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Article : Right to Die with Dignity in India

Karnataka’s Landmark Implementation

Prof. (Dr.) Smriti Sharma Bhatia,

Department of Chemistry, Miranda House, University of Delhi

1. Introduction

The right to die with dignity is a sensitive and evolving issue in India, encompassing legal, ethical, medical, and societal considerations. While the right to life is a fundamental right under Article 21 of the Indian Constitution, the interpretation of whether this right includes the right to die with dignity has been the subject of extensive legal debate.

Globally, countries have adopted different approaches toward end-of-life care, ranging from allowing active euthanasia (as in the Netherlands and Belgium) to permitting only passive euthanasia (as in India). In India, the Supreme Court’s 2018 ruling in Common Cause v. Union of India was a watershed moment, recognizing passive euthanasia and Advance Medical Directives (AMD). However, implementing these provisions remained challenging due to bureaucratic and procedural hurdles.

Table 1: Differences between Active and Passive Euthanasia:

Aspect	Active Euthanasia	Passive Euthanasia
Definition	Deliberate action to end a person's life	Withholding or withdrawing life-sustaining treatment to allow death
Method	Administering lethal drugs or injections	Turning off life-support machines, stopping medications, or not performing life-extending surgery
Role of Physician	Directly causes death by administering a lethal substance	Allows death by stopping or withholding medical interventions
Legality	Illegal in most countries, but allowed in Netherlands, Belgium, Canada, etc.	Legal in many countries, including India under strict conditions
Ethical Debate	Considered more controversial due to direct intervention	Less controversial as it allows natural death
Intent	Actively bringing about death	Allowing death to occur naturally
Example	A doctor injects a lethal drug to end suffering	A ventilator is turned off for a terminally ill patient

The Karnataka government’s recent circular, issued on January 30, 2025, marks a significant step toward enforcing the right to die with dignity. This move aligns with the Supreme Court’s modified 2023 judgment, which sought to simplify the execution of AMDs and the withdrawal of life-sustaining treatment (WLST) for terminally ill patients.

This article explores the legal evolution, recent developments, ethical dilemmas, medical guidelines, and the way forward in implementing the right to die with dignity across India.

2. Key Court Rulings

The legal discourse surrounding the right to die with dignity in India has evolved significantly through landmark judgments by the Supreme Court. The judiciary has played a crucial role in interpreting Article 21 of the Indian Constitution, which guarantees the right to life, and determining whether it also includes the right to die with dignity. The following key cases have shaped India's stance on euthanasia and end-of-life care.

2.1 Gian Kaur v. State of Punjab (1996)

The first significant ruling on the right to die in India came in the case of Gian Kaur v. State of Punjab (1996). The case arose when Gian Kaur and her husband were convicted under Section 306 of the Indian Penal Code (IPC) for abetting suicide. The central question before the Supreme Court was whether the right to life under Article 21 also included the right to die.

The five-judge Constitution Bench ruled that the right to life does not include the right to die. The Court held that life is a natural right and that suicide and abetment of suicide cannot be decriminalized, as doing so would contradict the constitutional guarantee of life. Consequently, Section 309 of the IPC, which criminalizes suicide, and Section 306 of the IPC, which penalizes abetment of suicide, were upheld as constitutional.

This verdict set the precedent that actively ending one’s life was not protected under fundamental rights. However, it did not address passive euthanasia, a concept that would come under legal scrutiny in later cases.

2.2 Aruna Shanbaug Case (2011)

A major turning point in India’s euthanasia debate came with the case of Aruna Ramchandra Shanbaug v. Union of India (2011). Aruna Shanbaug, a nurse at KEM Hospital, Mumbai, had been in a persistent vegetative state (PVS) for 42 years following a brutal attack in 1973. A petition for euthanasia was filed by journalist Pinki Virani, requesting permission for withdrawal of life support.

