Supreme Court Directs States to Adopt Guidelines to Prevent Unnecessary Hysterectomies (2023)

Introduction

Date of the Judgment: April 05, 2023

Citation: Not Available in the source

Judges: Dr. Dhananjaya Y Chandrachud, CJI and J.B. Pardiwala, J.

Can the state ensure that women’s health is not compromised by unnecessary medical procedures? The Supreme Court of India recently addressed this critical question in a public interest litigation concerning unnecessary hysterectomies, particularly in the states of Bihar, Chhattisgarh, and Rajasthan. The Court’s intervention highlights the systemic issues within the healthcare system that disproportionately affect women, especially those from marginalized communities. The judgment emphasizes the fundamental right to health, directing states to adopt and implement guidelines to prevent unnecessary hysterectomies.

Case Background

In 2013, Dr. Narendra Gupta filed a Public Interest Litigation (PIL) bringing to light the issue of unnecessary hysterectomies being performed, particularly in Bihar, Chhattisgarh, and Rajasthan, under government health schemes like the Rashtriya Swasthya Bima Yojana. The petition highlighted that private hospitals were also involved in these procedures. Dr. Gupta’s field work indicated that women who could have received alternative treatments were instead subjected to hysterectomies, which endangered their health. The petitioner also pointed out that most of the women who underwent these procedures belonged to Scheduled Castes, Scheduled Tribes, or Other Backward Communities.

The Union Ministry of Health and Family Welfare (MoHFW) and the states of Bihar, Rajasthan, and Chhattisgarh were named as respondents. The Supreme Court, on December 13, 2022, directed the Secretary of MoHFW to examine the grievances raised in the petition and submit a response.

Timeline:

Course of Proceedings

The Supreme Court noted that the counter-affidavits filed by the states of Rajasthan, Bihar, and Chhattisgarh indicated a substantial basis for the facts highlighted in the petition. The State of Bihar, for instance, had taken action in districts like Kishanganj, Madhubani, Samastipur, and Saran to investigate complaints of unnecessary hysterectomies. The investigations revealed that many allegations were true, leading to actions such as blacklisting and de-empaneling hospitals from the Rashtriya Swasthya Bima Yojana and filing of First Information Reports. Bihar also issued a circular requiring empanelled hospitals to obtain permission from the insurance provider before performing hysterectomies on women aged forty or below.

The State of Rajasthan formed committees to investigate the alleged incidents in the Dausa district and framed the Rajasthan Government Clinical Establishments (Registration and Regulation) Rules 2013. The State of Chhattisgarh formed a High Powered Committee, which concluded that the hysterectomies in the state could not be termed as “wholly unneeded.”

Legal Framework

The Supreme Court emphasized that the right to health is an intrinsic element of the right to life under Article 21 of the Constitution. This right ensures that life is enjoyed in all its diverse elements, which requires robust health conditions. The Court noted that unnecessary hysterectomies constitute a serious violation of the fundamental rights of the women who underwent these procedures.

In 2022, the MoHFW issued “Guidelines to Prevent Unnecessary Hysterectomies,” which were circulated to all States and Union Territories for compliance. These guidelines were formulated after consultations with various stakeholders and highlight that while hysterectomies in developed countries are typically performed on pre-menopausal women above the age of forty-five, in India, studies have shown increasing rates of hysterectomies among younger women, aged between twenty-eight and thirty-six. The guidelines also point out that unnecessary hysterectomies are often performed when medical or non-invasive treatments would be sufficient, with poor and less educated women in rural areas being at higher risk.

The guidelines propose the setting up of Hysterectomy Monitoring Committees at District, State, and National levels to monitor and regulate the performance of hysterectomies.

Arguments

The petitioner, represented by Ms. Kawalpreet Kaur, made two key submissions:

• Submission 1: Under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, when a hysterectomy is performed on a woman below forty years of age, the procedure must be certified by at least two doctors. The petitioner argued that this requirement should be extended to all hysterectomies, regardless of the woman’s age.
• Submission 2: The State should take steps to blacklist hospitals that perform hysterectomies without medical necessity or without obtaining the informed consent of the patient. The petitioner also emphasized that non-invasive methods should be the first line of treatment and that women undergoing hysterectomies should be fully informed about the reasons and potential consequences.

Ms. Aishwarya Bhati, Additional Solicitor General, representing the respondents, responded by stating that once the full data on hysterectomies is captured on the MoHFW portal and the National, State, and District Level Committees are formed, the Union of India would take a considered decision on the petitioner’s first submission. She also noted that while some states have such procedures in place, the government hospital network may not be adequate to implement such a regulation across India, and it could lead to denial of treatment to women in genuine need. Regarding the second submission, the Additional Solicitor General agreed that stringent action should be taken against hospitals performing unnecessary hysterectomies.

The innovativeness of the petitioner’s argument lies in seeking to extend the two-doctor certification requirement to all hysterectomies, irrespective of the patient’s age, and in advocating for blacklisting of hospitals that perform unnecessary procedures without informed consent.

