ' attempt to
commit suicide is a penal offence' unconstitutional.
Euthanasia: Indian law

32. • This issue again raised before the court in Gian Kaur v. State of
Punjab.
• Five judge Constitutional Bench of the Supreme Court overruled
the P. Ratinam’s case.
• It was held that Right to Life under Article 21 does not include Right to
die or Right to be killed
• Also, there is no ground to hold that the section 309, IPC is
constitutionally invalid.
Euthanasia: Indian law

33. • Legal Position of Active Euthanasia-
• Punishable under IPC Section 304
• Falls under Definition of Culpable Homicide Not Amounting to
Murder.
Euthanasia: Indian law

35. • Aruna Ramchandra Shanbaug
• The euthanasia was declined because of two reasons
1.KEM hospital (legal guardians refused for euthanasia)
2.Aruna did not qualified for brain death (but in persistent
vegetative state)

38. Common Cause vs UOl 2018
1.The right to die with dignity as fundamental right
2.An adult human being having mental capacity to take an informed
decision has right to refuse medical treatment including withdrawal
from life saving devices
3. A person of competent mental faculty is entitled to execute an
advance medical directive in accordance with safeguards.
• The right to execute an advance medical directive is nothing but a
step towards protection of the right to body integrity and self-
determination
Euthanasia: Indian law(2018)

39. 4.The 'living will' to be a legally valid document, it must be a written
document signed by two witnesses and a Judicial Magistrate
5.No one is permitted to cause death of another person including a
physician by administering any lethal drug even the objective is to
relieve the patient from pain and suffering.
6. In cases of incompetent patients who are unable to take an
informed decision, "the best interests principle" be applied and such
decision be taken by specified competent medical experts and be
implemented after providing a cooling period to enable aggrieved
person to approach the court of law
Euthanasia: Indian law(2018)

40. Advance Directive in Euthanasia (2018)
• Adult with intact Mental Capacity
• Voluntarily to be in written
• Stating as to when medical treatment may be withdrawn or no
specific medical treatment shall be given
• Only have the effect of delaying the process of death
• He may undergo anguish and suffering and further put him/her
in state of indignity

41. • Specific terms and the instructions must be absolutely clear and
unambiguous
• A nominated representative / quardian
• A guardian will take decision only during the loss of capacity
• More than one AD, last will be considered valid
• Two witness and a jurisdictional
Judicial Magistrate of First Class need to sign
JMFC and Registry of the jurisdictional
District Court will preserve the hard and soft copy
• The JMFC shall cause to inform the immediate family members of
the executor
Advance Directive in Euthanasia (2018)

42. Advance Directive in action(2018)
• Physician is made aware
• Physician ascertains the terminal illness and patient has lost his
capacity to consent
• Physician contacts the JMFC for authenticity
• Physician will take written consent from the NR to execute the
AD in process
• A four member medical board will be setup in the treating
hospital
• • Head of the department or institute will chief of the board

43. Advance Directive in action(2018)
• If rejected the process halts
• If accepted, then the treating physician will contact the
jurisdictional collector with the board report, advance directives
& medical records
• The Jurisdictional Collector will setup a four member medical
board with Chief district medical officer (chair) and three more
members - 20 years of experience in Cardiology, Neurology,
Psychiatry, Gene Medicine, Nephrology and Oncology

44. Advance Directive in action(2018)
• Board members will examine the patient jointly
• They will submit their report in writing accepting or rejecting the
euthanasia
• The chief of the board will submit the report to Collector and
also to jurisdictional JMFC
• If the Euthanasia is upheld, JMFC will visit the patient and
examine
JMFC will authorize to conduct passive euthanasia

45. • High Court Decision
• High Court shall render its decision at the earliest y keeping in
mind the princioles of "best interests of the patient" in writing
either revocation nor inapplicability of Advance Directive
Advance Directive in action(2018)

46. No Advance Directive(2018)
• If there is No Advance Directive written
• Physician will ascertain the terminal illness and patient is not in position
to give consent (loss of mental capacity)
• Physician will inform the hospital chief
• A four member medical board will be formed similar to earlier
• The medical board will discuss with family of the patient/guardian

47. No Advance Directive (2018)
• If the family members consent
• Patient will be examined in front of them and a preliminary
opinion will be given
• If euthanasia is 'reiected' process halts
• If euthanasia is 'accepted', the treating physician will inform the
DC
• DC will form a four member medical board
• Medical board will examine and submit the report
• That report will be forwarded to JMFC

48. No Advance Directive(2018)
• If euthanasia rejected process stops
• If accepted - JMFC will visit the patient and examine
• He will issue the order of passive euthanasia In case of
conflicting medical report, family members or doctor can
approach the High Court under Sec 226
• The High Court can form a three member medical board for
independent opinion Based on the report and case, High court
will issue the order

49. New (2023)
• Common Cause (A Regd. Society) VS UOl 2023 (Jan 24)
• Applicant - Indian Society of Critical Care Medicine
• Asking clarification on the 2018 judgement

50. Advance Medical Directive :2023
• Adult with intact Mental Capacity
• Voluntarily
• To be in written format
• Stating as to when medical treatment may be withdrawn or no
specific medical treatment shall be given
• Only have the effect of delaying the process of death
• He may undergo anguish and suffering and further put him/her
in a state of indignity