The Supreme Court, while denying active euthanasia, made a significant ruling by allowing passive euthanasia under strict conditions. The Court laid down detailed guidelines, stating that:

• Passive euthanasia could be permitted in cases where a patient is in irreversible coma or PVS.
• The decision to withdraw life support must be made by the patient’s immediate family or legal guardians.
• The approval of the High Court was required before withdrawal of life support.

This ruling was the first formal recognition of passive euthanasia in India, establishing a framework for cases where continuing medical treatment would be futile. However, the process was still heavily bureaucratic and required judicial intervention, making it lengthy and cumbersome.

2.3 Common Cause v. Union of India (2018)

The most pivotal judgment on the right to die with dignity came in Common Cause v. Union of India (2018). This case was filed by the NGO Common Cause, seeking legal recognition for passive euthanasia and Advance Medical Directives (AMDs), also known as Living Wills.

The Supreme Court, in a landmark verdict, ruled that:

• The right to die with dignity is a fundamental right under Article 21 of the Indian Constitution.
• Passive euthanasia is legal and does not require judicial intervention in every case.
• Individuals have the right to create an AMD (Living Will), allowing them to specify in advance whether they would want life support withdrawn in the event of a terminal illness or irreversible condition.
• Two medical boards—one at the hospital level and another at the district level—must approve the decision to withdraw life support.

This judgment strengthened individual autonomy and reduced unnecessary suffering for terminally ill patients. However, the lengthy approval process still made the execution of AMDs a complex and time-consuming task.

2.4 Modified Supreme Court Judgment (2023)

Recognizing the practical challenges in implementing the 2018 judgment, the Supreme Court modified its ruling in 2023 to simplify the procedure for withdrawing life support and executing AMDs.

The revised guidelines included:

• Reduction of bureaucratic hurdles: The requirement of judicial intervention was minimized, making it easier for families and medical professionals to follow the procedure.
• Streamlined approval process: The role of Primary and Secondary Medical Boards was reinforced, ensuring that decisions are made at the hospital and district levels rather than requiring High Court approval.
• Greater emphasis on patient autonomy: The new guidelines gave more weight to the wishes of the patient, as recorded in an AMD, making it legally binding in most cases.
• Integration with healthcare records: Hospitals were encouraged to digitally maintain AMDs, ensuring easy access for doctors and family members when needed.

This ruling marked a significant step in ensuring that the right to die with dignity is practically enforceable, reducing delays in decision-making for terminally ill patients.

The legal evolution of the right to die with dignity in India reflects the judiciary's progressive stance on end-of-life care. From Gian Kaur (1996), which upheld suicide laws, to Aruna Shanbaug (2011), which recognized passive euthanasia, to Common Cause (2018) and its 2023 modifications, the legal framework has gradually evolved to uphold patient autonomy. Therefore, the Karnataka Government’s 2025 decision to implement the Supreme Court’s modified guidelines marks a historic step in the practical realization of the right to die with dignity. By simplifying the procedure, ensuring medical oversight, and enabling the use of Advance Medical Directives, India has moved closer to a compassionate and patient-centric approach to end-of-life care.

3. Karnataka’s Landmark Decision: Key Provisions

The Karnataka government issued a circular on January 30, 2025, to implement the right to die with dignity, in compliance with the Supreme Court’s 2023 ruling. The directive establishes a structured legal and medical process for the withdrawal of life-sustaining treatment (WLST) and the execution of Advance Medical Directives (AMDs) for terminally ill patients. These provisions ensure ethical decision-making while preventing misuse.

3.1 Withdrawal of Life-Sustaining Treatment (WLST)

WLST, also referred to as passive euthanasia, involves stopping or withholding life-sustaining medical interventions when treatment is futile. The Karnataka government’s guidelines permit WLST for patients under specific conditions, ensuring a humane and legally sound approach.

