Supreme Court Modifies Advance Medical Directive Guidelines: Common Cause vs. Union of India (24 January 2023)

Date of the Judgment: 24 January 2023

Citation: 2023 INSC 77

Judges: K.M. Joseph, J., Ajay Rastogi, J., Aniruddha Bose, J., Hrishikesh Roy, J., C.T. Ravikumar, J.

What happens when a person’s previously made decisions about their medical treatment become practically impossible to implement? The Supreme Court of India addressed this issue in a recent application seeking clarification of its 2018 judgment on Advance Medical Directives. This case revisits the guidelines for “living wills,” aiming to make the process more workable while upholding an individual’s right to die with dignity. The bench comprised Justices K.M. Joseph, Ajay Rastogi, Aniruddha Bose, Hrishikesh Roy, and C.T. Ravikumar.

Case Background

The Indian Society of Critical Care Medicine filed an application seeking clarification of the Supreme Court’s 2018 judgment in *Common Cause (A Registered Society) v. Union of India and Another* [(2018) 5 SCC 1]. The 2018 judgment laid down guidelines for Advance Medical Directives, also known as living wills, which allow individuals to specify their wishes regarding medical treatment in the event they become incapable of making decisions. However, the implementation of these guidelines faced practical difficulties.

The applicant argued that certain requirements, particularly the need for a Judicial Magistrate of First Class (JMFC) to countersign the Advance Directive, created significant obstacles, hindering the very purpose of the directives. The Union of India initially opposed the application but later engaged in discussions to address these issues.

Timeline:

Course of Proceedings

The matter was initially heard by a three-judge bench, which then referred it to a Constitution Bench. This was due to the complex nature of the issues involved, particularly concerning the right to die with dignity and the implementation of Advance Medical Directives. The applicant, the Indian Society of Critical Care Medicine, highlighted the practical difficulties faced in implementing the 2018 guidelines. The Union of India initially opposed the application, but later participated in discussions to find solutions.

Legal Framework

The core of this case revolves around the interpretation and implementation of the guidelines for Advance Medical Directives established by the Supreme Court in its 2018 judgment. The court’s directions were aimed at giving effect to the right to life with dignity, which includes the right to refuse medical treatment in certain circumstances. The court had laid down detailed procedures for executing, recording, and implementing Advance Directives.

Arguments

The applicant, the Indian Society of Critical Care Medicine, argued that the requirement for a Judicial Magistrate of First Class (JMFC) to countersign the Advance Directive was impractical and created significant hurdles. They submitted that this requirement defeated the purpose of the directives, as it was difficult for individuals to access JMFCs, causing delays and distress. The applicant also highlighted other practical issues in the implementation of the guidelines.

The Union of India initially opposed the application, but later acknowledged the practical difficulties and engaged in discussions to find solutions. They eventually agreed to certain modifications to the guidelines to make them more workable.

The arguments of the applicant can be categorized as follows:

• Impracticality of JMFC Involvement: The requirement for a JMFC to countersign the Advance Directive was causing significant delays and difficulties in the implementation of the directive.
• Need for Simplified Process: The process for executing and implementing Advance Directives needed to be simplified to make it more accessible and effective.
• Practical Difficulties: Various practical difficulties were being encountered in the implementation of the guidelines, which needed to be addressed.

The arguments of the Union of India can be categorized as follows:

• Initial Opposition: Initially, the Union of India opposed the application for clarification.
• Acknowledgement of Difficulties: Later, the Union acknowledged the practical difficulties in implementing the guidelines.
• Agreement to Modifications: The Union agreed to certain modifications to the guidelines to make them more workable.

Issues Framed by the Supreme Court

The primary issue before the Supreme Court was whether the directions contained in paragraphs 198 to 199 of the 2018 judgment required modification to address the practical difficulties faced in their implementation. The court also considered specific aspects of the guidelines that needed clarification or modification.

Treatment of the Issue by the Court

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

Authorities

The Supreme Court primarily relied on its own previous judgment in *Common Cause (A Registered Society) v. Union of India and Another* [(2018) 5 SCC 1], which established the guidelines for Advance Medical Directives. The court also considered the practical difficulties highlighted by the applicant and the subsequent discussions with the Union of India.

Judgment

The Supreme Court modified the guidelines for Advance Medical Directives to address the practical difficulties in their implementation. The key modifications include:

What weighed in the mind of the Court?

The Supreme Court’s decision to modify the guidelines was primarily driven by the need to make Advance Medical Directives more accessible and effective. The court recognized that the original guidelines, while well-intentioned, had created practical hurdles that hindered their implementation. The court was also influenced by the need to uphold an individual’s right to die with dignity, which is a fundamental aspect of the right to life under Article 21 of the Constitution of India. The court also considered the discussions and agreed modifications with the Union of India.

The court’s reasoning was based on a combination of factual considerations (the practical difficulties in implementation) and legal principles (the right to die with dignity). The court’s decision was primarily driven by legal considerations, specifically the need to ensure that the guidelines for Advance Medical Directives are workable and effective in protecting an individual’s autonomy.

Logical Reasoning

Key Takeaways

• Simplified Attestation: The requirement for a Judicial Magistrate of First Class (JMFC) to countersign the Advance Directive has been replaced with attestation by a notary or Gazetted Officer.
• Streamlined Recording Process: The procedure for recording and preserving Advance Directives has been simplified. The JMFC is no longer required to preserve copies; instead, a copy is to be given to a competent local government officer and the executor’s family physician.
• Modified Medical Boards: The constitution of the Medical Board has been modified to include a Primary Medical Board and a Secondary Medical Board for better evaluation of cases.
• Focus on Accessibility: The modifications aim to make the process of executing and implementing Advance Medical Directives more accessible and less cumbersome.
• Upholding Dignity: The court’s decision reinforces the importance of upholding an individual’s right to die with dignity.

Directions

The Supreme Court directed the Registry to communicate a copy of this order to the Registrar Generals of all High Courts. The Registrar Generals of the High Courts were directed to dispatch a copy of this order to the Health Secretaries in the respective States/Union Territories for onward communication to all the Chief Medical Officers in the States/Union Territories.

Development of Law

The ratio decidendi of this case is that the guidelines for Advance Medical Directives, as laid down in the 2018 judgment, needed to be modified to address practical difficulties and make the process more accessible and effective. This case clarifies the process for executing, recording, and implementing Advance Medical Directives. It also reinforces the importance of upholding an individual’s right to die with dignity. The changes made in this judgment are a significant step towards ensuring that the directives are workable and can effectively protect an individual’s autonomy.

Conclusion

The Supreme Court’s order in *Common Cause vs. Union of India* (2023) represents a significant step towards making Advance Medical Directives more practical and accessible. By modifying the original guidelines, the court has addressed the practical difficulties that were hindering their implementation. The changes ensure that individuals can exercise their right to make decisions about their medical treatment, even when they are unable to communicate those decisions themselves. The modifications reflect a commitment to upholding an individual’s right to die with dignity, while also ensuring that the process is workable and effective.