Introduction
The Supreme Court’s recognition of passive euthanasia in Common Cause v. Union of India was hailed as a watershed moment for personal liberty. The judgment framed the “right to die with dignity” as a logical extension of Article 21’s protection of dignity and bodily integrity. Yet, beneath this altruistic rhetoric lies a profound and largely overlooked contradiction. Common Cause imagines an Indian patient capable of weighing complex medical choices and exercising informed autonomy at the end of life. This imagined subject, however, does not exist in the empirical reality of India where medical infrastructure is profoundly unequal, access to pain relief is rare, and palliative care is practically a geographical accident.
This piece presents the argument that in a country where palliative care access is as low as 4%, euthanasia consent is not a product of autonomy but of structural deprivation. This analysis proceeds in three steps, corresponding to the foundational structure of this critique. Firstly, it establishes the empirical reality of India’s near-complete absence of palliative care services. Secondly, it demonstrates how Article 21 already imposes positive duties on the State that extend to guaranteeing dignity at the end of life. Finally, it exposes the hidden failure within Common Cause, showing that its reliance on assumptions about patient autonomy is untenable and proposes a tightly tailored recognition of palliative care as a prerequisite to lawful euthanasia in India.
India’s Palliative Care ‘Desert’
Autonomy has no meaning unless it is exercised against a backdrop of real, viable options. The Indian medical and pharmaceutical landscape shows that those options simply do not exist. According to data by the Worldwide Hospice Palliative Care Alliance (WHPCA), fewer than 4% of Indians have access to any form of palliative care, and some studies estimate that geographic access is below 1%.
The consequences are starkly visible in mortality data. The recent 2025 update to the Lancet Commission on Palliative Care and Pain Relief reports that serious health-related suffering (SHS) is rising sharply, having increased by 74% between 1990 and 2021 to affect almost 73.5 million individuals. The greatest concentration of this suffering is found in low and middle-income countries, which accounted for 80% of SHS in 2021. Nations such as India, for example, fall within regions shouldering this disproportionate burden, even while India’s per capita SHS rate remained constant over the study period.
The pattern persists across every metric. India meets only around 0.22% of its annual morphine requirement, largely due to regulatory hurdles, inadequate training, and persistent stigma around opioid use. Even where morphine is legally permitted, physicians in many states are not trained to prescribe it, hospitals do not stock it, and primary health centres stand outside the supply chain altogether.
Palliative care, however, extends far beyond pain medication alone. It encompasses a multidisciplinary approach aimed at improving quality of life for patients with life-threatening illnesses and for their families. Alongside pharmacological pain relief, including access to opioids for severe pain, palliative care addresses breathlessness, nausea, fatigue, and other debilitating symptoms that often accompany terminal illness. Equally important are its non-clinical dimensions. These include assistance with basic daily activities, psychological counselling to address fear, depression, and loneliness, social support to reduce caregiver burden, and guidance for patients and families navigating the emotional and ethical complexities of dying. Home-based care, a core feature of effective palliative systems, allows patients to remain in familiar surroundings and reduces unnecessary hospitalisation. In the absence of these supports, suffering is not limited to physical pain but extends to isolation, anxiety, and loss of dignity, conditions that profoundly shape end-of-life decision-making.
The geographical inequity too is extreme. Kerala is the only Indian state where palliative care has approached universal access, the result of a three-decade, community-driven movement that began in the early 1990s. Its model grew from outpatient initiatives in Kozhikode and expanded through NGOs like the Pain and Palliative Care Society, eventually producing the first palliative-care policy in Asia in 2008. This policy embedded palliative care into health systems, mobilised community volunteers and created a public-private partnership that ensured access to essential medicines and care. Because of this sustained, community-driven infrastructure, Kerala now accounts for most of India’s functioning palliative-care services.
Outside Kerala, care remains the exception. Only scattered, urban pockets in Maharashtra, Delhi, and Karnataka have developed meaningful services. Most of the country has no palliative-care units, no trained volunteers, no home-visiting teams, and no reliable access to opioids. In practical terms, palliative care does not exist for the overwhelming majority of Indians.
This infrastructural deficit is not merely an administrative shortcoming. It constitutes a form of structural violence that quietly shapes the conditions under which many Indians approach the end of life. Akhil Gupta’s account of ‘poverty as biopolitics’ helps illuminate this reality. He argues that the true political failure lies in the State’s willingness to treat avoidable mortality as an ordinary feature of governance rather than as a crisis that demands intervention. This insight resonates strongly with the landscape of end-of-life care in India. When palliative services and pain relief are absent, patients face choices that are shaped more by circumstance than by autonomy. The request to withdraw treatment or to refuse life support often reflects the absence of humane alternatives rather than a considered expression of self-determination. In such contexts, passive euthanasia risks becoming an outcome produced by institutional neglect. What is presented as a safeguard of autonomy may instead operate as the final consequence of a system that has already failed the patient.
In the next part, the piece will argue that the state has positive obligations under Article 21 to provide access to palliative care to all individuals. However, the same has not been realized in practice. Until access to palliative care becomes truly universal, any argument on legalizing euthanasia will be misplaced.
Bio: Samaira Singh is a second-year law student at Jindal Global Law School. She enjoys writing on questions of contemporary and enduring legal significance, with a particular focus on their socio-political implications. Her interests lie in public law theory.
Ed Note: This piece was edited by Hamza Khan and published by Tamanna Yadav from the student editorial board.
