Authored By: Vibha Rana
Galgotias University
Abstract
The right to die with dignity has emerged as a critical legal and ethical issue in India, challenging conventional understandings of Article 21 of the Constitution. This paper critically examines the evolution of Indian jurisprudence on euthanasia and advance medical directives, with a focus on the landmark Common Cause v Union of India judgment and its 2023 clarification. It analyses the shift from judicial recognition to the need for a statutory framework, drawing comparative insights from countries like the Netherlands, Belgium, Canada, and select U.S. states. Despite progressive judicial developments, persistent challenges such as medical reluctance, lack of awareness, and absence of legislation hinder the practical enforcement of passive euthanasia and living wills. The paper argues for a comprehensive “End-of-Life Care Act,” improved institutional mechanisms, and public sensitisation to uphold patient autonomy and ethical healthcare practices. A legally sound, compassionate approach to end-of-life care must balance individual rights with safeguards against misuse, affirming dignity not only in life but also in death.
Keywords:
Passive euthanasia, advance directives, living will, right to die with dignity, Article 21, Indian Constitution, end-of-life care, Common Cause case, patient autonomy, medical ethics, legal framework, euthanasia law India.
Introduction
The right to die with dignity has emerged as one of the most morally and legally complex debates of the 21st century. At the intersection of law, medicine, ethics, and human rights, end of-life decisions—such as euthanasia and advance directives—raise fundamental questions about personal autonomy, the sanctity of life, and the role of the state in regulating death. The increasing importance of patient autonomy and the evolution of the right to privacy and dignity have compelled courts and lawmakers across jurisdictions to reconsider the legality of assisted dying and passive euthanasia.1
In India, the jurisprudence on euthanasia and the right to die has undergone significant transformation, culminating in the Supreme Court’s landmark decision in Common Cause v Union of India (2018),2 which recognised passive euthanasia and legally validated advance medical directives. This recognition, however, has brought forth new legal and procedural challenges. This article critically examines India’s legal position on euthanasia and end-of-life choices, compares it with international frameworks, and analyses the evolving jurisprudence under Article 21 of the Constitution. It argues for the need to develop a comprehensive legal and policy framework that strikes a balance between autonomy, ethical concerns, and necessary safeguards against abuse.
The Right to Die with Dignity: Indian Constitutional Perspective
The right to life under Article 21 of the Indian Constitution has, over decades, expanded to include several facets of personal liberty and dignity. From the right to privacy to the right to health and bodily integrity, the jurisprudence has grown dynamically to reflect changing societal values. Within this evolution lies the controversial aspect of the right to die with dignity—an idea once rejected but now partially embraced under specific conditions.
The Gian Kaur Reversal of P. Rathinam
The first significant judicial deliberation on the subject came in P. Rathinam v Union of India, where the Supreme Court controversially held that the right to die is a part of the right to life under Article 21, thereby striking down Section 309 of the Indian Penal Code (IPC), which criminalised suicide.31 However, this reasoning was overruled in Gian Kaur v State of Punjab, where a five-judge bench held that Article 21 does not include the right to die.4Importantly, though, the Court introduced the concept of a “dignified end of life,” noting that while the right to die per se is not protected, the notion of dignity in death may be part of Article 21.5
Aruna Shanbaug: Recognising Passive Euthanasia
The turning point came with Aruna Ramachandra Shanbaug v Union of India, where the Supreme Court for the first time conditionally allowed passive euthanasia in India.6 The Court, while dealing with the plea for euthanasia in a case involving a patient in a permanent vegetative state, distinguished between active and passive euthanasia. It permitted the withdrawal of life-sustaining treatment under strict judicial supervision, pending legislation by Parliament. This judgment opened the door to consider passive euthanasia not as an act of killing but as an act of letting die.
Common Cause v Union of India (2018): A Constitutional Recognition
The landmark judgment in Common Cause v Union of India settled the debate in favour of recognising passive euthanasia and legalising advance directives under constitutional protection.7 The Supreme Court held that the right to die with dignity is an intrinsic part of Article 21 and that individuals have the right to refuse life-prolonging treatment when in terminal stages of illness.
The Court issued comprehensive guidelines allowing individuals to make an advance medical directive (living will), whereby they could express their future healthcare choices in anticipation of a situation where they would be unable to communicate their decisions. The judgment provided procedural safeguards to prevent misuse, including requirements for medical board approvals, district magistrate supervision, and judicial oversight.
Although the guidelines were a breakthrough, critics pointed out that the complex procedural requirements made enforcement extremely difficult in practice. It wasn’t until 2023 that the Supreme Court simplified these norms in a new ruling, making the process of recording and executing living wills more realistic and patient-friendly.
