Recently, the Supreme Court allowed the withdrawal of life-sustaining treatment in the case of a 32-year-old man in an irreversible vegetative state for over 13 years. This has focused the nation’s attention on the right to live and the right to die with dignity. The culturally-sensitive issue involves complex medical, legal, and ethical considerations concerning patient autonomy and dignity. By allowing life support to be withdrawn in this case, the Court reaffirmed that forcing a person to exist indefinitely in a vegetative state may undermine this very dignity.
The Court has addressed this dilemma earlier too. In the historic Aruna Shanbaug ruling in 2011, the Court first recognised passive euthanasia under strict guidelines. This view was further strengthened in the landmark Common Cause v. Union of India judgment in 2018, where some of us who have been passionate about this cause went to the Supreme Court, and a Constitution bench held that the “right to die with dignity” is a basic right. That decision also legally recognised passive euthanasia and the concept of advanced medical directive “living will,” allowing persons to spell out their wishes concerning medical treatment, in case they become incapable of making decisions in the future.
The present case builds upon these precedents, with the Court emphasising that the law must sometimes acknowledge the limits of medicine. Modern medical technology has made it possible to artificially sustain bodily functions for prolonged periods. However, continuing medical intervention in life limiting conditions may just delay death, not prolong life — thereby prolonging suffering for the patient and her/his family. The judgment also emphasised the importance of palliative care, which focuses on improving the quality of life in life-limiting diseases.
In many health care facilities, the focus is primarily on medical treatment. However, palliative care emphasises patient needs, preferences, and values. By addressing physical, emotional, and social needs, palliative care supports both patients and their families during one of the most challenging periods of life. Despite its importance, palliative care services in India are still limited and unevenly distributed. The World Health Organization (WHO) reports that against the global average of 14% of those needing palliative care receiving it, in India, less than 4% requiring palliative care receive it, highlighting a wide disparity in end-of-life care. This number is as high as 70–80% in the UK and 60–70% in Australia, where this author trained in palliative care. These countries have higher access because palliative care is integrated into national health systems and supported by hospice networks.
In India, wide gaps exist, mostly because palliative care services are mainly NGO-driven and unevenly distributed. Kerala provides the bulk of what is available. There are only 10–12 medical colleges out of 780 in India that have palliative medicine departments, offering only 25 MD seats per year. This makes it one of the rarest MD specialties in India, reflecting the limited availability of specialised palliative care training.
Many health care professionals lack training in end-of-life care and awareness among the public remains low. Expanding palliative care education in medical training, strengthening health care policies, and developing community-based programmes are essential steps toward improving access. IHBAS is probably the only hospital in India to have a Neuropalliative Department and more such dedicated units are required to cater to this unmet need.
The Supreme Court judgment in the present instance also stressed upon advance medical directives (AMDs), often referred to as “living wills”. The legal framework allows individuals to document their medical wishes in advance, particularly regarding withdrawal or withholding of life-sustaining treatment in certain conditions. This has strengthened the ethical and legal foundation for end-of-life decision-making in the country.
One of the key reasons AMDs are important is that they uphold the principle of patient autonomy. An AMD provides clear instructions to doctors and family members about the patient’s treatment preferences, such as whether they wish to receive life-support systems, resuscitation, or other intensive medical interventions
Even after the courts simplified the procedures in 2023, AMD adoption remains low in India. Awareness among the general public is very low, and surveys suggest less than 30% of even highly educated, internet-using graduates know about AMDs. The UK recognises such decisions under the Mental Capacity Act 2005 (England & Wales), which allows competent adults to specify future treatment preferences that can be legally binding. A UK study reported around 53% awareness of advance directives among patients, with 31% having advance directives in place. Australia has no single national law, but each state has its own legislation on Advance Care Directives (ACDs) or similar documents. Studies have revealed a self-reported advance-directive prevalence of about 14% across the adult Australian population, with much higher documentation (30-47%) among older or frail populations in residential old-age care settings.
Another important benefit of AMDs is that they help doctors make ethical and legally- safe decisions. Physicians often face dilemmas when treating critically ill patients who cannot communicate their preferences. Without clear guidance, doctors may feel obliged to continue aggressive treatment even when it may not benefit the patient. An AMD provides legal and ethical clarity, enabling health care professionals to follow the patient’s wishes while maintaining professional responsibility.
As India continues to grapple with the ethical challenges of modern medicine, the conversation on end-of-life rights has begun. The body of judicial recognition so far represents a significant step toward preserving human dignity at the end of life. However, despite these landmark judicial decisions, India still lacks a comprehensive law governing euthanasia. Indian parliamentarians should now debate and shape a comprehensive legislation, with strong safeguards, improved palliative care services, and wider adoption of AMDs as the cornerstone.
The law must balance compassion with caution, autonomy with protection, and above all, humanity with justice. A lucid and unambiguous law will also provide uniform standards for hospitals and doctors balancing patient autonomy with ethical responsibility.
Rajinder K Dhamija is director, IHBAS, and chair, National Task Force on Brain Health, Government of India. The views expressed are personal
