Wednesday, 25 May 2016

Leading Judgment on patient autonomy

The US Supreme Court said in Cruzan Versus Director

Missouri Department of Health-(1990) 110 S.Ct 2841 (Scalia. J.),
while asserting a case of patient autonomy: “The point at which life
becomes 'worthless' and the point at which the means necessary to
preserve it to become “extraordinary” or “inappropriate”, are neither
set forth in the Constitution nor known to the nine Justices of this
court and better than they are known to nine people picked at
random from the Kansas City telephone directory.” At a
metaphysical level, the questions could be: Is death inherently evil?
Are we all not destined to die? Is it not more important how we live
than how long we live? (Charles I Lugosi, Visiting Professor, Yale
Law School). A dilemma that a court might face, when approached
whether the patient shall be allowed to die by withdrawal of life
support is quite different from a patient expressing desire not to be
treated. In the former, we are broaching issue of passive euthanasia
and in the latter, it is an issue of patient autonomy. The former
grapples with legal uncertainty and still debatable (an issue referred
to a larger Bench by a 5 Members Bench of the Supreme Court
(Common Cause Versus Union of India-(2014) 5 SCC 338)). In the
latter, there is no ambiguity; it is beyond debate.
IN THE HIGH COURT OF PUNJAB AND HARYANA
AT CHANDIGARH
 FAO No.4020 of 2015 (O&M)
 Date of decision:18.05.2016
The Oriental Insurance Company Limited ... Appellant
versus
Sh. R.K. Dogra @ Rajinder Kumar, through his LRs and another
 .... Respondents
CORAM: HON’BLE MR. JUSTICE K. KANNAN



1. The appeal is at the instance of the Insurance Company
challenging the award on the ground that there was no proof that the
death was on account of accident. It was a case of an accident
having taken place on 15.03.2013 when the MLR recorded that he
had head injuries. He was discharged from the hospital in a
satisfactory condition on 19.03.2013. He was readmitted on
03.05.2013 and the summary of treatment recorded from the hospital
showed that the problem was diagnosed to be “right temporoparietal
bleed with midline shift”. The condition of the patient was
said to be bad but he got discharged on 07.05.2013 against medical

advice. He ultimately succumbed to death on the day of his
discharge itself.
2. The counsel for the Insurance Company argued that he
was already a TB patient with cirrhosis of liver and it cannot be
surely predicated even without a post mortem that death was only
account of head injury suffered in the accident. The doctor, who
was examined in court, stated that chances of recovery could not be
ruled out if the deceased had stayed on for treatment. The doctor was
not however able to assess the “percentage of recovery possible”
(sic), meaning thereby he was not able to assess the prospect of
recovery. This, according to the counsel, would show that a patient
who was indiscreet to deny himself the treatment and who could
have been treated well could leave any cause of action for the
representatives to plead that the death was only on account of
accident.
3. In this case between the date of accident on 15.03.2013
to the date of death on 07.05.2013, there was no other intervening
episode that could have aggravated the medical condition except that
the petitioner denied to himself the treatment which perhaps was
available. The cause for death could also be easily discerned from
the fact that when he was readmitted on 03.05.2013, the diagnosis
was that there were internal bleeding within the skull and when there
was a reference about the general poor condition. Seen in the context

of such diagnosis with no reference to the condition of cirrhosis of
liver or the tuberculosis which the deceased was said to have already
contacted the precipitating factor for the poor condition was only the
head injury with internal bleeding within the skull in the brain area.
A decision to get discharged even against medical advice at the
terminal stage of life shall not be likened to an invitation to be
assisted suicide. It is embracing dignity in death.
4. The patient autonomy in the manner of treatment is a
facet of human right and it cannot be ever contended in court that
the patient ought to have taken treatment that had a good prognosis
for recovery. There have been instances where due to religious
beliefs (for instance, Jehovah's witnesses' denial of blood
transfusion), patients have declined to take treatment and courts
have confronted these problems as well and come to decisions of
hands off approach. That is precisely what has been also recorded in
the discharge summary that the patient was getting discharged at his
own risk and has assured that he will have no right of recourse
against the doctor from the hospital. The undertaking will thus go
far and no further. It will not exculpate a tort feasor or a person who
is bound to indemnify to make possible a plea that the patient ought
to have taken treatment. A right not to get treated is just as well a
significant right to a patient as a right to be treated.
5. The US Supreme Court said in Cruzan Versus Director

Missouri Department of Health-(1990) 110 S.Ct 2841 (Scalia. J.),
while asserting a case of patient autonomy: “The point at which life
becomes 'worthless' and the point at which the means necessary to
preserve it to become “extraordinary” or “inappropriate”, are neither
set forth in the Constitution nor known to the nine Justices of this
court and better than they are known to nine people picked at
random from the Kansas City telephone directory.” At a
metaphysical level, the questions could be: Is death inherently evil?
Are we all not destined to die? Is it not more important how we live
than how long we live? (Charles I Lugosi, Visiting Professor, Yale
Law School). A dilemma that a court might face, when approached
whether the patient shall be allowed to die by withdrawal of life
support is quite different from a patient expressing desire not to be
treated. In the former, we are broaching issue of passive euthanasia
and in the latter, it is an issue of patient autonomy. The former
grapples with legal uncertainty and still debatable (an issue referred
to a larger Bench by a 5 Members Bench of the Supreme Court
(Common Cause Versus Union of India-(2014) 5 SCC 338)). In the
latter, there is no ambiguity; it is beyond debate.
6. The ultimate decision making the insurer liable is
therefore inevitable of confirming the decision already rendered.
The appeal is dismissed.
18.05.2016 (K.KANNAN)

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