In a first, Supreme Court gives green signal for passive euthanasia

On 11 March, a Bench of Justices J.B. Pardiwala and K.V. Viswanathan permitted a plea seeking passive euthanasia for Harish Rana, a 32-year-old who has been in a permanent vegetative state for 13 years. Justice Pardiwala wrote the lead opinion, and Justice Viswanatahn penned a concurring one. 

Passive euthanasia involves withdrawing life-supporting medical treatment so that life is not artificially prolonged. This was the first instance where the passive euthanasia guidelines set out by the Supreme Court in Common Cause v Union of India (2018) were applied to their complete extent. In Common Cause, a Constitution Bench of five judges had held that the right to die with dignity is a facet of the right to life and liberty under Article 21. The guidelines had been simplified in 2023 by another five-judge Bench. 

In the present case, the Court stated that any withholding of treatment should be carried out in a manner that is humane—it should not result in an “abandonment” of the patient. 

Background

Rana’s fall from the fourth floor resulted in a diffuse axonal injury. He suffered from quadriplegia and 100 percent disability. He was put under Clinically Assisted Nutrition and Hydration (CANH) treatment. This became his primary form of consumption of food and hydration, through a Percutaneous Endoscopic Gastrostomy Tube (PEG) tube. 

Rana’s plea for passive euthanasia was first taken up by the Delhi High Court. In 2024, the High Court rejected his petition stating that the withdrawal of CANH treatment would result in him starving to death. Since he was not supported by medical ventilators, it would not amount to passive euthanasia. In August 2024, the Supreme Court said it prima agreed with the view of the High Court but issued notice to the Union to explore the possibility of moving Rana to a facility where his needs could be taken care for, given the financial drain on his aged parents. In November 2024, on the final day of then Chief Justice D.Y. Chandrachud’s tenure, the Bench suggested that the Uttar Pradesh government provide aid to cover his medical expenses. 

Later, a miscellaneous application was filed by Rana’s parents in October 2025, which was taken up by a Bench of Justices Pardiwala and Viswanathan. As per the Common Cause guidelines, the Bench set up the two-tier medical review process. The Primary Board stated that Rana had a negligible chance of recovery. After perusing a similar report by the Secondary Board, the Bench described Rana’s condition to be “very sad” and stated that it would take a “final call”. The Bench also met Rana’s parents. 

In a desk brief in December, we had written that Rana’s case was the ultimate litmus test for the implementation of the Common Cause guidelines. We highlighted two key questions: whether CANH amounts to “life-supporting” treatment, and whether the Court could deliver a verdict in the patient’s “best interests”. The present verdict answers both.

CANH as life-supporting treatment

The Court held that CANH cannot be classified as “primary care” and was a medical treatment for all intents and purposes. It was distinct from methods such as spoon feeding and required a technologically mediated medical intervention. The administration of CANH or PEG tubes requires periodic review, medical evaluation and clinical judgement. 

The Court concluded that CANH is subject to “the same ethical, legal, and clinical principles that govern the initiation, continuation, withholding, or withdrawal of other life-sustaining medical interventions”. The significance of determining CANH as a “medical treatment” would allow doctors to evaluate whether the continuation of treatment is in the “best interest of the patient”. The Court held that the Primary and Secondary Medical Board is at liberty to exercise their independent clinical judgement on the question of continuation or withdrawal of CANH. 

Welcoming the judgment, Vipul Mudgal, Director of the NGO Common Cause, told the Supreme Court Observer: “I think it is a step in the right direction. It is a good judgement, it vindicates our position. What it also tells us is that every case will be different because it is a matter of life and death. It is also a question of deeper human philosophy—it is not just a question of medical science.”

“Best interest of the patient”

In Common Cause, the Court held that any decision involving withdrawing or withholding treatment should be made keeping the “best interest of the patient” principle in mind, which is relevant when a patient is unable to communicate their own decision. Determining “best interest” is on the doctors and the courts. In Common Cause, former Chief Justice Dipak Misra concluded that the best interest of the patient overrides State interest too. 