Advance Medical Directives: Legal Status and Implementation in India
Advance medical directives—commonly referred to as “living wills”—are legal instruments that allow individuals to record their preferences regarding end-of-life care, including refusal of artificial life-support in the event of irreversible medical conditions. Their purpose is to uphold patient autonomy when the patient is no longer capable of expressing informed consent.8
- Legal Recognition and Judicial Guidelines
In Common Cause v. Union of India, the Supreme Court acknowledged advance directives as a facet of the right to die with dignity and laid down guidelines for their execution.9 According to the judgment, any adult of sound mind may execute a living will specifying the circumstances under which they do not wish to receive medical treatment, including artificial life support. The guidelines required the document to be executed before two witnesses and a Judicial Magistrate (First Class); reviewed by a Medical Board comprising the Chief Medical Officer and three expert doctors; and approved again by a district-level medical board before withdrawal of treatment. Though progressive in intent, the guidelines were seen as overly bureaucratic and impractical, particularly in emergency medical settings.10 The involvement of multiple layers of medical and judicial authorities made timely decisions difficult, potentially defeating the directive’s objective.
- 2023 Supreme Court Modification
Recognising the implementation difficulties, the Supreme Court in Common Cause (Clarification Order), 2023 simplified the procedure for drafting and enforcing living wills.11 Major changes included removing the requirement of Magistrate attestation; replacing two medical boards with one board comprising three doctors; allowing hospital ethics committees to participate in the process; and introducing digital registration and storage for easier access. These reforms aimed to strike a balance between respecting autonomy and preventing abuse, thus increasing the practical enforceability of advance directives in Indian hospitals.
- Persistent Challenges
Despite judicial recognition, several practical and ethical issues persist. These include lack of public awareness, as most individuals remain unaware of the option to execute advance directives; medical reluctance, with physicians often hesitating to honour living wills due to fear of legal consequences or familial pressure; and the absence of legislation, since there is no comprehensive statutory framework governing end-of-life care or advance directives, leading to uncertainty and inconsistent application.12 Without legislative support, judicial guidelines— even when simplified—may remain underutilised.
Comparative Legal Framework: Euthanasia and Assisted Dying Across Jurisdictions
A comparative analysis reveals that several countries have moved towards legalising euthanasia or assisted suicide under controlled circumstances. While the degree of permissibility varies, the common trend reflects an increasing emphasis on patient autonomy, dignity, and regulated consent.13
- The Netherlands and Belgium: Liberal Pioneers
The Netherlands was the first country to formally legalise euthanasia through the Termination of Life on Request and Assisted Suicide (Review Procedures) Act, 2002.14 The law allows both euthanasia and physician-assisted suicide, subject to several conditions: the request must be voluntary and well-considered; the patient must be experiencing unbearable suffering with no prospect of improvement; and a second physician must confirm eligibility. Belgium followed suit with similar legislation,15 even extending euthanasia rights to minors under strict supervision.16
- Canada: Medical Assistance in Dying (MAiD)
Canada legalised euthanasia through the Medical Assistance in Dying Act (2016) following the Supreme Court’s decision in Carter v Canada, which found a blanket ban on assisted dying unconstitutional.17 The law permits both active euthanasia and assisted suicide for competent adults suffering from grievous and irremediable medical conditions.
