In a landmark ruling that revisits one of medicine’s most difficult ethical questions, the Supreme Court on Wednesday allowed the withdrawal of artificial life support — or passive euthanasia as it is commonly referred to — for a 31-year-old man who had been comatose for over 13 years. The decision in the Harish Rana case marks the first time the court has directly permitted passive euthanasia for a patient in a permanent vegetative state. Dr Sushma Bhatnagar , former chief of AIIMS and professor of onco-anaesthesia and palliative medicine, tells TOI what this mean in medical practice, and how doctors decide when life support should be withdrawn.What does passive euthanasia mean in medical practice?In simple terms, it involves withdrawal of life support, stopping certain forms of artificial support that prolong life without improving the patient’s condition. For instance, doctors may stop artificial feeding, fluids, or other lifesustaining interventions when they are no longer beneficial. The aim is not to actively end life, but to stop treatments that only prolong suffering, and allow the illness to run its course when recovery is not possible.In what situations do doctors consider withdrawing life support?Doctors consider it when treatments are no longer helping the patient and are only increasing suffering. In such cases, continuing aggressive medical support may not be in the patient’s best interest. Situations may include a permanent vegetative state, severe and irreversible brain injury, terminal cancer, end-stage kidney failure where dialysis is no longer effective, or advanced heart disease where treatment options have been exhausted. It may involve withdrawing ventilatory support, stopping medicines that artificially maintain blood pressure, dialysis, artificial feeding through tubes, or other interventions that sustain bodily functions without improving the patient’s condition.

How do doctors determine that a patient has no chance of recovery, and what safeguards must be followed before life support can be withdrawn in India?There are established medical criteria and tests. For instance, specific tools are used to confirm conditions such as coma or a vegetative state. In terminal illnesses like advanced cancer, prognosis and chances of recovery are assessed using evidencebased medical guidelines. In India, decisions typically involve a review by a primary and a secondary medical board before any decision is taken. In some cases, hospital ethics committees may also be involved to ensure that the process adheres to medical ethics and legal guidelines laid down by the Supreme Court. These measures ensure that the decision is medically justified and ethically sound.How important are living wills or advance directives?They are extremely important. If a patient has clearly stated in advance what kind of treatment they would or would not want in such circumstances, doctors and families can follow those wishes. Respecting patient autonomy is a fundamental principle of medical ethics.How often do doctors get requests to withdraw life support in India?It is still relatively rare in India.Awareness about advance directives is limited. Culturally, many families find it difficult to accept death as a natural part of life.What is the difference between active and passive euthanasia, and how is the latter different from assisted suicide or assisted dying?Active euthanasia involves deliberately administering drugs to cause death. Passive euthanasia refers to withdrawing or withholding treatments that artificially sustain life and involves stopping medical interventions that are no longer beneficial. Assisted suicide involves actively helping a person end their life, usually by providing medication that the person takes themselves.What are some common misconceptions about passive euthanasia?Many people believe it means doctors are actively trying to end a patient’s life. In reality, it usually involves stopping medical interventions that are no longer useful, and focusing on comfort, care and dignity at the end of life.From a medical ethics perspective, why are these practices treated differently?Medical ethics emphasises not causing harm and avoiding treatments that offer no benefit. When treatment only prolongs suffering without any realistic chance of recovery, withdrawing it can be considered ethically appropriate.