Supreme Court: In a landmark ruling on right to die with dignity, the Supreme Court has, for the first time, allowed the withdrawal of life-sustaining medical treatment for a patient in a Persistent Vegetative State for 13 years. The Court was dealing with the application filed by a young man who has been in vegetative state for 13 years, seeking assessment of suitability of continuing the his Clinically Assisted Nutrition and Hydration (CANH) in accordance with the principles laid down in Common Cause v. Union of India, (2018) 5 SCC 1 and modified in Common Cause v. Union of India, (2023) 14 SCC 131 (Common Cause Guidelines). The Division Bench of J.B. Pardiwala* and K.V. Viswanathan**, JJ., applying the Common Cause Guidelines in full measure, unanimously directed that the medical treatment, including CANH, being administered to the applicant be withdrawn and/or withheld.
The Court further held that right to die with dignity is inseparable from the right to receive quality palliative and EOL care. The Court emphasised that it is imperative to ensure that the withdrawal process for the applicant is not marred by pain, agony, or suffering. “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”.
In his supplementing opinion, K.V. Viswanathan, J., also lauded the love and affection by which the parents and the siblings have nursed the applicant for 13 years in his vegetative state.
Background and Legal Trajectory
At the age of 20 years, while pursuing B. Tech degree at Punjab University, the applicant met with an unfortunate accident after he fell from the fourth floor of his paying guest accommodation. Consequently, he sustained a diffuse axonal injury. Given the severity of his condition, he was administered treatment in the form of conservative management, including AED, analgesics, ventilating support, antibiotics, tracheostomy, and feeding through a Ryle’s tube (nasogastric tube). Eventually, the mode of administering CANH came to be switched from Ryle’s Tube/nasogastric tube to a surgically placed PEG tube, which requires replacement at a hospital every two months.
Medical reports further indicated that the applicant exhibited no evidence of awareness of his environment and was incapable of interacting with others. The applicant remained bedridden ever since the incident, due to which he has often suffered terribly from painful bedsores, despite receiving the most attentive nursing care from his mother.
The Supreme Court in 2025 directed the constitution of a primary and secondary medical board of doctors in accordance with the Common Cause Guidelines and to submit its report ascertaining whether life sustaining treatment for the applicant ought to be withdrawn or withheld. The reports indicated that continued administration of CANH is required for the applicant’s sustenance, however, this may not aid in improving the applicant’s condition.
The applicant’s parents requested the Court to take necessary steps to ensure that the applicant does not suffer any more.
Court’s Assessment
Perusing this matter, the Court firstly noted that in Common Cause 2018 (supra), the Court held that- “right to live with dignity” under Article 21 of the Constitution inherently includes the “right to die with dignity” and passive euthanasia and Assisted Medical Directives (AMD) are both legal and permissible under the framework of Article 21 of the Constitution, being rooted in the constitutional values of liberty, dignity, and individual privacy. The Court further delved into the difference between active euthanasia and passive euthanasia and that this distinction was based on the constitutional principles underlying Article 21 of the Constitution.
Furthermore, the Court clarified that in the judgment, “Euthanasia” will refer strictly to active euthanasia, which remains impermissible; “Withdrawing or Withholding of Medical Treatment” will replace the term passive euthanasia.
The Court thus framed and answered the following issues”
Whether the administration of CANH is to be regarded as “medical treatment”?
The Court clarified that CANH refer to all forms of enteral nutrition and parenteral nutrition which are administered upon clinical indication, which is not inclusive of oral feeding, by cup, spoon, or any other method of delivering food or nutritional supplements into the patient’s mouth. Examining the clinical and procedural characteristics of CANH, the Court explained that this indicates that CANH cannot be regarded as a mere means of basic sustenance or primary care, but should be recognised as a technologically mediated medical intervention that is prescribed, supervised and periodically reviewed by trained healthcare professionals in accordance with established medical standards. Relying on relevant precedents, the Court explained that it is crucial that CANH be regarded as medical treatment, forming an integral part of a patient’s medical management, and be subject to the same ethical, legal, and clinical principles that govern the initiation, continuation, withholding, or withdrawal of other life-sustaining medical interventions. “To deny it recognition as a medical treatment would reduce the patient to being a passive subject of medical technology, while simultaneously depriving doctors of the agency necessary to responsibly assess the therapeutic value of such intervention in the discharge of their duty of care”. Answering whether CANH that is administered at home can still be regarded as a medical treatment, the Court clarified that merely because routine feeding in the form of CANH can be administered at home, by an informed lay person, it cannot be relegated to a non-medical status.
Therefore, the Court opined that CANH constitutes “medical treatment” and must be governed by the same legal principles applicable to the withholding or withdrawal of other forms of life-sustaining medical interventions, subject, of course, to the safeguards and procedural requirements laid down by this Court in Common Cause 2018 (supra).
Meaning, scope, and contours of the principle of “best interest of the patient” in determining whether medical treatment should be withdrawn or withheld?
Referring to several foreign cases on point, the Court noted that in India, particularly with respect to cases where there is an AMD, shows that the treating physician triggers the process for withdrawal or withholding of medical treatment upon the fulfilment of five broad conditions: (i) the Executor becomes terminally ill, (ii) is undergoing prolonged medical treatment, (iii) with no hope of recovery, (iv) no cure of ailment, and (v) the patient does not have decision-making capacity i.e., the patient is incompetent.
