John Rawls says that the liberal concept of autonomy focuses on choice and likewise, self-determination is understood as exercised through the process of choosing. The respect for an individual human being and in particular for his right to choose how he should live his own life is individual autonomy or the right of self- determination.
It is the right against non-interference by others, which gives a competent person who has come of age the right to make decisions concerning his or her own life and body without any control or interference of others.
Lord Hoffman, in Reeves v. Commissioner of Police of the Metropolis has stated:-
“Autonomy means that every individual is sovereign over himself and cannot be denied the right to certain kinds of behaviour, even if intended to cause his own death.”
In the context of health and medical care decisions, a person’s exercise of self-determination and autonomy involves the exercise of his right to decide whether and to what extent he/she is willing to submit himself/herself to medical procedures and treatments, choosing amongst the available alternative treatments or, for that matter, opting for no treatment at all which, as per his or her own understanding, is in consonance with his or her own individual aspirations and values.
In Airedale N.H.S. Trust v. Bland (1993) 2 WLR 31, Lord Goff has expressed that it is established that the principle of self-determination requires that respect must be given to the wishes of the patient so that if an adult patient of sound mind refuses, however unreasonably, to consent to treatment or care by which his/her life would or might be prolonged, the doctors responsible for his/her care must give effect to his/her wishes, even though they do not consider it to be in his/her best interests to do so and to this extent, the principle of sanctity of human life must yield to the principle of self-determination.
Lord Goff further says that the doctor’s duty to act in the best interests of his patient must likewise be qualified with the patient’s right of self-determination. Therefore, as far as the United Kingdom is concerned, it is generally clear that whenever there is a conflict between a capable adult’s exercise of the right of self-determination and the State’s interest in preserving human life by treating it as sanctimonious, the right of the individual must prevail.
In the United States, the aspect of self-determination and individual autonomy is concretised in law as all fifty States along with the District of Columbia, the capital, which is commonly referred as Washington D.C., have passed legislations upholding different forms of Advance Directives.
In the United States, even before the enactment of the said laws, a terminally ill person was free to assert the right to die as an ancillary right to the constitutionally protected right to privacy.
In Re Quinlan, where a 21 year old girl in chronic PVS was on ventilator support, the Court, while weighing Quinlan’s right to privacy qua the State’s interest in preserving human life, found that as the degree of bodily invasion increases and the prognosis for the patient’s recovery dims, the patient’s right to privacy increases and the State’s interest weakens.
The Supreme Court of New Jersey finally ruled that the unwritten constitutional right of privacy was broad enough to encompass a patient’s decision to decline medical treatment in certain circumstances.
Again, in Re Jobes, which was also a case concerned with a PVS patient, the Court, following the decision in In Re Quinlan, upheld the principle of self-determination and autonomy of an incompetent person.
The Canadian Criminal Code asserts and protects the sanctity of life in a number of ways which directly confront the autonomy of the terminally ill in their medical decision making. However, the Supreme Court of Canada in Reibl v. Hughes approved an oft-quoted statement of Cardozo J. that “every human being of adult years and sound mind has a right to determine what shall be done with his own body”
Thus, the Supreme Court of Canada suggested that competent adults have the right to make their own medical decisions even if such decisions are unwise.
In Aruna Shanbaug v. UOI (2011), Supreme Court has observed that autonomy means the right to self-determination where the informed patient has a right to choose the manner of his treatment. To be autonomous the patient should be competent to make decisions and choices. In the event that he is incompetent to make choices, his wishes expressed in advance in the form of a Living Will, or the wishes of surrogates acting on his behalf are to be respected.
The surrogate is expected to represent what the patient may have decided had he/she been competent or to act in the patient’s best interest. It is expected that a surrogate acting in the patient’s best interest follows a course of action because it is best for the patient, and is not influenced by personal convictions, motives or other considerations.
Thus, enquiring into common law and statutory rights of terminally ill persons in other jurisdictions would indicate that all adults with the capacity to consent have the common law right to refuse medical treatment and the right of self-determination.
In Common Cause v. UOI (2018), the court said,
“We may, however, add a word of caution that doctors would be bound by the choice of self-determination made by the patient who is terminally ill and undergoing a prolonged medical treatment or is surviving on life support, subject to being satisfied that the illness of the patient is incurable and there is no hope of his being cured. Any other consideration cannot pass off as being in the best interests of the patient.”
Social morality, medical ethicality and State interest:
The society at large may feel that a patient should be treated till he breathes his last breath and the treating physicians may feel that they are bound by their Hippocratic oath which requires them to provide treatment and save life and not to put an end to life by not treating the patient.
The members of the family may remain in a constant state of hesitation being apprehensive of many a social factor which include immediate claim of inheritance, social stigma and, sometimes, the individual guilt. The Hippocratic oath taken by a doctor may make him feel that there has been a failure on his part and sometimes also make him feel scared of various laws. There can be allegations against him for negligence or criminal culpability.
In this regard, two aspects are to be borne in mind. First, withdrawal of treatment in an irreversible situation is different from not treating or attending to a patient and second, once passive euthanasia is recognized in law regard being had to the right to die with dignity when life is ebbing out and when the prolongation is done sans purpose, neither the social morality nor the doctors’ dilemma or fear will have any place. It is because the sustenance of dignity and self- respect of an individual is inhered in the right of an individual pertaining to life and liberty and there is necessity for this protection.
And once the said right comes within the shelter of Article 21 of the Constitution, the social perception and the apprehension of the physician or treating doctor regarding facing litigation should be treated as secondary because the primacy of the right of an individual in this regard has to be kept on a high pedestal.
There are philosophers, thinkers and also scientists who feel that life is not confined to the physical frame and biological characteristics. But there is no denial of the fact that life in its connotative expanse intends to search for its meaning and find the solution of the riddle of existence for which some lean on atheism and some vouchsafe for faith and yet some stand by the ideas of an agnostic.
However, the legal fulcrum has to be how Article 21 of the Constitution is understood. If a man is allowed to or, for that matter, forced to undergo pain, suffering and state of indignity because of unwarranted medical support, the meaning of dignity is lost and the search for meaning of life is in vain.
Common Cause v. Union of India (2018)
  1 AC 360, 379
 355 A. 2d 647 : (1976) 70 NJ 10
 (1987) 108 N.J. 394
 1980 2 SCR 880 at 890-891