Abortion for the mentally retarded – the outer limit of patient autonomy

On 17.7.2009, a Division Bench of the Punjab & Haryana High Court, comprising of Justice Surya Kant and Augustine George Masih decided a case ordering the termination of the pregnancy of a rape victim, who was mentally retarded person and an orphan at that, staying in a Government Care Home. The judgment is like it has never come in any part of the world. A poignant tale of a girl discarded on road, picked up to be brought up in government run homes. Her mental retardation and inability to protect herself adequately, heightened her vulnerability to be repeatedly raped allegedly by male guards employed at the Home, aided as they were, by an Ayah for money to be ravished in the bathrooms.

The law distinguishes between mentally ill people from a mentally retarded person. The guardian procedures are consequently different: in the former, it would be the Mental Health Act and in the latter, it is the National Trust for Welfare of Persons with Autism, Cerebral Palsy, Mental Retardation and Multiple Disabilities Act, 1999. The National Trust Act establishes a Central Committee at Delhi and Local Committees in every district. The Committees shall have the power to appoint guardians for a mentally retarded person.

The Medical Termination of Pregnancy Act empowers a medical practitioner to terminate pregnancy of a woman whose length of pregnancy is not more than 12 weeks. If the pregnancy is more than 12 weeks and less than 20 weeks, the decision shall be at least by two medical practitioners. In both situations, the MTP could be undertaken, only (i) if the continuance of pregnancy would involve to the life of the pregnant woman or of grave injury to her physical or mental health. Where the pregnancy occurs by rape or a failure of any device or method used by a married woman or her husband for the purpose of limiting the number of children, it may be presumed that there is a grave injury to the mental health, or (ii) there is substantial risk that the child, if allowed to be born, may suffer from physical or mental abnormalities as to be seriously handicapped. No MTP carried out without the consent of the woman and if she is less than 18 years of age or a mentally ill person, without the consent of the guardian. In this case, since the woman was a mentally retarded person (and not mentally ill) and there was no local committee constituted under the National Trust Act, the Chandigarh Administration that was running the Institution where the woman was residing applied to the Court for the termination of pregnancy.

The Court assumed jurisdiction as a patria perens for deciding the question of desirability of MTP. It passed an interim order on 9.6.2009, containing inter alia, direction for constitution of an expert body of doctors for examining the pregnant woman (the Court used only the term 'victim' for the pregnant woman) and report on 13 points that included, the issue of consent of the mentally retarded person, any risk or complications relating to pregnancy and child birth and the most prudent course to be followed in the best interest of the victim. The report was a heart-wrenching record of what the mental condition of the victim, her desire to retain the fetus and deliver the child, the changes occurring to her over a period of time of constant crying, denial of entertainment such as TV viewing, which she was previously accustomed to and her inability to comprehend issues of parenting. Read what the doctor/ psychologist had to say about her:

She could identify the place but could not convey what is meant by a hostel, hotel or a hospital. She could name doctor but had no conceptual understanding of the roles and functions of a doctor. She acknowledged that she had a child inside her but had no idea of how conception takes place, the development of pregnancy or even the duration of pregnancy, age of child inside her, how will it come into the real world, chances of any harm to or abnormality to her unborn child, what is expected of her in child rearing, how to provide succor and sustenance to child. To the extent that in her unborn child she saw the possibility of having a brother to her. She even had no clear idea of female and male, sexual act and its attendant emotions, concept of marriage, her role as a wife except that she would cook for the "bhaiya") (refers to matrimonial partner as a bhaiya or possible to every man as a bhaiya). She had poor idea of her sexual role and expectations in marriage. Her simple mental operations are reflected by her anguish at a preferred suit (salwar and kameez) being torn during what she narrates attempt to undress her rather than an unwilling sexual encounter and its consequences thereof.

The judgment records the victim's point of view, as proffered by the counsel appointed to assist court in the following words: The learned amicus took us through a fine literary odyssey to impress upon us that in her lost world, the victim has now got a ray of hope of having someone as her own and it would be exhibiting gruesome cruelty to deprive her of what she now cherishes to come out of her and make her life meaningful. Besides asserting the right of self-determination for persons with intellectual disabilities, the learned amicus-curiae also relied upon two Division Bench decisions of Madras and Kerala High Courts in the cases of [i] V. Krishanan vs.G. Rajan @ Madipu Rajan and others, (a case where a minor girl alleged to be 16 had been married without the consent of her parents and when the parents of the girl wanted to terminate the pregnancy, the girl and her 'husband' wanted the continuation of the pregnancy and the Court denied permission to abort and upheld the desire of the girl to carry her pregnancy to full term and deliver the child) and (ii) Mrs. Usha Abraham v. Abraham Jacob (a case where a husband sought for divorce on the ground that the wife was mentally ill, but the court refused reasoning that the woman was only slightly mentally retarded and hence she could perform her marital ob ligations).

