Supreme Court Directs Implementation of Guidelines to Prevent Unnecessary Hysterectomies: Dr. Narendra Gupta vs. Union of India (2023)

Date of the Judgment: April 5, 2023
Citation: 2023 INSC 3222
Judges: Dr. Dhananjaya Y Chandrachud, CJI and J B Pardiwala, J.
Can unnecessary medical procedures, particularly those affecting women’s reproductive health, be justified under the guise of healthcare schemes? The Supreme Court of India, in a significant judgment, addressed this critical question by highlighting the issue of unnecessary hysterectomies performed on women, particularly those from marginalized communities, under government healthcare schemes. The Court’s intervention underscores the importance of protecting women’s health rights and ensuring ethical medical practices. The bench comprised of Chief Justice of India Dr. Dhananjaya Y Chandrachud and Justice J B Pardiwala. The judgment was authored by Chief Justice of India Dr. Dhananjaya Y Chandrachud.

Case Background

In 2013, Dr. Narendra Gupta filed a Public Interest Litigation (PIL) highlighting the alarming trend of “unnecessary hysterectomies” being performed in the states of Bihar, Chhattisgarh, and Rajasthan, particularly under the Rashtriya Swasthya Bima Yojana and other government healthcare schemes. The petitioner’s fieldwork revealed that many women, especially those from Scheduled Castes, Scheduled Tribes, and Other Backward Communities, were subjected to these procedures when alternative treatments were available. The PIL also pointed out the involvement of private hospitals in performing these unnecessary surgeries. The petitioner sought the intervention of the Supreme Court to address this violation of women’s health rights.

Timeline

Legal Framework

The Supreme Court recognized that the right to health is an intrinsic part of the right to life under Article 21 of the Constitution of India. The Court noted that life, to be enjoyed in all its diverse elements, must be based on robust conditions of health. The Court observed that there had been a serious violation of the fundamental rights of the women who underwent unnecessary hysterectomies.

Arguments

The petitioner, Dr. Narendra Gupta, through his counsel Ms. Kawalpreet Kaur, argued that unnecessary hysterectomies were being performed, particularly on women from marginalized communities, under government healthcare schemes. The petitioner highlighted the lack of proper medical evaluation and informed consent for these procedures. Two specific submissions were made to supplement the existing guidelines:

• Submission 1: The petitioner suggested that under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, where a hysterectomy is performed on a woman below the age of forty years, the requirement of the procedure has to be certified by at least two doctors. The suggestion is that this requirement should be extended to other cases as well, irrespective of the age of the woman undergoing a hysterectomy.
• Submission 2: The petitioner urged that the state should take steps for blacklisting hospitals where hysterectomies were carried out without medical necessity and without obtaining the informed consent of the patient. It was further argued that non-invasive methods should be adopted as a first line of treatment, and the woman undergoing the procedure should be properly informed about the reasons and likely consequences of the hysterectomy.

The respondents, represented by Additional Solicitor General Ms. Aishwarya Bhati, acknowledged the seriousness of the issue. The Union of India submitted that it had already issued the “Guidelines to Prevent Unnecessary Hysterectomies” in 2022 and was in the process of forming monitoring committees at the national, state, and district levels. The Additional Solicitor General responded to the petitioner’s submissions as follows:

• Response to Submission 1: The Additional Solicitor General submitted that once the full data on hysterectomies is duly captured on the portal of MoHFW and the National, State, and District Level Committees are constituted, a considered decision will be taken by the Union of India on this aspect. It was also submitted that while certain States already have such a procedure in place, the network of government hospitals may not be adequate enough to implement such a regulation across India even if it were made. Moreover, it was urged that there is a real danger that this may result in the denial of treatment to women who are genuinely in the need of it. It was submitted that since the situation is evolving, the Union of India would take a considered view once adequate data is available.
• Response to Submission 2: The Additional Solicitor General agreed that stringent action should be taken for blacklisting hospitals once it is detected that any unnecessary hysterectomy was carried out or that the procedure was taken recourse to without the informed consent of the patient.

Submissions Table

Issues Framed by the Supreme Court

The Supreme Court did not frame specific issues in this case. However, the Court’s focus was on the implementation of the “Guidelines to Prevent Unnecessary Hysterectomies” and addressing the concerns raised by the petitioner.

Treatment of the Issue by the Court

Authorities

The Supreme Court did not explicitly cite any specific cases or books in this judgment. However, the Court did refer to the following:

• Article 21 of the Constitution of India: The Court recognized that the right to health is an intrinsic element of the right to life under Article 21 of the Constitution.
• “Guidelines to Prevent Unnecessary Hysterectomies” (2022): The Court directed the implementation of these guidelines issued by the Ministry of Health and Family Welfare (MoHFW).
• Ayushman Bharat Pradhan Mantri Jan Arogya Yojana: The Court noted the scheme’s coverage of hysterectomy procedures and the need for proper regulation.