In Rana’s case, the Bench acknowledged that the “best interest” principle does not have a straight-jacket formula that fits all facts and circumstances. It required a holistic assessment of both medical and non-medical factors, which include  “the patient’s wishes, feelings, beliefs, values, and any other factor that would be likely to influence the patient’s decision, or which the patient himself would have taken into account, had he retained the capacity to decide.” 

In Rana’s case, the Court noted that the issue was not whether it was in his best interest to die but whether it was in his best interest for his life to be artificially prolonged. On this aspect, Mudgal told SCO that the decision should be viewed in the context of how medical science has made it possible to keep people alive for a “ridiculous amount of time.”

Ever since his accident, Rana has been on tracheostomy, urinary catheter and CANH administered through the PEG tube. He also has a history of seizures, with medical reports suggesting that he had no awareness of his environment and could not indicate by facial gestures that he was hungry or uncomfortable. Further, the Secondary Board had found his brain damage to be irreversible. While the CANH was necessary for his survival, it was not improving his condition. 

The Court took a balance sheet approach weighing the pros and the cons—the benefits of treatment against burdens caused due to it, which included physical suffering, invasiveness, indignity and psychological distress. Rana’s parents contended that they have the moral responsibility to speak for him in his best interest. Their decision to initiate the process under the Common Cause guidelines was taken after it became unequivocally clear that “continuing the medical treatment no longer serves any meaningful purpose for [Rana] and only prolongs his agony, which is causing an undignified life for the applicant.”

No ambiguity in the medical process

The Primary and the Secondary Boards were of the opinion that the treatment administered to Rana “has become prolonged, futile, and offers no hope of recovery.” The Court applied the “substituted judgement standard” which requires the Court to be “in the position of the patient and to consider in a patient-centric manner what that patient would have wanted if he had capacity to do so.” 

The Bench noted that there was no prior indication by Rana on withholding medical treatment—such as an advanced medical directive or ‘living will’. The substituted judgement standard pushed the Bench to conclude that “he would not have chosen to continue CANH in these circumstances.” Certain non-medical factors provided a “relevant lens” to the Bench in this regard—Rana was energetic and deeply engaged in physical activities such as sports and gymming.

Justice Chandrachud’s opinion in Common Cause had stated that the “best interest” has to be balanced with the substituted judgement standard as a matter of “public interest”. In the present case, the Court added that both the Primary and Secondary Medical Boards had stated that withdrawing CANH treatment was in the best interest of the patient. It clarified that the Court is not always the final arbiter when it comes to determining the patient’s welfare. 

Withholding of treatment not an “abrupt act” 

The Court underscored the importance of palliative medicine and End of Life (EOL) Care. It observed that doctors have an obligation to take care of the patient even after treatment is withheld. The Court directed that there should be step-by-step withdrawal or withholding of CANH through a “clearly articulated and medically supervised palliative and EOL care plan.” Mudgal told SCO that he was pleased with the Court’s reference to palliative care, which isn’t discussed enough. “We don’t have any system of palliative care in our country. Perhaps Kerala is the only state which has some amount of alternative options,” he said. 

The Bench said that the “right to die with dignity is inseparable from the right to receive quality palliative and EOL care.” It directed the All India Institute of Medical Sciences to admit Rana into palliative care.

Towards the end of his opinion, Justice Pardiwala wrote that the decision was not an “act of surrender” but one of “compassion and courage”. It was not rooted only in logic and reason but “sits in a space between love, loss, medicine and mercy”. Acknowledging the emotional weight of the decision, Justice Pardiwala addressed Rana’s parents directly: “You are not giving up on your son,” he wrote. “You are allowing him to leave with dignity. It reflects the depth of your selfless love and devotion towards him.”