Right to Refuse Treatment vs. State’s Duty to Preserve Life: A Constitutional Reconciliation in Indian Medical Jurisprudence

Abstract

The right to refusal for a medical treatment rest at the convergence of the personal liberty and the state responsibility. In India, Article 21 of the Indian Constitution guarantees the most important right that is right to life and personal liberty¹, which the jurisprudence has interpreted that fringes both bodily autonomy and the right to die with dignity. Yet, the same Article also imposes a very strict duty upon the State to preserve and protect life. Through this paper we will be understanding doctrinal and juxtaposition of the constitutional tension between these two peremptory. With the help of the Indian case law from Parmanand Katara v. Union of India (1989)² to Common Cause v. Union of India (2018)³ and parallel phenomenon in jurisdictions such as the United Kingdom and the United States, it argues that India’s constitutional framework demands a nuanced balance between individual autonomy and state paternalism. The study concludes recommending for a coherent legislative framework to recognize informed refusal as an extension of dignified living, while safeguarding medical ethics and public interest.

Keywords: Right to refuse treatment, Article 21, autonomy, medical ethics, constitutional reconciliation, euthanasia.

Introduction

The transformation of medical law in India reflects a very deep moral struggle within constitutionalism itself that is between the sanctity of life and the sovereignty of choice. Every single medical decision personifies a legal and ethical tension that is does the State’s basic duty that is to protect life, override an individual’s refusal to receive a life sustaining treatment?

The Indian Constitution, while it is silent on the “refusal of treatment,” provides through Article 21 a high-powered concept of life first one being that it includes dignity, privacy, and bodily integrity. As Justice Chandrachud very well observed in K.S. Puttaswamy v. Union of India⁴, that privacy includes control over one’s own body and medical decisions. However, the State, under its concept of parens patriae has an obligation, to ensure that life is well preserved, particularly in emergencies or where consent is ambiguous.

This research explores whether India can reconcile these competing obligations and what constitutional framework might harmonize personal liberty with collective welfare.

Literature Review

Early learnings in the Indian medical jurisprudence treated the patient as an amenable subject of medical expertise. And before the early 1990s the legal literature, such as H.L.A. Hart’s Law, Liberty and Morality placed very acute emphasis on bodily autonomy. However, after liberalization that is post liberalization discourse had shifted toward the rights-based medical governance.

Scholars such as Bhatia (2017) argue that the right to refusal of the treatment is a further extension of decisional autonomy, protected by the right to privacy. Conversely, Dhanda (2019) cautions that unregulated autonomy could erode public-health responsibilities, particularly in pandemic or mental-health contexts.

When compared to the, Western legal theory, especially Ronald Dworkin’s “Life’s Dominion,” supports this autonomy as integral to dignity, even at the end of life. This intellectual current significantly influenced the Indian Supreme Court in Common Cause (2018), which recognized advance directives.

Nevertheless, Indian legal writing continues to seek clarity on where the state’s protective role ends and individual liberty begins forming the central inquiry of this paper.

Constitutional and Legal Framework

Article 21 and the Right to Life

Article 21 states: “No person shall be deprived of his life or personal liberty except according to procedure established by law.” through various judicial precedents the term “life” has expanded to include the right to live with dignity (Francis Coralie Mullin v. Union of India, 1981⁵) and, by various suggestion, the right to make medical decisions.

In Gian Kaur v. State of Punjab (1996)⁶, the Court significantly held that Article 21 does not include the “right to die”, the right to die with dignity is encompassed within it by laying numerous groundworks for recognizing the passive euthanasia.

Directive Principles and State Obligation

Article 47 mandates the State to improve public health, framing a constitutional duty to preserve life. This was fortified by the judiciary in the case of Parmanand Katara (1989), which had declared that emergency care should be provided by the doctors and the hospitals regardless of any kind of procedural barriers.

Statutory Provisions

• Indian Penal Code, 1860 (Sections 89 & 92)⁷ and corresponding Bhartiya Nyaya Sanhita provisions legalize those kinds of medical acts which are done in a very good faith for a patient’s benefit.
• Mental Healthcare Act, 2017, Section 5⁸, specifically mentions that if a person’s right to make an advance directive, will include the refusal of treatment.
• Transplantation of Human Organs and Tissues Act, 1994⁹ and Medical Termination of Pregnancy Act, 2021¹⁰ embodies the principle of informed consent, that further strengthens the bodily autonomy.

Judicial Evolution in India

Analysis

This judicial approach unveils a gradual constitutional humanization of medical law. From Katara’s life-centric view to Common Cause’s autonomy-centric paradigm, the Court has transitioned from paternalism to partnership between patient and State.

However, the reconciliation remains incomplete. While autonomy is recognized, it is often subject to bureaucratic oversight or medical board approvals, reflecting judicial caution against potential misuse.

Comparative Jurisprudence

United Kingdom

In Airedale NHS Trust v. Bland [1993] AC 789, the House of Lords upheld withdrawal of life support where continuation served no therapeutic purpose, emphasizing patient dignity and medical futility. The UK thus treats refusal of treatment as a manifestation of self-determination protected under common law.¹¹

United States

Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990),¹² recognized that a competent individual may possesses a constitutional liberty interest in refusing unwanted medical treatment. Subsequent state legislations codified living wills and healthcare proxies.

Canada

In Carter v. Canada [2015] 1 SCR 331¹³, the apex Court held that physician-assisted dying would be decriminalized, under Section 7 of the Canadian Charter, grounding it in rights to liberty and security of the person.

European Human Rights System

Pretty v. United Kingdom (2002) ECHR 423¹⁴ established that personal autonomy over end-of- life decisions falls within “private life” under Article 8 of the European Convention on Human Rights.¹⁵

These comparative frameworks underscore a universal constitutional migration toward autonomy, subject to procedural safeguards.