51. Advance Medical Directive: 2023
• Specific terms and the instructions must be absolutely clear and
unambiguous
• A nominated representative (s) / guardian (s)
• A guardian will take decision only during the loss of capacity
incapable of taking decision)
• More than one AD, latest executed will be considered valid

52. Advance Medical Directive:2023
• Signed in front of two witness (independent)
• Attested before notary or gazetted officer
• Attesting authority will check for coercion and attestor signed
with full understanding of all the relevant information and
consequences

53. Advance Medical Directive: 2023
• • The executor may also choose to incorporate their advance
directive as a part of the digital health records, if any
• A copy of the AD shall be handed over to the competent officer
of the local Government or the Municipal Corporation or
Municipality or Panchayat

54. Advance Medical Directive:2023
• A copy shall be handed over to the family physician
• AD becomes active once the executor becomes mental
incapacity and terminally ill
• NR / guardian will inform the treating physician about the AD

55. Advance Directive in action:2023
• Physician is made aware of AD
• Physician ascertains the terminal illness and patient has lost his
capacity to consent
• Physician contacts the members mentioned in AD
• Discusses about the pro & cons of implementing AD
• Physician will take written consent from the
NR to or not to execute the AD

56. Advance Directive in action:2023
• If the NR gives consent to execute in writing process is set in
motion
• A three member medical board (including the treating physician
and two subject matter expert) will be setup in the treating
hospital
• Experts will be at least - 5 years of experience
• This will be called Primary Medical Board

57. Advance Directive in action:2023
• Board members will examine the patient in presences of family
members / guardian
• They will submit their 'preliminary opinion' in writing accepting or
rejecting the executing AD within 48hrs
• If the preliminary opinion is for Implementing AD (withdrawing of
treatment), Secondary Medical Board will be formed

58. Advance Directive in action:2023
• The secondary board will comprise of
• Three members - One RMP nominated by the Chief medical
officer of the district (chair) and two more subject matter of
expert - 5 years of experience
• Above members should not be part of the preliminary board
member

59. Advance Directive in action:2023
• Secondary board members will examine the patient jointly
• Check for the executors
• mental capacity make decision
• terminally ill (no hope for recovery)
• Discuss with NR under the AD about pros & cons of executing
AD
• Take written consent from the NR

60. Advance Directive in action:2023
• They will submit their report in writing in accepting or rejecting
the executing AD within 48hrs
• This opinion will be called as - Secondary opinion
• Primary opinion, secondary opinion, advance directive and
consent of the NR will be intimated to the JMFC before
executing the withdrawal of treatment

61. • If there is conflicting report
• Legal guardian / doctor / family member / executor /N can
approach the High Court under Sec 226 of the Constitution
The Chief Justice will constitute a division bench
• The bench will form a one more independent medical board of
three doctors - 20 years of experience in Cardiology, Neurology,
Psychiatry, General Medicine, Nephrology and Oncology

62. No Advance Directive:2023
• If there is No Advance Directive written
• Physician treating the patient will ascertain the terminal illness,
undergoing prolonged treatment in respect of ailment which is
• He will request to form a primary medical board
• Patient can refuse treatment

63. No Advance Directive:2023
• If the patient does not have mental capacity to take decision
• The primary medical board will discuss with family of the
patient/guardian and document their opinion
• Primary medical board will examine the patient and will submit
the opinion

64. No Advance Directive:2023
• Hospital will refer the case to secondary medical board
• Secondary medical board will examine and submit the report
within 48hrs
• That report will be forwarded to JMFC and also to family
members
• Then the withdrawal of the life support will be done

65. Advance Directive:2023 (specific)
• Draft advance directive
• Signature of two witness
• Notary certification (Affidavit)
• Give copies to concerned NR
• Family members & Family Physician
• Give copy to designated authorities
• It can also be part of the Digital Health Card

66. • Persistent Vegetative State
• AD present (will of the patient)
• AD Absent
• Discussion with the NR
• NR consent
• Primary Medical Board
• Secondary Medical Board
• Any discrepancies
• Intimation to JMFC
• Approach High Court Art

67. Positive points
• Right to life means Right to live with dignity and Right to die with
dignity Up to the end of natural life
• No active intervention for death allowed ( no active euthanasia)
• Right to autonomy means Right to self determination through giving
an option of drafting a Advance directive. 'Will' or 'Choice of the
patient will be honoured, even when the patient is terminally ill and
lost his capacity to consent.
• This can be achieved by AD
• • Adequate (excessive) checks and balances have been placed at
multiple places in the form of
• Two medical boards &
• Intimation to JMFC

68. Positive points
• Registration of AD with JMFC removed
• No ambiguity
• Appeal to High Court present
• Euthanasia for those, who have not executed AD is also clearly
articulated

69. Negative Points
• Process for euthanasia continuous to be lengthy
• Two medical boards (3+3) more than 5 years of experience
• High Court can form one more board (20 years of experience)
• Too many boards and lengthy procedures

71. This Photo by Unknown Author is licensed under CC BY-SA