Having dealt with the right to acceleration of the process of dying a natural death which is arrested with the aid of modern innovative technology as a part of Article 21 of the Constitution, it is necessary to address the issues of right of self-determination and individual autonomy.
IN THE SUPREME COURT OF INDIA
CIVIL ORIGINAL JURISDICTION
WRIT PETITION (CIVIL) NO. 215 OF 2005
Common Cause (A Regd. Society) ...Petitioner(s)
Versus
Union of India and Another …Respondent(s)
J U D G M E N T
Dipak Misra, CJI [for himself and A.M. Khanwilkar, J.]
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L. Right of self-determination and individual autonomy:
161. Having dealt with the
right to acceleration of the process of dying a natural death which is arrested
with the aid of modern innovative technology as a part of Article 21 of the Constitution,
it is necessary to address the issues of right of self-determination and individual
autonomy.
162. John Rawls says that the
liberal concept of autonomy focuses on choice and likewise, self-determination
is understood as exercised through the process of choosing. [Rawls,
John, Political Liberalism 32, 33, New York: Columbia University
Press, 1993.] The respect for an individual human being and
in particular for his right to choose how he should live his own life is individual
autonomy or the right of self- determination. It is the right against
non-interference by others, which gives a competent person who has come of age
the right to make decisions concerning his or her own life and body without any
control or interference of others. Lord Hoffman, in Reeves v. Commissioner
of Police of the Metropolis, [2000] 1 AC 360, 379 has stated:-
"Autonomy means that every individual is
sovereign over himself and cannot be denied the right to certain kinds of
behaviour, even if intended to cause his own death."
163. In the context of health
and medical care decisions, a person's exercise of self-determination and
autonomy involves the exercise of his right to decide whether and to what
extent he/she is willing to submit himself/herself to medical procedures and
treatments, choosing amongst the available alternative treatments or, for that
matter, opting for no treatment at all which, as per his or her own
understanding, is in consonance with his or her own individual aspirations and values.
164. In Airedale (supra), Lord Goff has
expressed that it is established that the principle of self-determination
requires that respect must be given to the wishes of the patient so that if an
adult patient of sound mind refuses, however unreasonably, to consent to
treatment or care by which his/her life would or might be prolonged, the
doctors responsible for his/her care must give effect to his/her wishes, even
though they do not consider it to be in his/her best interests to do so and to
this extent, the principle of sanctity of human life must yield to the
principle of self-determination. Lord Goff further says that the doctor's duty
to act in the best interests of his patient must likewise be qualified with the
patient's right of self determination. Therefore, as far as the United Kingdom
is concerned, it is generally clear that whenever there is a conflict between a
capable adult's exercise of the right of self-determination and the State's
interest in preserving human life by treating it as sanctimonious, the right of
the individual must prevail.
165. In the United States,
the aspect of self-determination and individual autonomy is concretised in law
as all fifty States along with the District of Columbia, the capital, which is commonly
referred as Washington D.C., have passed legislations upholding different forms
of Advance Directives. In the United States, even before the enactment of the
said laws, a terminally ill person was free to assert the right to die as an ancillary
right to the constitutionally protected right to privacy. In In Re Quinlan
(supra), where a 21 year
old girl in chronic PVS was on ventilator support, the Court, while weighing
Quinlan's right to privacy qua the State's interest in preserving human life,
found that as the degree of bodily invasion increases and the prognosis for the
patient's recovery dims, the patient's right to privacy increases and the
State's interest weakens. The Supreme Court of New Jersey finally ruled that
the unwritten constitutional right of privacy was broad enough to encompass a
patient's decision to decline medical treatment in certain circumstances.
Again, in Re Jobes, (1987)
108 N.J. 394 which was also a case concerned with a PVS patient, the Court,
following the decision in In Re Quinlan, upheld the principle of
self determination and autonomy of an incompetent person.
166. The Canadian Criminal
Code asserts and protects the sanctity of life in a number of ways which
directly confront the autonomy of the terminally ill in their medical decision making.
However, the Supreme Court of Canada in Reibl v. Hughes, [1980 2
SCR 880 at 890-891 approved an oft-quoted statement of Cardozo J. in Scholoendorf (supra) that "every
human being of adult years and sound mind has a right to determine what shall
be done with his own body" and Chief Justice Laskin in Reibl (supra) has further added
that battery would lie where surgery or treatment was performed without consent
or where apart from emergency situations, surgery or medical treatment was
given beyond that to which there was consent. Thus, the Supreme Court of Canada
suggested that competent adults have the right to make their own medical
decisions even if such decisions are unwise.
167. In Aruna
Shanbaug (supra), this Court has observed that autonomy means the right to
self-determination where the informed patient has a right to choose the manner
of his treatment. To be autonomous the patient should be competent to make
decisions and choices. In the event that he is incompetent to make choices, his
wishes expressed in advance in the form of a Living Will, or the wishes of
surrogates acting on his behalf ('substituted judgment') are to be respected.
The surrogate is expected to represent what the patient may have decided had he/she
been competent or to act in the patient's best interest. It is expected that a
surrogate acting in the patient's best interest follows a course of action
because it is best for the patient, and is not influenced by personal
convictions, motives or other considerations.
168. Thus, enquiring into
common law and statutory rights of terminally ill persons in other
jurisdictions would indicate that all adults with the capacity to consent have
the common law right to refuse medical treatment and the right of self determination.
169. We may, however, add a
word of caution that doctors would be bound by the choice of self-determination
made by the patient who is terminally ill and undergoing a prolonged medical
treatment or is surviving on life support, subject to being satisfied that the
illness of the patient is incurable and there is no hope of his being cured.
Any other consideration cannot pass off as being in the best interests of the
patient.
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