Judgment

Authorities:

• Article 21 of the Constitution of India: The Court relied on this provision to emphasize the fundamental right to health.
• “Guidelines to Prevent Unnecessary Hysterectomies” (2022): The Court directed the implementation of these guidelines, emphasizing their importance in preventing unnecessary procedures.
• Ayushman Bharat Pradhan Mantri Jan Arogya Yojana: The Court acknowledged the scheme’s role in healthcare access but stressed the need for regulation to prevent abuse.

What weighed in the mind of the Court?

The Supreme Court’s decision was primarily driven by the need to protect the health rights of women, particularly those from marginalized communities, who were being subjected to unnecessary hysterectomies. The Court emphasized the importance of informed consent, ethical medical practices, and the implementation of guidelines to prevent such abuses. The Court also considered the practical challenges in implementing stricter regulations across the country. The Court’s sentiment was strongly in favor of ensuring women’s health rights and preventing exploitation within healthcare schemes.

Fact:Law Ratio

The Court’s reasoning was influenced by the factual evidence of unnecessary hysterectomies being performed, which was balanced with the legal framework of the right to health under Article 21.

Logical Reasoning

Judgment

The Supreme Court, after considering the submissions and the status report filed by the Union Government, disposed of the petition with the following directions:

• All States and Union Territories shall adopt the “Guidelines to Prevent Unnecessary Hysterectomies” within three months and report compliance to MoHFW.
• All States and Union Territories shall implement the Guidelines without delay and report compliance to MoHFW.
• All States and Union Territories shall ensure that all public and private hospitals within their territories are made aware of the existence and importance of the Guidelines.
• The States and Union Territories must take stringent action for blacklisting hospitals once it is detected that any unnecessary hysterectomy was carried out or that the procedure was taken recourse to without the informed consent of the patient.

The Court observed, “The right to health is an intrinsic element of the right to life under Article 21 of the Constitution. Life, to be enjoyed in all its diverse elements, must be based on robust conditions of health.”

The Court also noted, “There has been a serious violation of the fundamental rights of the women who underwent unnecessary hysterectomies.”

Regarding the suggestion of certification by two doctors, the Court stated, “We accept the submission,” but deferred its implementation, noting that, “the Union of India would take a considered view once adequate data is available.”

The Court’s decision emphasizes the need for a balanced approach, ensuring that while regulations are in place to prevent unnecessary procedures, genuine medical needs are not overlooked. The judgment also underscores the importance of informed consent and ethical medical practices.

Key Takeaways

• Immediate Implementation: All States and Union Territories must immediately adopt and implement the “Guidelines to Prevent Unnecessary Hysterectomies”.
• Awareness and Training: Public and private hospitals must be made aware of the guidelines and their importance.
• Stringent Action: Hospitals performing unnecessary hysterectomies without informed consent will face blacklisting.
• Data-Driven Decisions: The Union of India will make future decisions based on data collected through the monitoring committees.
• Protection of Women’s Rights: The judgment reinforces the importance of protecting women’s health rights and ensuring ethical medical practices.

Directions

The Supreme Court gave the following directions:

• All States and Union Territories must adopt the “Guidelines to Prevent Unnecessary Hysterectomies” within three months and report compliance to MoHFW.
• All States and Union Territories must implement the Guidelines without delay and report compliance to MoHFW.
• All States and Union Territories must ensure that all public and private hospitals within their territories are made aware of the existence and importance of the Guidelines.
• The States and Union Territories must take stringent action for blacklisting hospitals once it is detected that any unnecessary hysterectomy was carried out or that the procedure was taken recourse to without the informed consent of the patient.

Specific Amendments Analysis

There were no specific amendments discussed in this judgment.

Development of Law

The ratio decidendi of this case is that the right to health, as enshrined in Article 21 of the Constitution, includes the right to be free from unnecessary medical procedures. The Supreme Court emphasized the need for informed consent and ethical medical practices, particularly in the context of government healthcare schemes. This judgment reinforces the State’s obligation to protect women’s health rights and prevent exploitation within the healthcare system.

Conclusion

The Supreme Court’s judgment in Dr. Narendra Gupta vs. Union of India & Ors. is a significant step towards protecting women’s health rights and ensuring ethical medical practices. By directing the implementation of the “Guidelines to Prevent Unnecessary Hysterectomies,” the Court has taken a proactive stance against the exploitation of women under government healthcare schemes. The judgment underscores the importance of informed consent, proper medical evaluation, and stringent action against unethical practices. This ruling will likely have a positive impact on healthcare practices and the protection of women’s health in India.