On the right to die with dignity

On an evening in 2013, 20-year-old Harish Rana fell from the fourth floor of his PG accommodation and sustained critical injuries. His condition confined him to a bed while tubes kept him on life support. Owing to his Persistent Vegetative State (PVS), he responded to no stimuli around him and was largely nursed by his parents, with frequent visits to the hospital. Mr. Rana’s closest friends and family, who fondly describe him as energetic and exuberant, were faced with the agonising pain of witnessing his stasis. His parents, along with the doctors, devoted 13 years in tending to Mr. Rana, but no improvement was seen. Confronted with such despairing circumstances, the parents moved the Supreme Court to withdraw life support, so that nature can be allowed to take its course. What followed was a pivotal discourse on the import of life under Article 21 of our Constitution.

A respectable death

The Constitution’s tryst with ‘Right to Life with dignity’ was first laid down in Gian Kaur vs State of Punjab (1996) where the Supreme Court held that ‘life’ under Article 21 included the right to live with dignity. However, in Gian Kaur, the Court opined that Article 21 did not include the right to die.

Fifteen years later, a similar case reached the Supreme Court when a young Aruna Shanbaug, owing to a brutal sexual assault, was left in PVS. Pinki Virani, journalist, and human-rights activist, petitioned the Supreme Court as Aruna’s friend for withdrawal of her life support. Although under its own circumstances, Virani’s plea was rejected, it culminated in the crucial decision of Aruna R. Shanbaug vs Union of India (2011). The Supreme Court drew sustenance from foreign legal frameworks and recognised passive euthanasia in cases of patients with terminal illness and undergoing prolonged, but ineffective treatment. Guidelines were framed to bridge the legislative gap, until Parliament promulgated on the subject. Additionally, the Law Commission in 2006 and 2012, entered into an in-depth examination of the above-detailed issues and made extensive observations. It reported that withholding life support from terminally ill patients should not attract criminal liability if done in pursuance of the “best interest of the patient.”

The watershed moment on the subject was the 2018 Constitution Bench’s decision in Common Cause vs Union of India. Armed with developing jurisprudence on the subject, the Supreme Court unequivocally recognised and permitted the withdrawal/ withholding of medical treatment to fall within Article 21. The right of refusal of medical treatment was held to be a manifestation of dignity intersecting with privacy, autonomy, and self-determination. This judgment provided extensive guidelines and underwent certain modifications in a similarly titled 2023 decision. These are now cumulatively referred to as the ‘Common Cause guidelines’, which rest on two core principles: first, that the intervention in question must qualify as “medical treatment”; and second, that its withdrawal must be strictly in the patient’s “best interest.”

The Supreme Court embedded various safeguards to prevent misuse and a detailed procedure involving opinions of primary and secondary Medical Boards prior to undertaking such decisions. The legislative void was once again highlighted by the Court and one Judge expressed the “pious hope” for legislative intervention. This hope still lingers.

Case evaluation

The Harish Rana chronicle has now reached its end with the intervention by the Supreme Court. Speaking through two judges, who authored separate but concurring judgments, the Court allowed the withdrawal of life support from Mr. Rana under the Common Cause guidelines. Since he relied on Clinically Assisted Nutrition and Hydration (CANH), the first question which required consideration was whether CANH qualified as ‘medical treatment.’ To answer this, the Court noted that the administration of CANH requires careful and experienced medical supervision. Since such skills are only available by drawing upon medical knowledge, and owing to its continuous periodic evaluation, emergency medical management and supervision, it was held to be ‘medical treatment.’ The second question was whether the withdrawal of CANH from Mr. Rana was in his best interests. It held that ‘best interests’ must be envisaged from the lens of the stakeholders, who are the next of kin and medical boards. It was rightly opined that a doctor’s duty to perform treatment continues till it is capable of “conferring some therapeutic benefit.” When recovery is impossible, the continuation of treatment merely prolongs biological existence de-hors any benefits. It led to the sole conclusion — withdrawal of treatment which was noted to be in Mr. Rana’s best interests.

A definitive end

“For in that sleep of death what dreams may come, when we have shuffled off this mortal coil, must give us pause.” Through his prose, the Bard cautioned that hesitation about death stems from the uncertainty of what comes after. However, what is definitive is that the ones who pass-on tend to live through us. Harish Rana will soon die. Yet, his contributions will forever be etched in history and in our constitutional jurisprudence. 

And so, the advancement of constitutional morality is not only circumscribed to legislative actions which reach the country at large. It is also through addressing uncomfortable issues that advance the cause for humanity, even if they concern just an indiscernible minority. 

Satvik Varma is a senior advocate in New Delhi. With inputs from Shantanu Parmar, advocate