3.1.1 Eligibility Criteria for WLST

WLST is allowed only if the patient meets the following conditions:

• The patient is terminally ill, with no possibility of recovery despite continued medical intervention.
• The patient is in a persistent vegetative state (PVS) or has permanently lost decision-making capacity.
• Continuing life support would not provide meaningful benefit but only prolong suffering.

3.1.2 Approval Process for WLST

To prevent unethical practices and ensure that the decision is medically justified, a structured approval process is required:

• Treating Doctor’s Recommendation: The attending doctor must confirm that the patient qualifies for WLST.
• Consent of the Next of Kin: The patient’s closest family members must provide written consent before proceeding.
• Approval by Medical Boards: Two independent medical boards (Primary and Secondary) must review and approve the decision.

These steps ensure that life-sustaining treatment is withdrawn only when it aligns with medical ethics and patient welfare.

3.2 Medical Boards and Approval Process

The Karnataka government mandates strict medical scrutiny through a two-tiered board system to ensure transparency and accountability in end-of-life decisions.

3.2.1 Primary Medical Board

• Formed at the hospital where the patient is admitted.
• Consists of three registered medical practitioners specializing in relevant medical fields.
• Responsible for conducting a thorough assessment and giving the first recommendation for WLST.

3.2.2 Secondary Medical Board

• Functions at the district level, providing an additional layer of oversight.
• Includes specialists such as a neurologist, neurosurgeon, surgeon, anesthetist, or intensivist.
• Members must be approved under the Transplantation of Human Organs and Tissues Act, 1994, ensuring their expertise in critical care decisions.

3.2.3 Judicial Oversight

• Once both medical boards approve WLST, their decision is submitted to the Judicial Magistrate of First Class (JMFC).
• The JMFC forwards the case to the Registrar of the High Court for record-keeping.
• This legal process ensures compliance and acts as a safeguard against misuse.

By enforcing this multi-layered review system, the Karnataka government has established a strong and ethical framework for passive euthanasia.

3.3 Advance Medical Directives (AMD) or Living Wills

An Advance Medical Directive (AMD), also known as a Living Will, allows individuals to predefine their medical treatment preferences if they lose decision-making capacity in the future. The Karnataka government’s guidelines set forth a clear legal procedure for executing and implementing AMDs.

3.3.1 Eligibility and Requirements for AMD

• Any mentally competent adult can create an AMD specifying medical treatments they wish to accept or refuse.
• The directive ensures that the patient’s preferences are respected even when they cannot communicate them.

3.3.2 Appointment of Healthcare Decision-Makers

• The individual must nominate two representatives to make healthcare decisions on their behalf.
• These nominees ensure that medical professionals follow the patient’s directives when the patient is incapacitated.

3.3.3 Registration and Maintenance of AMDs

• The AMD must be registered with a competent government officer designated for this purpose.
• Hospitals must maintain a copy of the AMD in the patient’s medical records, either in paper or digital format, ensuring accessibility when needed.

By legally recognizing AMDs, the Karnataka framework empowers individuals to exercise autonomy over their medical decisions while ensuring their wishes are honored.

3.4 Implementation Across Medical Establishments

• The Karnataka government’s circular applies to all medical institutions, including both government and private hospitals.
• Every healthcare facility must set up the necessary medical boards and ensure proper record-keeping and legal compliance.

By enforcing a structured, transparent process, Karnataka’s approach balances medical ethics, legal requirements, and patient rights, making it a significant step toward recognizing the right to die with dignity.

4. Ethical and Medical Considerations

The Karnataka government’s decision to legalize the right to die with dignity through the withdrawal of life-sustaining treatment (WLST) and Advance Medical Directives (AMDs) has sparked various ethical and medical debates. While the policy aims to ensure that terminally ill patients do not endure unnecessary suffering, it raises concerns about autonomy, societal values, medical ethics, and practical implementation. The balance between legal safeguards and humane end-of-life care remains a complex issue.

4.1 Ethical Challenges

The ethical implications of passive euthanasia and AMDs are deeply rooted in cultural, religious, and moral perspectives. While the right to refuse medical treatment aligns with the principles of autonomy and dignity, societal and familial influences can create challenges in decision-making.

