On 30 June 2025, P.D. Hinduja Hospital and Medical Research Centre in Mumbai established the first ‘Living will clinic’ in India. Doctors involved in the clinic include senior neurologist Dr Roop Gursahani and palliative care specialist Dr Smriti Khanna.

Advance Medical Directives, commonly known as ‘living wills’, are legally recognized documents allowing individuals to choose, in advance, the extent and capacity of medical treatment and care they wish to receive if a situation arises where they are unable to take, or communicate, a comprehensive decision for themselves. Elaborated upon in 2018 by the Supreme Court of India in its Common Cause v. Union of India ruling, the court laid down clear requirements and guidelines to support a framework to execute such living wills. These included defined criteria to identify executors of the living wills as well as witnesses to authenticate the execution of said wills, appropriate procedures by designated members of the judiciary to countersign the documents and ensure safeguarding, preservation and distribution of the advance medical directives in physical and digital format protecting their integrity, and evaluation by a designated, pre-determined medical board, should the person in question become incapacitated, in a vegetative state, or unable to communicate their decisions.

The directive was modified in 2023 by the Supreme Court to include unambiguous terminology stating whether the individual in question had chosen to withhold or discontinue treatment. It also offered scope for terminally ill individuals suffering from incurable conditions, who had not made living wills, to be offered passive euthanasia following a structured medical review. The revised directive mandated that guardians be identified in the living will, who would be authorized to make decisions for the individual for whom the advance medical directive was being prepared, with a provision for the individual and the guardian to revoke the decisions made in the will, if applicable.

While the original directive from 2018 and its modification issued in 2023 were meant to provide a legal framework to ensure compliance with the terms stipulated in the living will, they also sought to address nuances of balancing ethical and medical considerations in end-of-life decisions outside the boundaries of personal autonomy. The application of these guidelines, however, continues to be a challenge in India. Lack of awareness of the existence of such legal frameworks, under-preparedness of governmental, judicial and medical facilities tasked with implementation of these legal documents, cultural hesitations and societal perceptions compounded by administrative inefficiencies, have led to underutilization of advance medical directives as tools to ensure the right of refusal of medical care in end-of-life decision-making.

The creation of this clinic represents a step taken by medical institutions to address these shortfalls and to aid people in preparing the legal documents. The clinic, which at present operates once a week, offers counselling and knowledge-sharing about living wills and provides information and aid on medico-legal pathways to document an individual’s healthcare preferences, should a time arise where the individual is unable to make such decisions. It represents a structured initiative provided by a healthcare organization to empower people to take end-of-life decisions, including those of right-of-refusal of treatment, in an organized, legally recognized format. The Living Will Clinic at Hinduja Hospital helps people draft the advance medical directive, notarize it with two witnesses, and provides copies to the designated guardian and family members of the individual for whom the will is being prepared, as well as to their treating physicians. An online portal with relevant information is on the anvil as per members of the team associated with the clinic.

When contacted for his opinion on the clinic, and on the still-nascent field of living wills creation in India, Dr Roop Gursahani replied by email, ‘The response has been heartening, with appointments being booked weeks in advance. More importantly, both Dr Smriti Khanna and I are regularly contacted by colleagues wanting guidance on setting up similar clinics elsewhere.’

MAHARRA HUSSAIN, United Arab Emirates

ORCID iD: 0000-0001-7632-0631

In a pioneering development in transplant medicine, in August 2025, surgeons successfully implanted a genetically modified pig lung into a brain-dead human recipient at NYU Langone Health, New York, USA. This procedure represents the first documented attempt to transplant a porcine lung into a human body.

The experiment addresses the persistent shortage of donor organs, with xenotransplantation offering the potential to modify donor organs rather than relying solely on immunosuppression in recipients. The pig lung used was genetically engineered to reduce the risk of hyperacute immune rejection. The brain-dead recipient was maintained on ventilatory support to allow surgeons to assess lung function in real time.

As highlighted in Cooper’s editorial in The National Medical Journal of India (Cooper DK. Progress towards clinical pig organ xenotransplantation. Natl Med J India 2025;38:65–8. DOI: 10.25259/NMJI_348_2025), xenotransplantation research has advanced over the past 4 decades through innovations in genetic engineering and immunosuppressive therapy. Early challenges, such as immediate rejection from preformed anti-pig antibodies, have been mitigated by creating pigs with multiple gene edits and introducing human protective genes. Novel immunosuppressive regimens targeting T-cell co-stimulation pathways further protect the graft from immune attack.

The recent procedure serves as a proof of concept, showing that a pig lung can function temporarily in a human body without triggering immediate hyperacute rejection. Although the experiment was not intended for long-term survival, it offers valuable insights for upcoming clinical trials. In carefully selected cases, patients have already received pig kidneys and hearts in early studies, demonstrating promising short-term graft function.

