Reforming Passive Euthanasia in India

Why India's Passive Euthanasia Framework Needs Urgent Reform

In 2018, the Supreme Court of India, in *Common Cause v. Union of India*, legalized passive euthanasia and recognized the constitutional right to die with dignity—a landmark judgment under Article 21. Yet, as of 2025, fewer than 100 verified cases of advance directives have been formally registered, according to legal and medical boards. This is not because of disinterest but because the labyrinthine procedural and institutional framework has rendered the law practically inaccessible. Worse, these figures do not account for a vast majority of terminally ill patients who lack access to palliative care or informed guidance.

The Precedent: A Legal Right Shackled by Systems

The Supreme Court’s historic judgment broke ground by legalizing passive euthanasia, distinguishing it from the still-illegal *active euthanasia* prohibited under Sections 103 and 105 of the Bharatiya Nyaya Sanhita (BNS). The 2018 ruling also introduced the concept of *living wills*—advance medical directives expressing the will of a patient should they enter an irreversible vegetative state. But the complex web of approving institutions—Primary and Secondary Medical Boards, hospital committees, and judicial oversight—has turned dignity in death into a privilege available only to those who can navigate India’s overburdened healthcare and legal machinery. The procedural bottlenecks begin with advance directives themselves. These require notarization, approval by both state medical boards and hospital ethics committees, and repeated countersignatures—a process that can extend to weeks, even as patients languish in terminal suffering. Furthermore, these directives lack a centralized digital repository, adding to confusion and misuse across jurisdictions.

The Machinery: Weak Links and Overreach

Why hasn’t this legal right translated to meaningful reform? The Ministry of Health and Family Welfare issued guidelines in 2019 that should have streamlined these processes, but their implementation has been erratic. Hospitals, for instance, are required to constitute ethics committees to approve withdrawal of treatment. Yet, the majority of public hospitals—in states like Bihar and Madhya Pradesh—lack even basic ethics panels, let alone trained professionals in palliative care. Only **4% of Indian hospitals**, as surveyed by the Indian Council of Medical Research (ICMR) in 2022, adhere to ethical oversight mandates. Moreover, state-level disparity further entangles the process. Kerala and Tamil Nadu, which have relatively robust healthcare systems, report faster approvals for cases under passive euthanasia. Comparatively, Uttar Pradesh and Jharkhand—states with fragmented healthcare and systemic bureaucracy—present insurmountable hurdles, leaving families at the mercy of informal hospital gatekeepers. This inequality drains the moral legitimacy of the uniform legal framework envisioned by the apex court.

Ground Reality: The Data Obscures More Than It Reveals

The government claims ethical oversight mechanisms are sufficient to balance autonomy and safeguard against misuse. The numbers tell a different story. The **2023 NITI Aayog report** on end-of-life care revealed that only **8% of terminally ill patients in India receive professional palliative care**. Further, rural health infrastructure remains woefully inadequate, with primary healthcare centers (PHCs) across 60% of districts reporting vacancies for general practitioners. Without access to even basic counseling services, patients and families are left without the dignity or autonomy the court’s judgment promised. Compounding the issue is the lack of public awareness. A study by the Tata Institute of Social Sciences in 2021 found that **72% of respondents** were unaware of the legal recognition of living wills and passive euthanasia. The state's failure to disseminate this information perpetuates a culture of legal ineffectiveness and underutilization.

Lessons from Canada: A Contrast in Institutional Support

Take, for instance, Canada’s Medical Assistance in Dying (MAID) framework. Since its legalization in 2016, over **31,000 Canadians** have used the system, which is anchored by three pillars: universal healthcare coverage, accessible palliative care, and clear procedural guidelines. The Canadian system ensures decisions are made swiftly (within 10 days of a request) and transparently, overseen by independent regulatory bodies. India’s over-reliance on judicial and bureaucratic intermediaries stands in stark contrast. Here, simple requests to withdraw life support require convoluted, multi-tiered approvals, often leading to delays that frustrate patient autonomy. While Canada’s institutional guarantees are impossible to replicate wholesale, India could begin by decentralizing decision-making and strengthening hospital-level accountability mechanisms.

Uncomfortable Questions: Ethical Ambiguities and Safeguards

The fragility of India’s safeguards also raises critical ethical and procedural dilemmas. How do we ensure that patients’ autonomy in signing advance directives is not tainted by family or economic coercion? In a society where **80% of healthcare expenses** are borne out-of-pocket, families grappling with poverty may influence an elderly patient’s decision to forgo life support—not out of dignity, but desperation. Further, the Supreme Court’s guidelines include a 48-hour decision-making window for hospital committees. However, in low-capacity hospitals—especially in non-metro regions—this window often stretches to weeks due to administrative inefficiencies. The absence of any post-decision review process also leaves the system vulnerable to misuse or errors. Are these timeframes viable without introducing monitoring bodies capable of independent audits?

Reforming with Compassion and Clarity

If India is to genuinely uphold the constitutional principle of dignity in death, passive euthanasia laws require structural refinements that prioritize accessibility, efficiency, and safeguards against misuse. Any reform must include:

• **National Digital Repository for Living Wills**: Link advance directives to Aadhaar, allowing for easy verification and reduced procedural delays.
• **Mandatory Ethics Committees**: Allocate central government funding to ensure every district hospital establishes a functioning ethics panel, including palliative care specialists.
• **Decentralized Oversight**: Replace state-level medical boards with empowered hospital committees monitored by state-mandated independent auditors.
• **Public Awareness Campaigns**: Run nationwide awareness programs on living wills and passive euthanasia, modeled on the success of the polio immunization drive.

Finally, any framework must recognize the socio-religious sensitivities that inform India’s end-of-life decision-making. Jainism’s *Sallekhana*, or Hinduism’s *Prayopavesa* (spiritual fasting unto death), are deeply ingrained in Indian tradition and offer a cultural road map to navigate passive euthanasia within ethical bounds.

Exam Questions

Prelims MCQs 1. Which of the following cases legalized passive euthanasia in India? a) Kesavananda Bharati v. State of Kerala b) Aruna Shanbaug v. Union of India c) Common Cause v. Union of India d) Maneka Gandhi v. Union of India **Answer: c) Common Cause v. Union of India** 2. Under the Bharatiya Nyaya Sanhita (BNS), which sections criminalize active euthanasia? a) Sections 103 and 105 b) Sections 121 and 123 c) Sections 108 and 110 d) Sections 147 and 149 **Answer: a) Sections 103 and 105** Mains Question **Critically evaluate whether India's current institutional framework for passive euthanasia adequately fulfills the constitutional promise of dignity in death. Include perspectives on accessibility, cultural sensitivities, and state capacity.**

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