With respect to cases where there is no AMD, the treating physician triggers the process for withdrawal or withholding of medical treatment upon the fulfilment of three broad conditions: (i) the Patient is terminally ill, (ii) is undergoing prolonged treatment in respect of an ailment which is, (iii) incurable or where there is no hope of being cured.
The Court opined that the patient’s next of kin/next friend/guardian, the medical boards, or the courts (if involved), while determining what constitutes the best interests of the patient, are required to undertake a holistic assessment of all relevant circumstances, both medical and non-medical, including but not limited to, 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.
Explaining that the best interest principle cannot be defined by a single, straight-jacketed test that would fit across all facts and circumstances, the Court opined that the principle of “best interest of the patient” may include, but not be limited to, the following considerations:
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While deciding upon the withdrawal or withholding of medical treatment, the correct question should be whether it is in the patient’s best interests that life should be prolonged by the continuance of the particular medical treatment in question.
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The determination of “best interests” requires due evaluation of all relevant circumstances and considerations, both medical and non-medical.
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At the foundational level, the best interests inquiry is anchored in a strong presumption in favour of preserving life, reflecting the sanctity of life. This presumption is not absolute and may be displaced where continuation of medical treatment ceases to serve any therapeutic purpose, i.e., becomes futile, merely prolongs the suffering without the hope of recovery or causes indignity to the life of the patient.
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Assessment of best interests must, therefore, necessarily encompass an evaluation of the futility of treatment, the absence of therapeutic purpose, the invasive and burdensome nature of continued medical intervention, and the indignity attendant upon artificially prolonging life in a state devoid of awareness, autonomy, or human interaction.
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Decision-makers such as the patient’s next of kin/next friend/guardian, the treating physician, the members of the medical boards, or the courts (if involved), as the case may be, must look at the patient’s welfare in the widest sense, not just medical but also social and psychological.
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Decision-makers must try to put themselves in the place of the individual patient and ask what his wishes and attitude to the treatment is or would be likely to be; and they must consult others who are looking after him or interested in his welfare, in particular for their view of what the patient would have wanted.
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Best interests principle shall incorporate a strong element of the substituted judgment standard, requiring the decision maker 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. However, substituted judgment would not operate as an autonomous or overriding standard. The ultimate inquiry remains what course of action serves the patient’s best interest.
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Decision-makers, after identifying and collating necessary and ascertainable considerations, both medical or non-medical, must engage in the balance sheet exercise, which would involve weighing the potential benefits of continued treatment against its burdens, including physical suffering, invasiveness, indignity, psychological distress, wishes and welfare of the patient, the impact upon the patient’s lived experience and family life, and other like considerations.
Whether it is in the best interest of the applicant that his life be prolonged by continuation of medical treatment?
Answering this issue, the Court took note of the current state of the applicant, his medical reports and opinions expressed by his next of kins/next friends/guardians, after being informed of medical considerations by the doctors. It was noted that all across the board and without any ambiguity, it has been opined that the applicant would remain in Persistent Vegetative State (PVS) for years to come, with the tubes inserted all over his body. However, he would never be able to recover from such a condition. The treatment being administered to the applicant has become prolonged, futile, and offers no hope of recovery.
Emphasising that the present matter is the first case that has reached the Court wherein the Common Cause Guidelines are being applied in their full measure, the Court clarified that discussion demonstrating how the best interest principle applies to the facts of the present matter should not be misconstrued to mean that a court must always be the final arbiter of what is in the best interest of the patient.
What are the further steps to be undertaken in the event that a decision to withdraw or withhold medical treatment is arrived at?
The Court emphasised that the withdrawal or withholding of medical treatment must be effected through a structured and humane process, accompanied by a palliative and EOL care plan. The Court opined that two aspects are required to be addressed at this stage: (i) streamlining of the Common Cause Guidelines; and (ii) the need for a subject-specific legislation.
Decision and Directions
With the aforestated assessment, the Court directed the withdrawal of applicant’s CANH and waived the reconsideration period of 30 days due to the peculiar facts of the case.
The Court directed AIIMS to grant admission and provide necessary facilities to the applicant in its Palliative Care department so that the withdrawal and/or withholding of the applicant’s medical treatment, including CANH, can be given effect to. AIIMS was directed to ensure that such withdrawal and/or withholding is carried out through a robust palliative and EOL care plan, which is specifically tailored to manage symptoms without causing any discomfort to the applicant, and ensuring that his dignity is preserved to the highest degree.
High Courts of all States shall issue appropriate directions to all Judicial Magistrates of First Class (JMFC) within their jurisdiction to receive intimation from the hospital, in accordance with the guidelines as laid down in Common Cause (supra), in the event the primary medical board and secondary medical board are unanimous in their decision to withdraw and/or withhold the medical treatment of any patient.
Union of India in coordination with the respective Secretaries of Health & Family Welfare of all States/UTs, shall ensure that the CMOs of all concerned districts across the country, forthwith prepare and maintain a panel consisting of registered medical practitioners possessing qualifications in accordance with the guidelines as laid down in Common Cause (supra), for the purpose of nomination to the secondary medical board.
It shall be the duty of the Secretaries of Health and Family Welfare of each State/UT to make sure that such periodic review and updation at regular intervals is undertaken by the CMOs of all districts falling within their respective State/UT.
[Harish Rana v. Union of India, Miscellaneous Application No. 2238 of 2025, decided on 11-3-2026]
*Judgment by Justice J.B. Pardiwala
**Supplementing opinion by Justice K.V. Viswanathan