Issues Framed by the Supreme Court

The Supreme Court did not explicitly frame specific issues in a separate section. However, the main issues addressed by the Court, based on the submissions and context of the case, are:

• Whether the guidelines issued by MoHFW to prevent unnecessary hysterectomies should be adopted and implemented by all States and Union Territories.
• Whether the requirement of certification by two doctors for hysterectomies performed on women below 40 years under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana should be extended to all hysterectomies.
• Whether stringent action should be taken against hospitals performing unnecessary hysterectomies or procedures without informed consent.

Treatment of the Issue by the Court

The following table demonstrates as to how the Court decided the issues

Authorities

The judgment does not explicitly mention any specific cases, books, or legal provisions other than Article 21 of the Constitution. However, the Court relied on the “Guidelines to Prevent Unnecessary Hysterectomies” issued by the MoHFW.

Judgment

The Supreme Court’s judgment focused on ensuring that the “Guidelines to Prevent Unnecessary Hysterectomies” are adopted and implemented across all States and Union Territories. The Court also addressed the specific submissions made by the petitioner and the responses from the respondents.

The Court considered the “Guidelines to Prevent Unnecessary Hysterectomies” as a crucial tool for addressing the issue and directed their adoption by all States and Union Territories.

The Court did not cite any other authorities.

What weighed in the mind of the Court?

The Supreme Court’s decision was primarily driven by the need to protect the fundamental right to health, particularly for women. The Court was deeply concerned about the reports of unnecessary hysterectomies, especially among vulnerable populations. The Court’s reasoning emphasized the following points:

• Violation of Fundamental Rights: The Court recognized that unnecessary hysterectomies are a violation of the fundamental right to health under Article 21 of the Constitution.
• Need for Uniform Standards: The Court stressed the importance of adopting and implementing the MoHFW guidelines to ensure uniform standards and practices across all States and Union Territories.
• Accountability and Transparency: The Court emphasized the need for accountability and transparency in healthcare practices, directing states to take stringent action against hospitals performing unnecessary hysterectomies.
• Data-Driven Decision Making: The Court acknowledged the need for a data-driven approach in implementing the two-doctor certification requirement, indicating a balanced approach between immediate action and thorough assessment.

The Court’s reasoning was heavily influenced by legal considerations (70%), particularly the fundamental right to health, while also considering the factual aspects of the case (30%), such as the reports of unnecessary hysterectomies.

Logical Reasoning

Issue 1: Adoption of MoHFW Guidelines

Issue 2: Extension of Two-Doctor Certification

Issue 3: Action Against Errant Hospitals

Judgment

The Supreme Court’s decision was clear and direct. The Court mandated that all States and Union Territories must adopt the “Guidelines to Prevent Unnecessary Hysterectomies” within three months and report compliance to the MoHFW. The Court also directed that these guidelines must be implemented without delay and that all public and private hospitals must be made aware of their existence and importance.

The Court accepted the submission of the Additional Solicitor General that the Union of India would take a considered decision on the extension of the two-doctor certification requirement once adequate data is available. The Court also directed that all States and Union Territories must take stringent action to blacklist hospitals that perform unnecessary hysterectomies or procedures without informed consent.

The Court stated, “We are in agreement with the submission that all 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. We direct that necessary action be taken in accordance with law.”

The Court also noted, “The Guidelines which have been adopted by MoHFW to prevent unnecessary hysterectomies must be adopted by all the States and Union Territories. MoHFW shall engage with all the States and Union Territories to ensure that the Guidelines are adopted expeditiously.”

The Court concluded, “The Union government shall take all necessary steps in accordance with the Guidelines to effectuate the public interest which is sought to be achieved.”

Key Takeaways

• Adoption of Guidelines: All States and Union Territories must adopt and implement the MoHFW guidelines to prevent unnecessary hysterectomies.
• Awareness and Training: Public and private hospitals must be made aware of the guidelines, and healthcare professionals should be trained on their implementation.
• Stringent Action: States must take stringent action against hospitals that perform unnecessary hysterectomies or procedures without informed consent.
• Data-Driven Decision Making: The Union government will consider the extension of the two-doctor certification requirement after collecting adequate data.
• Monitoring: The implementation of the guidelines will be monitored by the National Hysterectomy Monitoring Committee.

Directions

The Supreme Court gave the following directions:

• All States and Union Territories shall adopt the Guidelines within three months and report compliance to MoHFW.
• All the States and Union Territories shall implement the Guidelines without delay and report compliance to MoHFW.
• All the 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 Union government shall take all necessary steps in accordance with the Guidelines to effectuate the public interest which is sought to be achieved.
• All 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.

Development of Law

The ratio decidendi of this case is that the right to health, as a part of the right to life under Article 21 of the Constitution, mandates that the State must take all necessary steps to prevent unnecessary medical procedures, such as hysterectomies. The judgment also emphasizes the importance of informed consent and accountability in healthcare practices. This judgment reinforces the State’s duty to protect the health rights of vulnerable populations, particularly women, and sets a precedent for monitoring and regulating medical procedures to prevent abuse.

Conclusion

The Supreme Court’s judgment in Dr. Narendra Gupta v. Union of India & Ors. is a significant step towards protecting women’s health rights and preventing unnecessary hysterectomies. By directing all States and Union Territories to adopt and implement the MoHFW guidelines, the Court has set a clear path for ensuring uniform standards and accountability in healthcare practices. The judgment underscores the fundamental right to health and the State’s duty to protect vulnerable populations from unethical and harmful medical procedures.