Passive euthanasia: What are ‘best interests’ of a patient in vegetative state? Supreme Court explains

The Supreme Court on Wednesday explained the legal test for determining the “best interests of a patient” in cases involving passive euthanasia while allowing withdrawal of life-sustaining treatment for a man who has remained in a vegetative state since 2013 [Harish Rana v. Union of India & Ors].

A Bench of Justices JB Pardiwala and KV Viswanathan held that the best interest principle cannot be construed in a narrow, rigid manner. The determination of the same, the Bench held, requires due evaluation of all relevant circumstances and considerations, both medical and non-medical.

After going through how the 'best interest' principle is adopt across the globe, the Court culled out the relevant factors, including:

• the patient’s medical prognosis;

• the invasiveness and futility of treatment;

• the patient’s dignity and welfare, and

• the views of next of kin/next friend/guardian who have cared for the patient.

It observed that modern medical technology can prolong biological existence even where there is no prospect of recovery, raising complex ethical and legal questions. In such situations, the Court said that the law must ensure that decisions are guided by the patient’s welfare and dignity rather than the mere possibility of extending life through artificial means. It went on to note,

"The best interests principle shall incorporate a strong element of the substituted judgment standard, requiring the decisionmaker to place himself, so far as possible, 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 Court was dealing with a plea filed by the parents of one Harish Rana, a 32-year-old man who has remained in a permanent vegetative state following an accident in 2013. Rana suffered severe brain injury and has since been dependent on artificial feeding and medical support.

His parents approached the Court seeking permission to withdraw life-sustaining treatment, including clinically assisted nutrition and hydration (CANH), arguing that his condition was irreversible and that the continuation of life support served no meaningful purpose.

Medical reports placed before the Court indicated that Rana had suffered irreversible brain damage and had been in a non-progressive vegetative condition for more than a decade.

The Court examined whether the continuation of CANH through a feeding tube could legally be treated as “medical treatment” capable of being withdrawn under the passive euthanasia framework laid down in Common Cause v. Union of India (2018).

The Bench noted that Rana was being sustained through a percutaneous endoscopic gastrostomy (PEG) tube and recorded that such artificial feeding constitutes medical intervention.

By recognising artificial nutrition and hydration as medical treatment, the Court clarified that it can be withdrawn where the statutory and judicial safeguards governing passive euthanasia are satisfied.

It concluded that Rana’s condition was irreversible and that continued artificial life support did not serve any therapeutic purpose. It, therefore, held that withdrawal of CANH and other life-sustaining treatment would be consistent with the best interests of the patient.

The Court emphasised that the decision was being taken strictly within the passive euthanasia framework recognised in the Common Cause case, which permits withdrawal of life-sustaining treatment under judicial oversight and subject to medical safeguards.

At the same time, the Bench reiterated that active euthanasia remains impermissible under Indian law.

Emotional weight of the decision

In its judgment, the Court placed on record its appreciation for the care given by Rana’s family over the past thirteen years.

The Bench noted that despite the severity of his condition, his parents and siblings had continued to care for him with dedication and compassion.

“Throughout the adjudication of this matter, we have been gripped by profound sadness. The issues in this matter have once again brought to the fore the fragility and transient nature of the life we live, and how swiftly the tide can turn for the worse. For the past thirteen years, the applicant has lived a life defined by pain and suffering…We note with immense respect that the applicant’s parents and siblings have stood as unyielding pillars of support…We can only place on record our deepest appreciation for their boundless love, endurance, and kindness in the face of such adversity.” it noted.

The Court further observed that the decision to permit withdrawal of life-sustaining treatment was not about choosing death, but about recognising when medical intervention no longer improves life.

“Our decision today does not neatly fit within logic and reason alone. It sits in a space between love, loss, medicine and mercy. This decision is not about choosing death, but is rather one of not artificially prolonging life. It is the decision to withdraw life-sustaining treatment when that treatment no longer heals, restores, or meaningfully improves life. It is allowing nature to take its course when medicine can only delay the inevitable because survival is not always the same as living.”

Addressing Rana’s family directly, the Court acknowledged the emotional difficulty of the decision.

“To Harish’s family, we want to acknowledge the deep emotional weight this decision carries. This decision can feel like an act of surrender, but we believe it is, in truth, an act of profound compassion and courage. You are not giving up on your son. You are allowing him to leave with dignity.”

Call for end-of-life framework

In the end, the Court also expressed concern over the absence of a comprehensive statutory framework governing end-of-life decisions in India.

It noted that despite recommendations made by the Law Commission in 2006 and again in 2012, parliament has not enacted a dedicated law regulating end-of-life care and withdrawal of treatment.

The Bench urged the Central government to consider enacting legislation so that decisions relating to end-of-life care are guided by clear legal safeguards and are not influenced by factors such as financial distress or gaps in insurance coverage.

The Court also disapproved of the common hospital practice of discharging vegetative patients against medical advice.

It observed that the practice of “Discharge Against Medical Advice” (DAMA) often shifts responsibility away from medical institutions in cases involving patients requiring end-of-life care.

The Court held that hospitals should instead provide a structured palliative and end-of-life care plan for such patients.

[Read judgment]