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CC BY 4.0 · Indian Journal of Neurotrauma
DOI: 10.1055/s-0045-1808269
Letter to the Editor

Legal Aspects of Consent in Managing Jehovah's Witness Patients in India

Ananth Rupesh Kattamreddy 
1   Department of Forensic Medicine and Toxicology, Andhra Medical College, Maharani Peta, Visakhapatnam, India
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I read with deep concern the case report on the management of a Jehovah's Witness (JW) patient with polytrauma, published in the Indian Journal of Neurotrauma.[1] The case report examines several gray areas within the legal framework of consent in India and brings forth moral and ethical questions surrounding the interplay between patient autonomy, physician's duty to preserve life, and state intervention. The issue of consent in such cases is exceptionally complex, necessitating a balance between respecting religious beliefs and ensuring that medical professionals are not complicit in preventable harm. Nevertheless, with the utmost respect for the medical team responsible for managing the JW patient referenced herein, I refrain from offering any observations on the standard of care provided by the esteemed team, recognizing their professional expertise and clinical judgment in the given circumstances.

With the advancement of modern medical techniques and the availability of effective management strategies, if a JW patient can be treated successfully and survives without a blood transfusion, it presents a totally agreeable scenario.[2] I commend the authors for publishing this case report, as it highlights a precarious situation of a medical team. In contrast to previous instances where the attendants of a JW patient ultimately consented to a blood transfusion,[3] this case presents a situation where the family remained steadfast in their refusal. Whatsoever, in cases where the refusal of a blood transfusion leads to an imminent risk of death, there must be cogent legal guidance on the prevailing position to ensure consistency in medical decision-making and adherence to constitutional principles.

A plain textual reading of Articles 25 and 26 of the Indian Constitution affirms that the rights to profess, practice, and propagate religion, as well as the autonomy of religious denominations, are subject to public order, morality, and health. The term morality in this context refers to constitutional morality, as evolved through judicial interpretation and grounded in the basic structure of the Constitution.[4]

It is a matter requiring adjudication by the Supreme Court of India as to whether the fundamental tenets of the JW faith, particularly the refusal to accept blood transfusions, constitute an essential and integral religious practice within the meaning of Articles 25 and 26 of the Indian Constitution. This determination must be examined in light of the Supreme Court's jurisprudence on constitutional morality in secular matters (Shayara Bano vs. Union of India [2017], Indian Young Lawyers Assn. [Sabarimala Temple-5 J.] vs. State of Kerala).[5] [6]

Furthermore, when no individual in Indian law has an inherent right to die under Article 21 (Right to Life),[4] it is legally untenable to suggest that a specific religious group can claim such a right under the freedom of religion provisions. The assertion that religious belief can override the state's interest in preserving life raises a significant constitutional question that warrants judicial scrutiny. The mere acknowledgment of a practice by the Supreme Court of India in the national anthem case[7] (Bijoe Emmanuel vs. State of Kerala, 1986) cannot be construed as granting sacred authority to every practice of the JW community.

In its judgment in Common Cause vs. Union of India and Anr (2018),[8] while allowing passive euthanasia in the country, the Supreme Court overruled certain aspects of the Gian Kaur (1996) judgment and Aruna Ramachandra Shanbaug (2011), explicitly stating that the right to die with dignity at the end of life should not be confused with or equated to the right to die through an unnatural death that curtails the natural span of life. The Court clarified that the right to die with dignity pertains to situations where life is naturally ebbing away and should not be misconstrued as a justification for hastening death through artificial means.

In our present discussion on the right to die, it is essential to consider the nuances surrounding voluntary death practices, particularly in the context of Santhara and Sallekhana. These practices, rooted in the Jain religion, involve individuals who, having fulfilled their worldly duties, voluntarily choose to cease consuming food and water as part of a vow to embrace death. However, unlike other forms of euthanasia, there is no external agency or medical intervention involved in hastening or delaying death. The individual retains the ability to reconsider their decision, as the process of death is not immediate.