Ethical and Philosophical Dimensions

Autonomy and Bodily Integrity

Autonomy, as per Kantian ethics, is to represents the moral right of rational beings to self- legislate. In medical law, this manifests as informed consent and informed refusal. Forcing treatment on a competent adult violates the principle of voluntas aegroti suprema lex this maxim means that the patient’s will be supreme.¹⁶

Paternalism and the State’s Role

Parens patriae is a doctrine under which the state acts, assuming role and responsibility for protecting those who are unable to protect themselves such as the minors, incapacitated persons. However, when practiced excessively paternalism undermines the liberty and tend reduce the individuals to subjects of welfare governance rather than bearers of rights.

The Bioethical Triad: Autonomy, Beneficence, and Justice

Balancing autonomy with beneficence this is what the medical ethics actually requires (doctor’s duty to help) and justice (societal interests). Hence, when absolute autonomy, it may be constrained where refusal endangers public health or violates professional ethics.

Constitutional Reconciliation: Toward a Harmonized Framework

There is a doctrinal balance created by Reconciling the right to refuse treatment with the State’s duty to preserve life as it was grounded in constitutional proportionality.

The Proportionality Principle

In Modern Dental College v. State of Madhya Pradesh (2016)¹⁷, the Supreme Court adopted proportionality as the test for reconciling conflicting rights. Applying it here:

1. The objective—preservation of life—is legitimate.
2. The means—mandatory treatment—must be necessary and least restrictive.
3. The impact on autonomy must not be disproportionate to the benefit of saving life.

Thus, coercive treatment may be justified only when refusal threatens others (e.g., contagious disease control) or where competence is doubtful.

Role of Advance Directives

Common Cause empowered individuals to pre-determine medical choices. Yet, procedural hurdles remain complex. A simplified statutory scheme should validate notarized directives without excessive judicial intervention, ensuring both efficiency and accountability.

Judicial Oversight and Medical Ethics Boards

To prevent misuse, the National Medical Commission was made specialized ethics boards so that it could review contested refusals, ensuring that decisions are well informed, self-made or voluntary, and consistent with the medical standards.

The Concept of Qualified Autonomy

Absolute autonomy may be with conflict with the social responsibility. So, the State’s duty becomes very vital to preserve life, and it should yield only when autonomy is informed, competent, and non-coerced. This approach aligns with the constitutional vision of liberty balanced by public interest.

Recommendations

1. Enact a “Medical Autonomy and End-of-Life Care Act” by codifying the right to refuse treatment, establishing a well-structured legal procedure for the living wills, and protecting those physicians who are acting in a good faith.
2. Institutionalize Ethics Committees in every paramount hospital should have access to document treatment refusals, reducing the apprehension litigation.
3. Public Awareness and Consent Literacy: campaigns explaining what actual patient rights are under the Mental Healthcare Act and Common Cause guidelines nationwide.
4. Judicial Streamlining: Create designated benches in High Courts for medical-ethics cases to avoid inconsistent interpretations.
5. Integration of Technology: As the technology advances there should be Digital registration of advance directives linked with Aadhaar or health IDs to authenticate decisions securely

Conclusion

The constitutional dialectic between the autonomy and obligation defines the ethos of the Morden Indian medical law. The right to refuse the treatment is neither a proclamation of death wish nor a converse of life’s sanctity it is a pure affirmation of self-ownership and dignity within the constitutional promise of Article 21.

At the same time, there is the State’s duty to preserve life and ensures that this liberty does not degenerate into neglect or indifference toward vulnerable citizens. Reconciliation lies not in choosing one over the other, but in constitutional moderation a framework where the State respects voluntary, informed refusals while safeguarding against coercion or ignorance.

India’s journey from the landmark case of Parmanand Katara to case of Common Cause reveals a steady, step by step evolution toward humane constitutionalism, where the body is not treated merely biological but a site of personal liberty and moral choice. The future of medical law must therefore affirm:

“To preserve life is noble; to preserve dignity within life is justice.”

Footnotes

1. INDIA CONST. art. 21. ↩︎
2. Parmanand Katara v. Union of India, (1989) 4 SCC 286 ↩︎
3. Common Cause v. Union of India, (2018) 5 SCC 1. ↩︎
4. Justice K.S. Puttaswamy (Retd.) v. Union of India, (2017) 10 SCC 1. ↩︎
5. Francis Coralie Mullin v. Union Territory of Delhi, (1981) 1 SCC 608. ↩︎
6. Gian Kaur v. State of Punjab, (1996) 2 SCC 648. ↩︎
7. Indian Penal Code, No. 45 of 1860, §§ 89, 92 (India). ↩︎
8. Mental Healthcare Act, No. 10 of 2017, § 5 (India). ↩︎
9. Transplantation of Human Organs and Tissues Act, No. 42 of 1994 (India). ↩︎
10. Medical Termination of Pregnancy (Amendment) Act, No. 8 of 2021 (India). ↩︎
11. Airedale NHS Trust v. Bland, [1993] AC 789 (H.L.). ↩︎
12. Cruzan v. Director, Missouri Dept. of Health, 497 U.S. 261 (1990). ↩︎
13. Carter v. Canada, [2015] 1 S.C.R. 331. ↩︎
14. Pretty v. United Kingdom, App. No. 2346/02, 35 Eur. H.R. Rep. 1 (2002). ↩︎
15. European Convention on Human Rights, art. 8. ↩︎
16. Voluntas aegroti suprema lex (Latin maxim meaning “the patient’s will be supreme”). ↩︎
17. Modern Dental College and Research Centre v. State of Madhya Pradesh, (2016) 7 SCC 353. ↩︎