Harish Rana v. Union of India & Ors. 2026 INSC 222

On Active and Passive Euthanasia: The Court reaffirmed the distinction drawn between Active and Passive Euthanasia in the case of Common Cause v. Union of India, (2018) 5 SCC 1. It was observed by the Bench that Active euthanasia involves a deliberate act to cause death. It requires positive intervention by a doctor or another person like administering lethal injection, giving life-ending drugs, etc. It is considered as causing death and is punishable under the Indian Penal framework. The Court defined passive euthanasia as allowing death to occur naturally by withdrawing or withholding medical treatment. It involves omission rather than commission like removing artificial life support, etc. It has been held to be constitutionally permissible in India as an element of right to die with dignity under Article 21. Passive euthanasia is not about ending life, but about refusing to artificially prolong suffering when treatment is futile. In the 2018 and 2023 Common cause guidelines, the Court has recognised the enforceability of living wills or Advance Medical Directives (AMD) in the cases of terminal illness without any chance of recovery. The recognition of passive euthanasia is rooted in the right to bodily autonomy and the right to self-determine. The Court looked at euthanasia jurisprudence by classifying patients into three categories: I. Competent patients: It consists of individuals who possess the mental capacity to make informed decisions regarding their medical treatment. The Court held that such patients enjoy complete autonomy under Article 21, which includes the right to refuse medical treatment. This right flows from the principles of dignity, bodily integrity, and self-determination. A competent patient’s decision to withdraw or refuse treatment is absolute and does not require validation from the State, courts, or even medical professionals. In this category, the governing principle is the primacy of autonomy. II. Incompetent patients who have executed a valid AMD: These are individuals who, while being of sound mind in the past, had documented their preferences regarding medical treatment in situations where they might later lose decision-making capacity. The Court recognized that such directives operate as an extension of the patient’s autonomy, bridging the gap between past competence and present incapacity. However, unlike the case of a presently competent patient, the enforcement of an AMD is not absolute and is subject to certain conditions. It becomes operative only when the patient is terminally ill or in a PVS, and the continuation of treatment is medically futile with no reasonable prospect of recovery. Medical boards are required to verify both the authenticity of the directive and the medical condition of the patient. Therefore, while autonomy remains central, it is exercised through a structured and conditional framework. III. Incompetent patients who have not executed an AMD: In such cases, the patient is unable to express any present or prior choice, and therefore, the legal basis shifts from autonomy to the principles of dignity and best interests under Article 21. The Court held that decision-making authority lies with the patient’s family members, next of kin, or guardians, but this authority is not to be exercised based on their personal preferences but in the best interests of the patient.

Harish Rana: a case of incompetent patient without AMD: Since the present case falls within the third category of patients, the Court examined when and how the next of kin can make decisions for the patients. The Court looked at various jurisdictions like the USA, UK, Australia, etc. and harmonised the two tests: substituted judgment test and the best interest test. The Court explained that the substituted judgment test is rooted in the principle of autonomy and requires the decision-maker to reconstruct, as far as possible, what the patient would have chosen if competent, based on their prior wishes, values, beliefs, and personality. However, it cautioned that this test has inherent limitations, particularly in cases where the patient has left no advance directive or reliable indication of their preferences. In such situations, the substituted judgment test cannot be applied in a strict sense. In such cases, the best interests test comes in. The Court then emphasised that the best interests test is the overarching and controlling standard in Indian law. It clarified that this test is not confined to a narrow medical inquiry but involves a holistic evaluation of the patient’s condition, including medical prognosis, quality of life, dignity, emotional and psychological factors, and the balance between the benefits and burdens of continued treatment. The Court reformulated the central question: not whether the patient should be allowed to die, but whether the continuation of life-sustaining treatment serves any real benefit to the patient. While there is a presumption in favour of preserving life, this presumption can be rebutted where treatment is futile, offers no prospect of recovery, and merely prolongs biological existence without consciousness or dignity. The Court highlighted the benefit versus burden analysis, often described as a “balance-sheet approach.” Here, the decision-maker must weigh whether the treatment provides any real therapeutic benefit to the patient against the pain, invasiveness, indignity, or suffering it imposes. If treatment merely prolongs the dying process without improvement, it may count against continuation. Significantly, the Court rejected the rigid distinction often drawn between the substituted judgment approach associated with autonomy and the best interests approach associated with welfare. Instead, it held that the two are interrelated and must be applied in a complementary manner. The patient’s wishes, where ascertainable, form an important component of the best interests and respecting such wishes is generally considered to be in the patient’s best interests.

CANH – a medical treatment? The Court rejected the idea that tube feeding is basic care like spoon-feeding. Because it involves surgical intervention (PEG tubes) and medical protocols to manage risks like peritonitis or aspiration, it is inherently a medical procedure. It observed that when nutrition and hydration are administered through artificial means such as feeding tubes or intravenous methods, they involve medical expertise, technological intervention, and continuous clinical supervision. In such circumstances, CANH cannot be equated with simple acts of feeding or caregiving, but must be treated as part of life-sustaining medical treatment.

Can the treatment be withdrawn? The Supreme Court ultimately held that the treatment being administered to Harish Rana, including CANH, could be lawfully withdrawn, as its continuation was not in his best interests. The Court reached this conclusion after applying the best interests test in a detailed and structured manner. It relied heavily on medical evidence which established that the patient was in a persistent vegetative state with no realistic prospect of recovery, and that the treatment being provided was non-therapeutic in nature, serving only to sustain biological functions without any improvement in consciousness or cognitive capacity. The Court observed that the continuation of such treatment did not confer any real benefit on the patient and instead prolonged a state of existence that lacked awareness, dignity, and meaningful interaction with the world. It emphasised that the constitutional guarantee of life under Article 21 does not mandate the indefinite preservation of mere biological survival when it is stripped of dignity and purpose. In this context, the withdrawal of treatment, including CANH, was not seen as causing death but as allowing the underlying condition to take its natural course.