THE LIMITS OF PRESERVATION: DIGNITY AT THE END OF LIFE

There are decisions in law that cannot be contained within logic alone—decisions that emerge from a fragile intersection of love, loss, medicine, and mercy. “This decision is not about choosing death, but rather about not artificially prolonging life.” Following the ‘Best Interest Principle’, with these words, the Supreme Court of India, in permitting the withdrawal of life-sustaining treatment in the Harish Rana case, articulated a dilemma that increasingly defines modern healthcare. Harish Rana passed away on March 23, concluding a prolonged period of medical dependency and judicial consideration. The question, then, is no longer simply whether life must always be preserved, but how dignity is to be understood when medicine can sustain biological existence even after the possibility of conscious living has irreversibly faded.

India has a legal response to this question. In Aruna Shanbaug v Union of India (2011), the Supreme Court recognised passive euthanasia under judicial oversight. This position was further developed in Common Cause v Union of India (2018), where a Constitution Bench affirmed that the right to die with dignity forms part of the Fundamental Right to Life under Article 21. Courts also recognise advance medical directives, commonly known as ‘living wills’, allowing individuals to state their preferences regarding medical treatment in situations where they may no longer be able to decide for themselves. The legal position, therefore, is not absent; rather, it is careful, evolving, and constitutionally grounded.

Building on this framework, a deeper constitutional question emerges: if Article 21 protects dignity in life, must it not also recognise a limit to the right of not being subjected to futile or nonbeneficial medical intervention when recovery is no longer possible? This is not a claim to end life, but a resistance to its indefinite technological prolongation. The inquiry, therefore, is not whether death is being chosen, but whether life is being meaningfully preserved.

However, the realities of end-of-life care (EOLC) in India suggest that this framework operates within a far more complex social and medical context. Access to structured palliative services remains limited and uneven across the country. Services are concentrated in a few regions, while large parts of India continue to face a shortage of trained personnel, institutional support, and awareness regarding EOLC. These disparities cut across geography, as the condition of the urban poor is often no better—and at times worse— than that of the rural poor. While the legal framework exists, such gaps shape its real-world experience. This makes a compelling case for urgent policy attention, including clearer legislative direction on EOLC and the institutionalisation of standardised EOLC protocols across healthcare systems.

Today, modern medicine has fundamentally altered the nature of dying. Lifesupport technologies like ventilators, dialysis, and assisted nutrition can prolong biological functions even when recovery is unlikely. While they save countless lives, they can also extend existence without awareness or autonomy, raising the ethical question: when does preserving life stop preserving what makes it meaningful?

Bioethical scholarship sheds light on this shift. Ezekiel Emanuel notes that many patients seek control over dying, avoiding prolonged suffering and loss of agency. Judith Travis Thompson adds that withdrawing futile treatment lets natural disease progress, rather than causing death. This distinction underpins Indian law, which allows passive but not active euthanasia.

Concerns about misuse remain important, especially in a socio-economically unequal country where vulnerable individuals might be pressured in end-of-life decisions. The ‘slippery slope’ argument highlights this, but Hallvard Lillehammer notes the risk stems from weak safeguards. With informed consent, independent evaluation, and transparency, misuse can be minimised.

In the Indian context, these concerns must be balanced with lived realities. Families often play a central role in caregiving, particularly in prolonged medical conditions. This reflects a social structure that is relational rather than strictly individualistic. While this can provide emotional and practical support, it can also place significant burdens on families navigating complex medical decisions. Ensuring that the patient’s dignity remains central within this relational framework is therefore essential.

For medical professionals, this ethical dilemma is equally complex. The duty to preserve life is foundational to medical practice, but so is the responsibility to alleviate suffering. When treatment no longer offers recovery, continuing intervention may not always align with the patient’s best interests. Clearer and more accessible frameworks can support clinicians in making these decisions with confidence, ensuring that care remains both compassionate and ethically grounded.

Indian legal scholarship has also contributed to this evolving understanding, as Upendra Baxi has emphasised that constitutional rights must be interpreted in a manner that reflects lived realities, where dignity is not an abstract ideal but a condition that shapes the quality of life itself. This perspective aligns with the Supreme Court’s recognition that dignity is integral to Article 21, not separate from life, but inherent in it.

The Harish Rana case illustrates how these principles operate in practice. The decision to withdraw life-sustaining treatment followed careful medical assessment, the involvement of family members, and judicial consideration. It was not an act of abandonment, but a recognition that continued intervention no longer served a therapeutic purpose. At the same time, the case highlights the importance of ensuring that such decisions can be approached with clarity, awareness, and support.

The ethical weight of this question grows in today’s richly connected world, where travel, communication, art, and knowledge expand life’s possibilities. To exist without awareness or participation is more than a medical condition; it is a rupture between existence and living, a tragedy defined by the gap between life’s potential and its reality.

Looking ahead, the need is not so much for a fundamental shift in legal principles, but for greater coherence and accessibility in their application. Awareness of advance medical directives remains limited. Institutional mechanisms for implementing EOLC decisions vary across regions. Palliative care services require expansion, particularly beyond urban centres. These are challenges that call for measured, thoughtful strengthening rather than abrupt change.

The euthanasia debate in India is less about life versus death and more about preserving dignity in an era where medicine extends life’s boundaries. The constitution affirms dignity; the challenge is to translate this into humane, informed practices that respond to social realities.

Ultimately, the question is not simply whether life can be prolonged, but whether, in prolonging it, we continue to preserve the person who lives it.

THE VIEWS EXPRESSED BY THE AUTHOR ARE PERSONAL

Dr Richa Tiwari, Assistant Professor of Politics and International Studies, Pondicherry University