PART – I
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.
PART – II
In the previous part, this article argued that access to palliative care in India remains deeply unequal and inaccessible to the vast majority of the population. This part continues on the ramifications of lack of access to palliative care to the debate on euthanasia in the Indian context.
Article 21 and the State’s Positive Obligations
The Supreme Court of India, through decades of jurisprudence, has expanded the scope of Article 21 as not being confined to merely providing negative liberty against State interference. It also mandates certain positive obligations, requiring the State to create the enabling conditions necessary for individuals to live with dignity.
In Paschim Banga Khet Mazdoor Samity v. State of West Bengal, the Court held that the State has a constitutional duty to provide adequate medical facilities to preserve the right to life under Article 21, even if resources are strained. Along similar lines, in Parmanand Katara v. Union of India, the Apex Court ruled that the State and all hospitals, both public and private, have a legal obligation to provide immediate medical aid to injured people as it is their fundamental right under Article 21.
This brings me to my contention that if Article 21 obliges the State to provide life-saving medical care, it must logically extend to life-affirming medical care too. Dignity must not vanish at the point where death becomes inevitable. If anything, pain relief and proper psychological support are components of the right to live with dignity even in one’s final months or days.
In the case of Samira Kohli v. Dr Prabha Manchanda, the Court held that valid consent requires knowledge of alternatives. This is crucial. If a terminally-ill patient is unaware of palliative options because those options do not exist, then the decision to refuse treatment or request withdrawal cannot be considered “informed”. Consent obtained in a context devoid of alternatives is no consent at all.
Article 21 therefore requires the State to secure the conditions for genuine autonomy. Without minimally adequate palliative care, the State is permitting decisions that present themselves as autonomous but are, by default, shaped by avoidable suffering.
Common Cause’s Assumption of Autonomy
Common Cause forms the binding centrepiece of India’s euthanasia jurisprudence today. The Court, however, built its framework on the tacit assumption that patients are able to weigh the burdens of continued medical treatment against the comfort offered by palliative alternatives. The judgment refers repeatedly to “informed” and “voluntary” choices. It imagines patients who understand their prognosis, know the options available, and can meaningfully determine how to die with dignity. This vision of patient autonomy, which is crucial to the Court’s reasoning, lacks solid empirical foundation in India.
The core critique is that this reliance on idealised autonomy generates profound contradictions within the very framework established by the Court:
Firstly, the Court explicitly roots its reasoning in dignity, repeatedly affirming that the right to live with dignity extends to a dignified death. In the judgment, the Court held that dignity is essential to liberty, requires protection against cruel, inhuman, or degrading treatment, and is beyond definition, speaking for itself. The Court found that dignity must subsist “even in the culminating phase of human existence”.
However, dignity requires a baseline of humane care. The empirical reality of India demonstrates otherwise as stated in the above thesis. Consequently, when structural pain relief is functionally absent, dignity is compromised not primarily by the disease itself, but by inadequate State support and the structural failure to build the necessary infrastructure. The concept of dignity, as emphasised in Common Cause, demands protection against suffering and indignity, yet when pain relief is absent, the patient is forced to endure precisely the suffering Article 21 is meant to guard against.
Secondly, the Court expanded autonomy but ignored its enabling conditions. It noted that liberty, which is a facet of Article 21, allows the “freedom of choice with respect to their healthcare”. However, the Court ignored the structural and institutional conditions necessary to enable genuine autonomy. Autonomy is no freestanding ideal and autonomy without options is, at best, a hoax. In a context where alternatives, such as adequate palliative care are absent, a patient’s desire to withdraw treatment becomes a matter of desperation rather than a fully informed choice. The State is, therefore, permitting decisions that appear autonomous but are shaped by suffering, resulting in a distorting state of affairs.
Thirdly, the Court creates an elaborate procedural structure for both Advance Directives and cases without them, mandating the involvement of Primary and Secondary Medical Boards. This framework aims to ensure that the decision to withdraw life support is taken in the “best interests of the patient”. Yet, the Court created this framework without ensuring that hospitals possess the specialist expertise required to evaluate palliative alternatives. The empirical reality of India suggests that most Medical Boards will be convened in institutions with no palliative care specialists at all. The boards must ideally include experts from fields like neurology, cardiology, and psychiatry, but given the infrastructure deficit (where Kerala accounts for over 90% of resources), the required expertise, particularly in palliative medicine, is evidently missing. Consequently, decision-making will be informed primarily by medical and institutional limitations, rather than genuine patient preferences and access to viable alternatives.
The result of these doctrinal flaws is a framework that appears constitutionally sophisticated yet remains practically hollow. It asserts that individuals may determine the manner of their dying, but such determination becomes meaningful only when supported by a basic level of health infrastructure. In the absence of constitutional recognition of the conditions required for dignity at the end of life, the State risks turning the safeguard of passive euthanasia into an arrangement that distorts autonomy. Rather than protecting self-determination, it may reproduce the effects of structural neglect and present them as voluntary choice.
Conclusion
Recognising a constitutional obligation to provide palliative care does not demand sweeping reforms. It requires minimum guarantees consistent with Common Cause and existing Article 21 jurisprudence. The Parliament must incorporate palliative care standards into the Clinical Establishments (Registration and Regulation) Act. This would ensure uniform minimum service requirements across states. The State must also address the raging morphine gap. Streamlined licensing and mandatory training programmes can correct the regulatory bottlenecks that currently deny patients basic pain relief. Medical Boards must include at least one clinician trained in palliative medicine. Without this expertise, assessments of “best interests” are incomplete. Moreover, palliative care should be integrated into Ayushman Bharat and similar schemes, ensuring financial access for low-income patients as well.
India’s euthanasia framework aspires to honour autonomy and dignity. Yet, aspiration alone cannot substitute for infrastructure. Article 21 cannot sustain a right to die where the preconditions for a dignified life remain unmet. Thus, the right to palliative care is implicit in the very logic of Common Cause. The State must first guarantee minimum end-of-life support before any decision to forgo treatment or withdraw life support can be considered informed, voluntary, or legally valid.
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.