📋 Editorial Notes
Question(s):
(i) Whether the Clinically Assisted Nutrition and Hydration (“CANH”) constitutes "medical treatment" that can be lawfully withdrawn under the passive euthanasia framework.
(ii) What is the meaning, scope, and contours of the principle of “best interest of the patient” in determining whether medical treatment should be withdrawn or withheld?
(iii) What directions are to be issued keeping in view the unanimous medical opinion confirming Harish Rana’s irreversible vegetative state, the absence of benefit from continued CANH, and the consideration of non-medical factors and family consultations.
Factual Background:
In 2018, the Supreme Court in Common Cause v Union of India [2018 INSC 223] ("Common Cause") held that the right to die with dignity is part of the right to life under Article 21. The Court clarified that euthanasia stays unlawful in India, but withholding or withdrawing life-sustaining treatment is legally permissible in certain situations. It set out three points. First, a person with decision-making capacity has the right to refuse life-sustaining treatment. Second, an adult may execute an Advance Medical Directive ("AMD") setting out their wishes for future treatment if they later lose the capacity to decide. Third, life-sustaining treatment may be withheld or withdrawn from a person lacking decision-making capacity, whether or not they left an AMD. The Court emphasised that a person refusing life-sustaining treatment remains entitled to palliative care and other medical support.
Harish Rana suffered a severe brain injury after falling from a fourth-floor building in August 2013. This left him in a Permanent Vegetative State (“PVS”) with 100% permanent disability. For over thirteen years, he has been bedridden and sustained entirely by CANH through a Percutaneous Endoscopic Gastrostomy ("PEG") tube.
Harish, through his parents, approached the Delhi High Court in 2024 seeking a Medical Board to withdraw the PEG tube. The High Court dismissed the petition on the ground that he was not kept alive mechanically, could sustain himself without external aid, and that active euthanasia was legally impermissible.
The Court had earlier disposed of the Special Leave Petition by its order dated 8 November 2024, noting the parents' satisfaction with the Respondents' efforts to explore alternative care for the petitioner. The Court granted liberty to approach it again through the parents. The parents then filed the Miscellaneous Application that led to this judgment, on the ground that Harish's continued vegetative existence violated his right to live with dignity. The Court constituted Primary and Secondary Medical Boards, which unanimously confirmed that his condition is irreversible and that continuing CANH gave him no therapeutic benefit.
Decision of the Supreme Court:
A Two-Judge Bench of the Supreme Court allowed the Miscellaneous Application, permitting the withdrawal and withholding of the medical treatment, including CANH, being administered to the Applicant. The Supreme Court directed All India Institute of Medical Sciences, New Delhi (“AIIMS”) to admit the applicant to its Palliative Care department to implement the withdrawal through a robust palliative and End of Life (“EOL”) care plan, ensuring the preservation of his dignity. The standard 30-day reconsideration period was waived given the unanimity among all stakeholders. The Supreme Court also issued directions to streamline the Common Cause guidelines and urged the Union Government to enact comprehensive legislation on the subject. The judgment of the court was authored by Justice Pardiwala. Justice Viswanathan authored a concurring opinion.
Guidelines
The Supreme Court explained and streamlined the principles recognised by Common Cause to address the practical difficulties faced by stakeholders, acknowledging that doctors remain hesitant and apprehensive about starting this process (¶255, J. Pardiwala).
Safeguarding Checkpoints: The Supreme Court reiterated the Common Cause requirement of a collaborative, multi-tiered process, involving Primary and Secondary Medical Boards and the High Court, to keep the process neutral and remove doctors' hesitation.
Role of Next of Kin: The Supreme Court held that the Medical Board must identify the patient's caregivers as next of kin, inform them of the pros and cons of withdrawing treatment, and record the minutes of that discussion (¶262, J. Pardiwala). Their written consent, which is mandatory, must reflect the patient's best interests and not merely the parents' preferences (¶263, J. Pardiwala).
Home-Care Patients: The Supreme Court held that families of patients treated at home can either admit them to a hospital or approach a hospital solely to have a primary treating physician designated.
i) The next of kin or guardian may admit the patient to any hospital of their choice, which then bears responsibility for complying with the guidelines (¶266, J. Pardiwala).
ii) Where admission is not feasible, they may approach a hospital to have a primary treating physician designated, who will assess the patient and start the process (¶266, J. Pardiwala).
iii) In both situations, medical practitioners and hospitals are expected to assist, not refuse care (¶267, J. Pardiwala).
CMO Nominations: The Supreme Court held that to prevent arbitrary discretion in choosing the CMO-nominated practitioner (¶271, J. Pardiwala), Chief Medical Officers in every district must maintain an updated panel of registered practitioners and nominate one to the Secondary Medical Board, preferably within 48 hours of a hospital's request. This panel must be reviewed at intervals not exceeding twelve months (¶272, J. Pardiwala).
Reconsideration Period: The Supreme Court held that a 30-day cooling period applies after medical experts agree on withdrawal, during which any aggrieved person with locus may approach a court of law (¶¶274–275, J. Pardiwala).
Court Intervention: The Court held that judicial intervention should remain minimal, but a party may approach the High Court under Article 226 if the Medical Boards disagree on withdrawal, or if a hospital fails to constitute a Board (¶¶277–278, J. Pardiwala).