The development has attracted global attention, emphasizing xenotransplantation’s potential to alleviate organ shortages. Advocates highlight that successful translation to living patients could save thousands of lives annually. However, scientific and ethical considerations remain, including the risk of cross-species viral transmission and the use of brain-dead individuals for research purposes. Regulatory approval, such as from the US Food and Drug Administration, is currently restricted to controlled experimental protocols.

If further trials demonstrate safety and efficacy, xenotransplantation could mark a turning point in transplantation medicine, providing new hope for patients with end-stage organ failure and representing a milestone in decades of research.

NISCHAL P.M.,

Mysuru, Karnataka, India

ORCID iD: 0000-0003-3491-5500

In a groundbreaking development for human genetics, the UK has launched the Synthetic Human Genome (SynHG) project, aimed at developing tools to create a human chromosome. The initiative, officially launched on 26 June 2025, is funded partly by the Wellcome Trust and involves researchers from several British universities, with Jason Chin of the University of Oxford serving as project lead.

The project seeks to expand the frontiers of genomic science by enabling researchers to not only read DNA but also to design and synthesize functional human chromosomes. This ambition builds on decades of progress in synthetic biology. The first synthetic gene was produced in the 1970s, followed by the construction of entire bacterial genomes, including those of Mycoplasma genitalium, Mycoplasma mycoides, and Escherichia coli in 2008, 2010, and 2019, respectively. More recently, the yeast genome (a eukaryotic organism closer to humans than bacteria) has been fully synthesized, with its last chromosome completed in January 2025.

The SynHG project also integrates artificial intelligence to accelerate the design and prediction of DNA function. The Arc Institute in Palo Alto released Evo 2, a generative AI capable of proposing new genomic sequences from short DNA prompts. In parallel, Google DeepMind launched AlphaGenome, a deep-learning model able to predict the cellular effects of specific genetic changes. Together, these tools are expected to allow scientists to design human DNA sequences with targeted cellular functions, potentially transforming cell therapies, organ transplantation, and tissue engineering.

Despite the promise, substantial technical challenges remain. DNA strands must be built nucleotide-by-nucleotide, which is a reliable method for small segments, but is expensive and also error-prone for longer sequences. The largest completed synthetic genome to date, yeast, measures 12 million base pairs, while the smallest human chromosome, chromosome 21, contains 45 million base pairs. Cost estimates for synthesizing a full human chromosome range widely: Dr George Church of Harvard University suggests more than $20 million, whereas Dr Chin projects approximately $650 000.

Ethical considerations also form a central component of SynHG. Testing the functionality of a synthetic human chromosome in living humans raises profound ethical and legal concerns. SynHG has established a dedicated programme, Care-full Synthesis, to examine these issues. Dr Chin emphasises that the project does not involve implantation in human subjects, focusing instead on laboratory-based verification.

If successful, SynHG would mark the first occasion that a human chromosome is artificially created, moving from beyond reading the language of life to writing it. The project promises to advance understanding of how genomic sequences determine cellular function and could lay the groundwork for precise, customizable biomedical interventions in the future.

NISCHAL P.M., Mysuru, Karnataka, India

ORCID iD: 0000-0003-3491-5500

Traumatic brain injuries (TBI) constitute a major cause of morbidity and mortality, especially in rural India, where computed tomography (CT) and magnetic resonance imaging (MRI) are often not easily available. A handheld, noninvasive, portable brain injury diagnostic tool named CEREBRO has been developed to address this issue. CEREBRO has been developed jointly by the Indian Council of Medical Research-Medical Device and Diagnostics Mission Secretariat (ICMR-MDMS); All India Institute of Medical Sciences (AIIMS), Bhopal; National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru; and Bioscan Research.

Bioscan Research, the company behind the CEREBRO technology, has been supported by several entities, including iCreate, IIT Kanpur, the Biotechnology Industry Research Assistance Council (BIRAC), the Department of Health Research (DHR), and the ICMR.

CEREBRO has already passed clinical validation in multi-centre performance trials supported by ICMR’s Product Ignition and Development Enabler (mPRiDE) scheme and has received approval from the Drugs Controller General of India (DCGI). Expected to cost about `1 500 000 (`15 lakhs), CEREBRO is radiation-free and is safe for infants and pregnant women.

CEREBO has been developed using advanced near-infrared spectroscopy technology powered by machine learning that delivers radiation-free, colour-coded results at a lower cost compared to MRI and CT. It is user-friendly, operable by paramedical staff or unskilled personnel after just 30 minutes of training. Additionally, a pre-installed ‘How to use’ help video simplifies the learning process for users.

With CEREBRO, the optical density values of the right and left hemispheres of the brain in four different regions are compared non-invasively to detect intracranial bleeding and brain oedema within minutes. The device provides colour-coded results that enable quick triage and decision-making. The device has the potential of being cost-effective, eliminating the need for expensive imaging infrastructure. Efforts are underway to integrate CEREBO into existing healthcare systems, scaling up for use in the military, as well.

ALLADI MOHAN, Tirupati, Andhra Pradesh, India

ORCID iD: 0000-0002-3214-9884