4.1.1 Autonomy vs. Societal Norms

• The principle of patient autonomy asserts that individuals have the right to make medical decisions about their own bodies, including the choice to forgo life-sustaining treatment.
• However, many religious and cultural traditions in India view life as sacred, and the idea of intentionally withdrawing treatment may be seen as morally unacceptable.
• Certain faith-based communities argue that human life should be preserved at all costs, regardless of suffering or medical futility.
• Families often struggle with the emotional burden of deciding to withdraw life support, fearing social stigma or guilt associated with allowing a loved one to pass naturally.

4.1.2 Possibility of Coercion

• There is a concern that financial, emotional, or social pressures may influence families to misuse euthanasia laws, particularly in cases where long-term medical care imposes significant economic burdens.
• Vulnerable patients, especially the elderly, may feel pressured to opt for WLST to avoid being a financial or emotional burden on their families.
• To prevent coercion, the government’s framework includes multiple levels of medical and judicial oversight, ensuring that decisions are made solely based on medical necessity and patient welfare.

4.2 Medical Challenges

Beyond ethical dilemmas, medical professionals face significant challenges in implementing the policy. Doctors must balance their duty to preserve life with respecting a patient’s wishes, and the healthcare system must be adequately prepared to handle these sensitive decisions.

4.2.1 Doctors’ Ethical Dilemma

• Physicians take the Hippocratic Oath, which emphasizes preserving life and minimizing harm. This oath can create internal conflicts for doctors required to approve the withdrawal of life-sustaining treatment.
• Many doctors struggle with the emotional and ethical burden of stopping treatment, even when continuing it is futile.
• Differentiating between justified medical decisions and external pressures (such as family influence) can be challenging for healthcare providers.

4.2.2 Need for Medical Training

• Proper education and training are crucial for medical professionals to handle AMDs and WLST procedures ethically and legally.
• Doctors must be trained to communicate effectively with families, explaining medical conditions, treatment futility, and the legal provisions surrounding end-of-life care.
• Hospitals must develop clear protocols to ensure that AMDs are properly documented, accessible, and respected during critical medical situations.

By addressing these ethical and medical challenges, the Karnataka government’s decision can be implemented in a way that respects patient dignity while maintaining safeguards against misuse. The policy’s success will depend on effective medical training, legal oversight, and continued societal dialogue.

5. Global Comparison: Right to Die Policies Worldwide

The right to die with dignity is a complex legal and ethical issue that has been approached differently across the world. While some countries have recognized both active and passive euthanasia as a fundamental right, others strictly prohibit any form of assisted dying due to legal, cultural, or religious concerns. A comparative analysis of global policies can provide insights into how India’s approach aligns with international practices and what lessons can be learned for further refinement.

5.1 Countries Allowing Active and Passive Euthanasia

Certain countries have adopted a progressive approach to euthanasia, permitting both active and passive forms under stringent legal frameworks. These nations include the Netherlands, Belgium, and Canada, where patients can opt for physician-assisted dying under carefully defined medical and ethical conditions.

• Netherlands and Belgium: These countries have some of the most liberal euthanasia laws in the world. Active euthanasia, where a doctor administers a lethal injection to end a patient’s life, is legal under strict medical supervision. Patients must be experiencing unbearable suffering with no hope of improvement, and their decision must be voluntary and well-documented.
• Canada: Canada legalized Medical Assistance in Dying (MAID) in 2016, allowing terminally ill patients to request either active euthanasia (physician-administered) or assisted suicide (where the patient self-administers the prescribed medication). Notably, Canada’s laws extend beyond terminal conditions, permitting euthanasia for patients with severe non-terminal medical conditions as well.

These countries have established rigorous consent mechanisms, medical evaluations, and judicial oversight to ensure that euthanasia is carried out ethically and responsibly.