Although the Rajasthan High Court, in Nikhil Soni vs. Union of India and Others,[9] prohibited these practices, the Supreme Court has stayed the ruling pending further examination by a Constitutional Bench. It is crucial to differentiate these voluntary death practices from those that directly involve medical intervention such as blood transfusion, as the involvement—or lack thereof—of medical professionals plays a significant role at the altar of life and death.

Section 226 of the BNS (Bhartiya Nyaya Sanhitha, 2023)[10] criminalizes suicide attempts made with the intent to compel or restrain a public servant from discharging their duties, imposing penalties such as simple imprisonment for up to 1 year, a fine, or community service. While an individual's autonomy to engage in a hunger strike is constitutionally protected, the general law of the land stipulates that once death becomes imminent, the person must receive medical care. This underscores the state's duty to preserve life, affirming that autonomy cannot supersede the fundamental obligation to protect health and prevent harm. Furthermore, the decriminalization of suicide under the Mental Healthcare Act, 2017 does not constitute an affirmation of the right to die.[11]

In India, the general legal principle regarding consent for medical examination and treatment is well-established, in accordance with the Indian Contract Act, 1872, the Indian Majority Act, 1875, and relevant parallels drawn from criminal laws (defense of infancy under sections 20 and 21 of BNS, 2023).[10] As a customary practice, for general physical examination, individuals aged 12 years or older can provide valid consent. However, for invasive medical procedures, including those that may involve significant bodily harm or risk to life, the threshold for consent is set at 18 years or older. Under Indian law, the consent of a child below the age of 12 years (doli incapax) and that of a person of unsound mind is considered invalid. However, the law remains silent on the concept of “capacity to consent,” an essential element in determining compos mentis, particularly with regard to individuals with cognitive impairments. The law generally presumes that every adult who is conscious and coherent possesses the capacity to consent.

In cases where a minor JW (below the age of 18 years) requires a life-saving procedure, but the parents refuse consent for a blood transfusion, the state, acting in its parens patriae capacity,[12] bears the overriding responsibility to act in the best interests of the child. Legal precedents consistently affirm that parental authority cannot extend to decisions that may lead to preventable death. In such instances, judicial intervention is necessary, and an expedited court order should be sought to authorize the required medical treatment. The financial implications of such procedures may be addressed either through insurance coverage or, if applicable, by the state. As the loco parentis, the state is empowered to determine what is in the best interest of the child, prioritizing the preservation of life above conflicting religious beliefs. The same works for a person of unsound mind. In both these groups, even for elective procedures, the state can intervene and make decisions in the best interest of an individual who is not in a position to make decisions for themselves, pursuant to the doctrine of parens patriae.

For a fully competent JW adult (18 years or older) undergoing an elective procedure, their right to refuse blood transfusion must be respected to the best extent possible. However, the moral and ethical implications become critical if complications arise during surgery and transfusion becomes necessary to prevent death. In such cases, preoperative counseling must include a clear, legally binding advance directive outlining the patient's wishes in case of unforeseen complications. This directive needs to be reviewed by the territorial High Court if the refusal leads to a preventable death, and the hospital authorities are supposed to act accordingly with a direction from the court about the consequences of a patient getting discharged against medical advice.

In emergency situations where a JW patient is unconscious or otherwise incapable of providing consent, the principle that the attending doctor must act in the patient's best interest is paramount. Courts have generally ruled that in life-threatening circumstances, medical professionals are not bound by religious refusals of treatment, particularly when no advance directive is available. In such cases, it is advisable for the medical team to seek legal immunity from the territorial High Court, ensuring protection from subsequent litigation for damages. This request for legal immunity can be made concurrently with the procedure being undertaken. It is important to emphasize that under Section 30 of the BNS Act, 2023, no action performed in good faith for the benefit of a person, even in the absence of consent, constitutes an offense. Therefore, no question of criminal prosecution arises in such situations.