In 2021, Canada further broadened eligibility criteria by removing the requirement that a natural death be reasonably foreseeable, signalling a more liberal approach.18
- United States: State-Specific Legislation
In the U.S., euthanasia remains illegal, but several states—like Oregon, Washington, and California—permit physician-assisted suicide under laws modelled after the Oregon Death with Dignity Act (1997).19 These statutes typically require a terminal illness diagnosis; two verbal and one written request; and waiting periods and mental competence evaluations. Assisted dying in the U.S. remains a state matter, leading to a fragmented legal landscape.20
- Lessons for India
While India has cautiously recognised passive euthanasia and advance directives, its framework lacks the legislative clarity and institutional support seen in countries like Canada or the Netherlands. Critical takeaways include the need for clear statutory criteria for end-of life decisions; the role of ethics committees and medical oversight; and the legal recognition of patient autonomy and informed consent as core principles.21
Ethical and Legal Debates
The legalisation of euthanasia and advance directives continues to raise deeply polarising questions that straddle law, ethics, medicine, and theology. The core dilemma revolves around individual autonomy on one hand, and the state’s obligation to protect life on the other.22
Autonomy vs. Sanctity of Life
Proponents argue that allowing euthanasia respects an individual’s autonomy and bodily integrity, enabling them to avoid prolonged and meaningless suffering.23 It is an extension of the right to refuse treatment and choose the manner of one’s death—especially in cases of terminal illness or vegetative conditions. The Common Cause judgment reflected this view by rooting passive euthanasia in Article 21 of the Indian Constitution.24
However, opponents cite the sanctity of life doctrine, arguing that legalising euthanasia devalues life and contradicts the state’s duty to protect vulnerable individuals.25 From a constitutional standpoint, they warn against interpreting Article 21 in a way that permits the state to sanction death.26
Slippery Slope and Potential for Abuse
A key concern in the euthanasia debate is the “slippery slope” argument.27 Legalising assisted dying, even with safeguards, could eventually lead to abuse, especially in a socio-economically diverse country like India, where elders may face coercion, neglect, or pressure to forego life saving treatment due to financial or familial reasons.28
The absence of robust state regulation and accountability mechanisms may amplify these risks. Cases from the Netherlands and Belgium demonstrate how ethical lines can blur—such as extension of euthanasia to psychiatric patients or minors under special conditions.29
Role of Religion and Medical Ethics
Religious traditions in India—Hinduism, Islam, Christianity, and others—generally oppose euthanasia as interfering with the natural cycle of life and death.30 Many medical professionals also remain uncomfortable with the idea of intentionally ending a life, as it contradicts the Hippocratic Oath and the professional ethic of “do no harm.”31
Nonetheless, others argue that modern bioethics calls for compassionate care, which may sometimes mean allowing a patient to die with dignity rather than prolonging agony through artificial means.32
The Way Forward
Despite the evolving jurisprudence, India’s legal and medical systems still lack a comprehensive framework on end-of-life decision-making. The recognition of passive euthanasia and living wills, though significant, must now be translated into statutory legislation, public awareness, and institutional support.33
- India urgently needs a comprehensive “End-of-Life Care Act” or a specialised chapter within the Medical Council of India’s ethical regulations to provide a clear legal structure.34 Such legislation should govern the execution and registration of advance directives; outline the legal procedure for withholding or withdrawing life support; and define the role of hospitals, ethics committees, and the judiciary in decision-making processes.35
Additionally, the law must specify punishments for misuse, coercion, or forgery of directives to prevent abuse.36 This statutory framework will help ensure consistency, transparency, and enforceability across jurisdictions, thereby reinforcing dignity, autonomy, and ethical integrity in end-of-life care.37
- Training and Institutional Support
Medical professionals should be trained in ethical end-of-life care and educated about the legality of living wills.38 Institutional mechanisms like hospital ethics committees, as seen in Canada and the U.S., can act as oversight bodies facilitating the ethical and legal application of euthanasia-related decisions.39
- Enhancing Palliative Care Access
Rather than treating euthanasia as the sole solution to suffering, India must invest in palliative care infrastructure. Inadequate pain management and end-of-life counselling often drive patients toward desperate choices.40 The right to die with dignity must be seen as an extension of the right to live with dignity, including appropriate terminal care.41
- Public Education
Citizens should be informed about their rights regarding medical treatment refusal, terminal care, and advance directives. Government campaigns, digital platforms, and NGOs can play a key role in demystifying euthanasia laws and procedures.42
Conclusion
The debate on end-of-life decisions in India has finally moved beyond moral condemnation and legal inertia to embrace constitutional compassion. The recognition of passive euthanasia and living wills under Article 21 reflects the judiciary’s progressive role in interpreting the right to life as a right to a dignified death. However, a rights-based approach must now be supported by clear statutory provisions, medical infrastructure, and public awareness.
India stands at a legal and ethical crossroads. While upholding the sanctity of life remains vital, denying individuals the agency to make informed, humane choices about their death infringes upon the very dignity that the Constitution seeks to protect. The time is ripe for a comprehensive, empathetic, and practical legal framework to govern euthanasia and end-of life care.
Reference(S):
1 John Keown, Euthanasia, Ethics and Public Policy: An Argument Against Legalisation (2nd edn, CUP 2018); Sheila McLean, Autonomy, Consent and the Law (Routledge-Cavendish 2009); Loane Skene, ‘Euthanasia: The Legal Issues’ (1998) 6(3) Journal of Law and Medicine 297.
2 Common Cause v Union of India (2018) 5 SCC 1 (SC).
3 P Rathinam v Union of India (1994) 3 SCC 394.
4 Gian Kaur v State of Punjab (1996) 2 SCC 648.
5 ibid [24].
6 Aruna Ramachandra Shanbaug v Union of India (2011) 4 SCC 454.
7 Common Cause v Union of India (2018) 5 SCC 1.
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