(i) Whether the Clinically Assisted Nutrition and Hydration (“CANH”) constitutes "medical treatment" that can be lawfully withdrawn under the passive euthanasia framework.
(ii) What is the meaning, scope, and contours of the principle of “best interest of the patient” in determining whether medical treatment should be withdrawn or withheld?
(iii) What directions are to be issued keeping in view the unanimous medical opinion confirming Harish Rana’s irreversible vegetative state, the absence of benefit from continued CANH, and the consideration of non-medical factors and family consultations.
Factual Background:
In 2018, the Supreme Court in Common Cause v Union of India [2018 INSC 223] ("Common Cause") held that the right to die with dignity is part of the right to life under Article 21. The Court clarified that euthanasia stays unlawful in India, but withholding or withdrawing life-sustaining treatment is legally permissible in certain situations. It set out three points. First, a person with decision-making capacity has the right to refuse life-sustaining treatment. Second, an adult may execute an Advance Medical Directive ("AMD") setting out their wishes for future treatment if they later lose the capacity to decide. Third, life-sustaining treatment may be withheld or withdrawn from a person lacking decision-making capacity, whether or not they left an AMD. The Court emphasised that a person refusing life-sustaining treatment remains entitled to palliative care and other medical support.
Harish Rana suffered a severe brain injury after falling from a fourth-floor building in August 2013. This left him in a Permanent Vegetative State (“PVS”) with 100% permanent disability. For over thirteen years, he has been bedridden and sustained entirely by CANH through a Percutaneous Endoscopic Gastrostomy ("PEG") tube.
Harish, through his parents, approached the Delhi High Court in 2024 seeking a Medical Board to withdraw the PEG tube. The High Court dismissed the petition on the ground that he was not kept alive mechanically, could sustain himself without external aid, and that active euthanasia was legally impermissible.
The Court had earlier disposed of the Special Leave Petition by its order dated 8 November 2024, noting the parents' satisfaction with the Respondents' efforts to explore alternative care for the petitioner. The Court granted liberty to approach it again through the parents. The parents then filed the Miscellaneous Application that led to this judgment, on the ground that Harish's continued vegetative existence violated his right to live with dignity. The Court constituted Primary and Secondary Medical Boards, which unanimously confirmed that his condition is irreversible and that continuing CANH gave him no therapeutic benefit.
Decision of the Supreme Court:
A Two-Judge Bench of the Supreme Court allowed the Miscellaneous Application, permitting the withdrawal and withholding of the medical treatment, including CANH, being administered to the Applicant. The Supreme Court directed All India Institute of Medical Sciences, New Delhi (“AIIMS”) to admit the applicant to its Palliative Care department to implement the withdrawal through a robust palliative and End of Life (“EOL”) care plan, ensuring the preservation of his dignity. The standard 30-day reconsideration period was waived given the unanimity among all stakeholders. The Supreme Court also issued directions to streamline the Common Cause guidelines and urged the Union Government to enact comprehensive legislation on the subject. The judgment of the court was authored by Justice Pardiwala. Justice Viswanathan authored a concurring opinion.
Guidelines
The Supreme Court explained and streamlined the principles recognised by Common Cause to address the practical difficulties faced by stakeholders, acknowledging that doctors remain hesitant and apprehensive about starting this process (¶255, J. Pardiwala).
Safeguarding Checkpoints: The Supreme Court reiterated the Common Cause requirement of a collaborative, multi-tiered process, involving Primary and Secondary Medical Boards and the High Court, to keep the process neutral and remove doctors' hesitation.
Role of Next of Kin: The Supreme Court held that the Medical Board must identify the patient's caregivers as next of kin, inform them of the pros and cons of withdrawing treatment, and record the minutes of that discussion (¶262, J. Pardiwala). Their written consent, which is mandatory, must reflect the patient's best interests and not merely the parents' preferences (¶263, J. Pardiwala).
Home-Care Patients: The Supreme Court held that families of patients treated at home can either admit them to a hospital or approach a hospital solely to have a primary treating physician designated.
i) The next of kin or guardian may admit the patient to any hospital of their choice, which then bears responsibility for complying with the guidelines (¶266, J. Pardiwala).
ii) Where admission is not feasible, they may approach a hospital to have a primary treating physician designated, who will assess the patient and start the process (¶266, J. Pardiwala).
iii) In both situations, medical practitioners and hospitals are expected to assist, not refuse care (¶267, J. Pardiwala).
CMO Nominations: The Supreme Court held that to prevent arbitrary discretion in choosing the CMO-nominated practitioner (¶271, J. Pardiwala), Chief Medical Officers in every district must maintain an updated panel of registered practitioners and nominate one to the Secondary Medical Board, preferably within 48 hours of a hospital's request. This panel must be reviewed at intervals not exceeding twelve months (¶272, J. Pardiwala).
Reconsideration Period: The Supreme Court held that a 30-day cooling period applies after medical experts agree on withdrawal, during which any aggrieved person with locus may approach a court of law (¶¶274–275, J. Pardiwala).
Court Intervention: The Court held that judicial intervention should remain minimal, but a party may approach the High Court under Article 226 if the Medical Boards disagree on withdrawal, or if a hospital fails to constitute a Board (¶¶277–278, J. Pardiwala).