The Division Bench posed to themselves the question 'Should we not permit the petitioner - Administration to medically terminate the victim's pregnancy solely on the ground that the victim wants to keep the child as she likes children or should we adopt a holistic approach after taking into consideration several other factors which have a direct bearing on the future of the victim as well as of the foetus in her womb ?' The court examined the physical conditions of the mother ( she had abnormalities of gait and spinal deformity), the mental capacity of the mother ( she had a mental growth of 7 - 8 year old child, with little communication skills of social behaviour) , the report of the social worker who opined that the victim believed a child to a toy that one can play with, the social conditions and surrounding environment, where the girl had been abandoned by her own parents and brought up in shelter homes her 100% financial dependence with no employable skills than carrying out simple orders like clearing a table, dusting under supervision, pealing vegetables and above all, nil family support.

The Bench concluded, 'we find that except her physical ability, the victim is neither intellectually nor on social, personal, financial or family fronts, is able to bear and raise a child. We are satisfied with the reports of the Experts that the victim is incapable of understanding the concept of motherhood or of pregnancy or pre and post delivery implications. The victim, notwithstanding her innocent emotional expressions, is not mentally in a position to bear and raise the child. Asking her to continue with the pregnancy and thereafter raise the child would be a travesty of justice and a permanent addition to her miseries. The "toy" with which she wants to play, would want her to invest hugely which she is incapable of…

We also cannot over-look the fact that if allowed to be born, the child's own life, grooming and future prospects may itself be highly disappointing. There would be no choice but to keep the child in Ashreya (the government home) where the victim is living, in the company of other mentally ill inmates. There shall, thus, be a consistent risk to the innocent life. His mother's own mental age being 7-8 years, the learning process of the child would be highly inadequate. The grooming and education of the child would again be at the mercy of the Government run/aided institutions whose dismal performance or the severely negligent behavioural attitude towards the inmates has already prompted us to issue various reformatory directions and to monitor their implementation in future. If born, the child would not only be deprived of the care and protection of a father, but, on account of the mental handicap of the victim, the mother also…"

Was there a doubt that with such persuasive reasoning, the conclusion could not have been to retain the fetus, but a direction to medically terminate the pregnancy? Like we said at the beginning, there has been no reported case of such complex situation, a woman made pregnant by rape, by an act, she did not understand as a sexual compulsion except that in the process, her best clothes were torn, a woman that is mentally retarded with a mental maturity of a 7 year old girl, a woman that does not have her own family, having been discarded on road and picked up to be brought in a government run welfare home that paradoxically subverted her welfare. Now, the interesting twist is that the Supreme Court reversed this decision and the victim continues to have the child growing in her womb. It is a significant victory for pro-life campaigners. The case for pro-life has powerful arguments, which we will discuss, after the Supreme Court gives its reasoned decision. Even by a reversal of the decision of this case by the Supreme Court, the strength of the logic expounded in the judgment of P & H High Court is not a wee-bit dimmed. It shows a beautiful course of judicial opinions: there is always the other side of the coin and a better wisdom of a higher court!

Now the woman will hopefully (& prayerfully from our part) deliver the child and get her own 'toy' that she bears in rueful pain and expectant ecstasy.

Litigations after death

Bury the body or cremate it, whatever way you may want, it may be yet a matter of personal preference, but normally, the religion that the person was born to, dictates the choice. The integrity of the body is always desired, as it goes up in flames or allowed to putrefy. Any internal organs that are harvested after death and before delivery to relatives may leave no trace in the external appearance of the human frame. For the same reason, when the eyeballs are removed from the dead person, it is considered ethical that the sockets are stuffed and the eyelids are made to look normal. Even a mutilated body by accident or bomb blast are pieced together and stitched up before it is buried or cremated. When Michael Jackson’s brain was redelivered to the relatives after clinical examination for the criminal case that has been registered and for finding the cause of death, the brain was surgically re-fixed within the skull. Now that the body is fully integrated, the burial, it is expected, may take place soon.