5.2 Countries Allowing Only Passive Euthanasia

Some nations permit passive euthanasia—where life-sustaining treatment is withdrawn—but prohibit active euthanasia. This distinction recognizes a patient's right to refuse prolonged suffering without crossing into active intervention by medical professionals.

• United States: In the U.S., euthanasia is not legal at the federal level, but certain states such as Oregon, Washington, and California allow physician-assisted suicide through "Death with Dignity" laws. Patients must be terminally ill, mentally competent, and must make repeated voluntary requests before being granted a prescription for life-ending medication. Unlike in Canada, euthanasia remains prohibited, and patients must administer the medication themselves.
• India: The Indian legal framework currently permits only passive euthanasia. The Supreme Court’s landmark rulings in the Aruna Shanbaug case (2011) and Common Cause v. Union of India (2018) established the right to withdraw life-sustaining treatment for terminally ill patients, provided it follows strict legal and medical guidelines. However, active euthanasia remains illegal and is treated as homicide under Indian law.

5.3 Countries Where Euthanasia is Prohibited

Despite growing global recognition of end-of-life rights, many countries still prohibit euthanasia due to strong legal and cultural opposition.

• Japan: In Japan, euthanasia and assisted dying are strictly prohibited. Japanese cultural and religious beliefs emphasize the sanctity of life, making the legalization of euthanasia highly controversial. However, there have been ongoing debates about the need for better palliative care options for terminally ill patients.
• China: China does not permit euthanasia, and its legal framework treats any form of assisted death as a criminal offense. Traditional Chinese values strongly emphasize filial piety and caring for the elderly, making the acceptance of euthanasia a difficult prospect. However, as medical costs rise and the aging population grows, discussions on end-of-life care are becoming more prevalent.

These variations in euthanasia laws across different countries highlight the complexities involved in balancing ethical, medical, and legal considerations while protecting patients' rights.

6. The Way Forward: Nationwide Implementation

While Karnataka’s decision is a progressive step, a nationwide implementation strategy is essential to ensure consistency in the application of passive euthanasia laws across all states. Several key areas must be addressed to make the right to die with dignity a well-regulated and ethical practice in India.

6.1 Strengthening Legal Clarity

One of the major challenges in India’s euthanasia laws is the lack of uniformity in implementation across different states. Karnataka has taken the lead, but other states need a clear legal framework to follow.

• The central government must formulate a national policy to provide consistency in how passive euthanasia is implemented across India.
• Standard guidelines for Advance Medical Directives (AMDs) must be issued to ensure that patients’ end-of-life decisions are honored regardless of their location.
• Judicial oversight mechanisms should be streamlined to avoid unnecessary delays that may prolong a patient’s suffering.

A well-defined national policy can ensure that patients, families, and healthcare professionals are all aware of their rights and responsibilities in end-of-life care decisions.

6.2 Public Awareness and Medical Training

Lack of awareness about euthanasia laws and AMDs remains a significant issue in India. Many people are unaware of their right to create a living will or the procedures involved in withdrawing life support. To address this, two crucial steps are required:

6.2.1 Public Awareness Campaigns

• The government must launch educational initiatives to inform citizens about Advance Medical Directives and the right to refuse medical treatment.
• Information should be disseminated through hospitals, healthcare centers, legal aid clinics, and public awareness programs.
• Engaging religious and community leaders in discussions can help address cultural concerns and dispel misconceptions about euthanasia.

6.2.2 Training for Medical Professionals

• Healthcare providers need specialized training on how to handle WLST and AMD cases with sensitivity and professionalism.
• Medical colleges and institutions should incorporate end-of-life ethics into their curriculum to ensure future doctors are well-equipped to manage such situations.
• Hospitals should establish clear internal protocols for processing AMDs and verifying their authenticity.

6.3 Balancing Ethics and Law

Striking a balance between ethical considerations and legal safeguards is critical to ensuring that euthanasia laws are neither misused nor overly restrictive.

