Harish Rana euthanasia ruling: The Supreme Court of India on Wednesday permitted the withdrawal of life-sustaining medical support for 32-year-old Harish Rana, who has been in a persistent vegetative state since 2013, while emphasising that the process must be carried out “in a humane manner”.

Speaking exclusively to The Indian Express, advocate Rashmi Nandakumar, who represented Harish Rana’s family before the Supreme Court, said the judgment reinforces the process already laid down by the court in the Common Cause decision without requiring families to approach the court.

“There is already a detailed directive under the Common Cause judgment. When a request is made for withdrawal of life-sustaining treatment, it is first examined by a Primary Medical Board. In the event the Primary Medical Board certifies the option of withdrawal or refusal of further medical treatment, the hospital shall then constitute Secondary Medical Board a comprising in the manner indicated in the common cause judgement. The Secondary Medical Board has to then visit the hospital for a physical examination of the patient, and after studying the medical papers, the board may concur with the opinion of the Primary Medical Board. In that event, intimation has to be given by the hospital to the JMFC and the next of kin/next friend/guardian of the patient,” she said.

Notably, over the years, the top court has dealt with several petitions seeking the withdrawal of life-sustaining support or treatment for patients in a similar state or those facing irreversible medical conditions. 

While the latest landmark ruling has once again brought into focus the evolving legal framework around passive euthanasia and the right to die with dignity in India, there have been important cases in the past that shaped the legal landscape dealing with the plea of “death with dignity”.

All Creatures Great and Small, an NGO, filed a plea before the Supreme Court in 2019 seeking a procedure to treat rabies as an exceptional disease and permit patients and their guardians to avail the option of death with dignity.

The NGO also sought directions to lay down the guidelines for the circumstances and the manner under which such relief can be sought by patients suffering from rabies or by their guardians. 

The two-judge bench of the Supreme Court agreed to take up the petition last year. The matter is pending before the apex court. 

The five-judge bench of the Supreme Court,  in this case, recognised that the right to “die with dignity” is an integral part of the right to life guaranteed under Article 21 of Constituion. 

The court also laid down guidelines for making a  “living will” by a terminally ill person who is aware of their chances of slipping into a permanent vegetative state. 

The “living will” suggests that a person may expressly deny or withdraw life-sustaining treatment if they fall into an irreversible terminal illness or a persistent vegetative state.

It was observed by the court in the case that depriving an individual of dignity towards the end of his life suggests depriving them of a meaningful existence. 

The Supreme Court, for the first time, recognised the legality of passive euthanasia in the case of Aruna Ramchandra Shanbaug v Union of India in 2011.

Aruna Shanbaug, a nurse, was left in a ‘persistent vegetative state’ for decades, with no possibility of recovery after being sexually assaulted by a ward attendant in a Mumbai Hospital in 1973. 

The plea seeking the end of her life was filed by a journalist and author, Pinki Virani, in the Supreme Court in 2009. Virani, who also wrote a book on Shanbaug, argued that she should be allowed to die peacefully.

While the court declined permission in the case, it recognised the concept of passive euthanasia and ruled that withdrawal of life support could be permitted with the approval of the relevant high court under strict safeguards.

In 2015, Shanbaug, 67,  died of pneumonia, 42 years after the assault.

Nandakumar also pointed out that during the proceedings, concerns had been raised about the absence or non-constitution of Secondary Medical Boards in several states.

“The court has now clarified that CMOs at the district level must ensure that doctors are empanelled so that Secondary Medical Boards can be constituted whenever required. The process laid down by the Supreme Court in Common Cause is essentially a medical process, and ordinarily does not require judicial intervention unless there is some disagreement or between the primary and secondary boards,” she added.

Nandakumar continued, “Hopefully, this judgment will make the process clearer and more workable in practice, so that doctors are able to follow the process laid down by the court and families are not compelled to approach courts in every such situation.”

The Supreme Court, in its 338-page order, underscored the “prolonged absence of comprehensive legislation” on end-of-life care.

This, the bench said, had compelled the court, time and again, to step in to fill the vacuum, out of constitutional necessity rather than institutional choice. The verdict further highlighted that the case of Common Cause (2018) has definitely laid guidelines to protect the right to live and die with dignity, but they were never intended to operate as a permanent substitute for legislation.

Throughout the adjudication of this matter, we have been gripped by profound sadness. The issues in this matter have once again brought to the fore the fragility and transient nature of the life we live, and how swiftly the tide can turn for the worse.

For the past thirteen years, the applicant has lived a life defined by pain and suffering. A suffering made all the more cruel by the fact that, unlike most of us, he was stripped of the ability to even give voice to his anguish.

However, while this case highlights how unforgiving life can be, it is easy to lose sight of another vital fact. We note with immense respect that the applicant’s parents and siblings have stood as unyielding pillars of support. They have exhausted every effort to care for him and continue to do so with unwavering dedication. We can only place on record our deepest appreciation for their boundless love, endurance, and kindness in the face of such adversity.

Among the manifold truths about human existence that this case reveals, the most enduring is the resilience of love. In our considered opinion, the greatest tragedy in life is not death, but abandonment.

Despite the catastrophic tragedy that struck the applicant, his family never left his side. He has been cared for, protected, and cherished at every moment. To us, this unwavering vigil is a testament to the true meaning of love. To love someone is to care for them not just in times of joy, but in their saddest and darkest hours. It is to care for them even when the horizon is devoid of hope.

It is to stand by them as they prepare to cross the threshold into the beyond. Ultimately, to love is nothing but to care deeply, softly, and endlessly.

Our decision today does not neatly fit within logic and reason alone. It sits in a space between love, loss, medicine and mercy. This decision is not about choosing death, but is rather one of not artificially prolonging life. It is the decision to withdraw life-sustaining treatment when that treatment no longer heals, restores, or meaningfully improves life. It is allowing nature to take its course when medicine can only delay the inevitable because survival is not always the same as living.

The Supreme Court penned these words as a final, emotional tribute to the case.

The Supreme Court, in 2018, laid down detailed guidlines for passive euthanasia, recognising the legality of  ‘passive euthanasia’ for terminally ill patients. The apex court also pointed out that the ‘right to die with dignity’ is a part of the right to life under Article 21 of the Constitution.

These guidelines for passive euthanasia were provided for cases where the patient left an ‘advance directive’ or a ‘living will’ stating that life support should be withdrawn if they fall terminally ill, and in cases where no such directive was left behind.

In January 2023, another five-judge bench modified the Supreme Court’s 2018 order to make the process of withdrawal of treatment for terminally ill patients less stringent and more workable.

The changes included the introduction of timelines for each board to make its decision, and limiting the role of the judicial magistrate in the process.

Euthanasia refers to the practice of an individual deliberately ending their life. This practice is often linked with getting relief from an incurable condition or intolerable pain and suffering. 

Euthanasia can only be administered by a physician and can be either “active” or “passive”. 

Wednesday’s judgment was in relation to Rana, who was a student of Panjab University and had been on life support after suffering severe head injuries due to a fall from the fourth floor of his paying guest accommodation in Chandigarh in August 2013.