Statutory laws and cases associated with dead bodies and removal of organs, after death, are rather weird. The Anatomy Act, 1949 sets out procedure in India for authority for removal of organs from dead bodies or dead bodies themselves for therapeutic, research or criminal investigations. In the case of a dead body lying in a hospital or prison and not claimed by any of the near relatives of the deceased person within forty-eight hours from the time of the death of the concerned person, the authority for the removal of any human organ from the dead body which so remains unclaimed may be given by the person in charge, for the time being, of the management or control of the hospital or prison, or by an employee of such hospital or prison authorised in this behalf by the person in charge of the management or control thereof. No authority shall be given if the person empowered to give such authority has reason to believe that any near relative of the deceased person is likely to claim the dead body even though such near relative has not come forward to claim the body. Can a person insist that the Hospital shall take his body after his death? In K. Uma Mahesh v The State of Tamil Nadu, rep. by its Secretary to Government, Health and Family Welfare Dept. Fort St. George, Ms. 9 and 2 others (1998), there was a challenge to the provisions of the Anatomy Act itself on the ground that there was no provision for acceptance of the body, except those that were unclaimed. Without testing the validity of the Act itself, the Madras Court said that the desire of the petitioner was commendable and directed the Director, Institute of Anatomy to accept the body if the same was intimated and the body had been brought without losing much time after death.

Does a person have a right to protect any part of the body of his or her spouse before death? In Smt. Sumakiran Mallena v The Secretary, Medical and Health and others (2008), the wife of the donor filed a writ petition challenging the decision of her husband to donate a portion of the liver to his father who was reportedly suffering from decomposed cirrhosis of liver, - a HCV related incurable liver function. The court rejected the petition as not maintainable, holding that no legal right existed for the wife to prevent her husband’s decision. The court pointed out that the case had been filed on two wrong presumptions that (i) her husband’s affection towards his parents should be subservient to the marital relationship between him and the petitioner, and (ii) that he cannot donate his organs with her consent. On both counts, the court found against the petitioner.

In Madhu Vijayan and another v S.G.Ravishankar (2006) the dispute was for custody of the ashes between the wife and son of the deceased O.V.Vijayan ( a renowned author and story teller) on the one hand and the nephew of the deceased on the other who had performed the obsequies. The Court said there was no property in the ashes but resolved the controversy between parties by allowing the legal heirs to offer prayers with the ashes kept in the custody of the nephew and that the ashes could be jointly immersed at Hardwar by both the litigating parties, a ceremony that was completed nearly a year after the death.

The foreign jurisdiction in U.K. and U.S.A.have had their share of interesting cases as well. In so far as there can be property in corpses or parts thereof, presumably it will vest initially in person carrying out the stuffing or embalming process, or taking steps for their preservation, on the basis that he is the first possessor. Re Organ Retention Group Litigation(2004) is authority for the proposition that if autopsy is conducted with consent, the removal of organs for the purpose of lab tests and report is implicit and no action will lie for damages for removal of organs. The U.S courts have always recognized the rights of next of kin of a deceased person a right to possession of the dead body for decent burial or cremation but not a right to the body as if it were property. To provide California non-profit eye banks with an adequate supply of corneal tissue, Cal. Gov't Code § 27491.47(a) authorized the coroner to remove and release or authorize the removal and release of corneal eye tissue from a body within the coroner's custody without any effort to notify and obtain the consent of next of kin if the coroner has no knowledge of objection to the removal. The law also provided that the coroner or any person acting upon his or her request shall not incur civil liability for such removal in an action brought by any person who did not object prior to the removal nor be subject to criminal prosecution, Cal. Gov't Code § 27491.47(b). In Robert Newman, as father and next of kin of Richard A. Newman and Others v L. Sathyavaglswaran, M.D., in his official capacity as Chief Medical Examiner-Coroner Of The County Of Los Angeles(2002) , the parents, whose deceased children's corneas were removed by the Los Angeles County Coroner's office without notice or consent brought a suit challenging the removal. The court of appeals concluded that the longstanding recognition in the law of California, paralleled by national common law, that next of kin have the exclusive right to possess the bodies of their deceased family members created a property interest, the deprivation of which must be accorded due process of law under U.S. Const. amend. XIV. The court ruled that parents have property interests in the corneas of their deceased children protected by the Due Process Clause of U.S.

Litigations just do not last merely a life time. In death as in life, will litigations thrive!