In seeking a direction, only courts of law, specifically the High Courts, should be involved, and not a district medical officer or any executive authority, unless there is a specific legislation enacted by a state legislature or by the Parliament of India. Although there is no question of legal prosecution for acts done in an emergency, a prior sanction from the courts for these cases will pre-empt the question of future tort litigation. In reality, if the patient survives and wishes to sue the doctor for damages, such a claim would be unfounded, as the actions taken were in good faith and for the patient's benefit, based on legitimate medical intervention provided by the hospital or doctor.

Given the complexities involved in managing such cases, it is imperative to establish a streamlined legal mechanism where hospitals can rapidly petition courts for emergency intervention. The process should involve a dedicated green channel for hospitals to seek urgent judicial review via an online portal or designated judicial bench that caters to such needs round the clock.

The practical concerns regarding who will bear the costs, how to manage unsupportive parents or guardians, and the potential disruption in the hospital setting must be planned ahead as we generally do for “conflict of consent” scenarios. Insurance companies should be tasked with resolving the financial aspects; if they do not, the state must ensure coverage through existing reimbursement procedures. Additionally, police authorities may need to be involved to maintain order and ensure smooth handling of the situation, including the execution of a court decree. Until the Government of India establishes a proper mechanism through an executive order or legislation, or until the Supreme Court of India provides comprehensive guidelines that serve as the law of the land, it will be necessary to petition the territorial High Courts on a case-by-case basis for permission. The doctrine of precedents will help streamline the process in the future. A physician, as an external agency, risks becoming complicit in a crime if they permit faith-driven, unnatural termination of life.

It is crucial to recognize that there could be a criminal dimension to the situation if decisions regarding medical consent are solely based on the wishes of relatives or parents. For instance, in cases where parents or guardians may wish to endanger or neglect a child who has been subjected to abuse at home, relying on their consent could facilitate harm. To preserve societal integrity and prevent potential crimes, decisions in such sensitive scenarios cannot be entrusted solely to relatives, particularly in the cases of children, individuals of unsound mind, or young adults who have not made advance directives. In these situations, it is imperative that the state's intervention, guided by legal and ethical considerations, safeguards the well-being of the individual. The principle of parens patriae must be applied to ensure that decisions are made in the best interests of the person, free from any undue influence or malicious intent by family members or guardians.

The intersection of faith and evidence-based medicine presents a profound ethical dilemma, challenging the core principles of medical practice. It requires a delicate balance between patient autonomy, beneficence, and the physician's duty to preserve life. While autonomy is a fundamental right, it cannot be considered in isolation, as doing so risks undermining the other essential pillars of bioethics—nonmaleficence, beneficence, and justice—which collectively shape ethical medical decision-making.

This issue is not merely a conflict between faith and medicine but a broader question of legal clarity. The state must establish a well-defined legal framework that provides medical practitioners with clear, context-specific guidelines for managing cases involving JW patients. Physicians, already burdened with immense professional and ethical responsibilities, cannot reasonably be expected to resolve complex medicolegal dilemmas in high-stakes, time-sensitive situations without established protocols.

While the right to religious freedom is constitutionally protected, it cannot supersede a physician's fundamental duty to preserve life. In the absence of clear legal safeguards, medical professionals may be placed in ethically and legally untenable positions, potentially becoming unwilling participants in faith-driven medical neglect. To avoid such conflicts, a structured legal mechanism is necessary—one that ensures clinical decisions remain grounded in both medical ethics and the rule of law.


#

Conflict of Interest

None declared.

Acknowledgment

I would like to express my sincere gratitude to Mr. Kattamreddy Divya Chaitanya Reddy, LLM, for his invaluable insights and contributions in the preparation of this manuscript.


Address for correspondence

Ananth Rupesh Kattamreddy, MD, LLB
Department of Forensic Medicine and Toxicology, Andhra Medical College
Maharani Peta, Visakhapatnam 530002, Andhra Pradesh
India   

Publikationsverlauf

Artikel online veröffentlicht:
29. April 2025

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