6.3.1 Preventing Coercion

• Strict safeguards are required to ensure that vulnerable patients, particularly the elderly and disabled, are not pressured into withdrawing life support due to financial or emotional burdens.
• Medical boards and judicial oversight mechanisms must remain vigilant in assessing each case to prevent abuse.

6.3.2 Religious and Cultural Sensitivities

• Since euthanasia remains a controversial topic, awareness campaigns should include interfaith dialogues involving religious scholars, doctors, and legal experts.
• Clear messaging can help bridge the gap between cultural values and medical ethics, ensuring that the right to die with dignity is understood as a humane, rather than controversial, practice.

7. Conclusion

The Karnataka government’s decision to implement the right to die with dignity is a historic and progressive step. By aligning with the Supreme Court’s 2023 ruling, Karnataka has ensured that terminally ill patients have the ability to make informed and humane end-of-life decisions.

7.1 Implications of Karnataka’s Decision

Karnataka’s model sets a significant precedent that could influence other Indian states and even central legislation.

• Sets a Precedent for Other States: Karnataka’s implementation can serve as a blueprint for other states considering similar regulations.
• Encourages National-Level Reforms: The central government may take Karnataka’s model as a foundation for framing nationwide euthanasia laws.
• Reduces Legal Ambiguity: The well-structured approval process protects both patients and medical practitioners from legal uncertainty.

7.2 The Road Ahead

For India to fully realize the right to die with dignity, additional reforms and continued awareness are necessary.

• Expanding Awareness: More patients should be educated about AMDs and their legal rights to avoid confusion or misinformation.
• Strengthening Safeguards: Regular legal reviews and ethical audits should be conducted to prevent misuse or coercion.
• Encouraging Palliative Care: While passive euthanasia is a solution for terminally ill patients, improving hospice and palliative care services can ensure that end-of-life patients receive compassionate medical care.

Ultimately, the right to die with dignity is an extension of the right to life. Karnataka’s initiative marks a significant shift in India’s medical and legal landscape, paving the way for a more humane and ethical approach to end-of-life care.

References:

• Gian Kaur v. State of Punjab (1996) – Supreme Court of India judgment on the right to life and euthanasia.
• Citation: Gian Kaur v. State of Punjab, (1996) 2 SCC 648
• Aruna Shanbaug Case (2011) – Landmark case that recognized passive euthanasia in India.
• Citation: Aruna Ramachandra Shanbaug v. Union of India & Ors., (2011) 4 SCC 454
• Common Cause v. Union of India (2018) – Supreme Court ruling allowing passive euthanasia and Advance Medical Directives.
• Citation: Common Cause (A Regd. Society) v. Union of India, (2018) 5 SCC 1
• Supreme Court Judgment on Euthanasia (2023) – Modification of procedures for Advance Medical Directives.
• Citation: Common Cause v. Union of India, Review Petition (Civil) No. 30581/2018

Government and Policy Documents:

• Transplantation of Human Organs and Tissues Act, 1994 – Defines medical board composition relevant to end-of-life decisions.
• Source: Ministry of Health and Family Welfare, Government of India
• Karnataka Government Circular on Right to Die with Dignity (2025) – Policy framework on passive euthanasia in the state.
• Official Source: Karnataka Health Department (Not publicly available yet)

International References:

• Euthanasia Laws in the Netherlands and Belgium – Government policies on active and passive euthanasia.
• Source: Government of the Netherlands and Belgium Federal Government
• Medical Assistance in Dying (MAID) in Canada – Canadian policies on euthanasia.
• Source: Government of Canada

Medical and Ethical Sources:

• World Medical Association (WMA) Statement on Euthanasia (2022) – Ethical considerations on euthanasia and physician-assisted suicide.
• Source: World Medical Association
• Indian Journal of Medical Ethics (IJME) Articles on Euthanasia – Academic discussions on euthanasia in India.
• Source: Indian Journal of Medical Ethics