The doctrinal path to Harish Rana

Indian courts have long guarded against conflating a right to die with dignity with a general right to die. In Gian Kaur v State of Punjab, a Constitution Bench upheld Sections 306 and 309 of the Indian Penal Code, holding that Article 21 does not encompass a general right to die, while leaving open a narrower question, that of a dignified death for the terminally ill. Parliament later softened this position through Section 115 of the Mental Healthcare Act 2017, decriminalising attempted suicide. Additionally, Justice KS Puttaswamy v Union of India located bodily autonomy within Article 21, clearing a path for a narrower right: not to hasten death, but to refuse futile treatment and die without needless suffering.

Indian courts have long been wary of equating the right to die with dignity with a broad right to die. In Gian Kaur v State of Punjab, a Constitution Bench upheld Sections 306 and 309 of the Indian Penal Code, holding that Article 21 does not include a general right to die, leaving open a narrower question, that of a dignified death for the terminally ill. Later, Parliament softened this stance through Section 115 of the Mental Healthcare Act 2017, decriminalizing attempted suicide, and Justice KS Puttaswamy v Union of India placed bodily autonomy within Article 21, leading to a narrower right: not to hasten death, but to refuse futile treatment and die without unnecessary suffering.

In Aruna Ramchandra Shanbaug v Union of India, the Court permitted passive euthanasia in principle but required High Court approval case by case. The 241st Report of the Law Commission of India then recommended legislation, which Parliament never enacted. A Constitution Bench went further in Common Cause v Union of India, holding that the right to die with dignity is intrinsic to Article 21, validating living wills and prescribing a two tier medical board procedure, later simplified in 2023. The right remained theoretical, presupposing a competent patient or an executed living will.

In Harish Rana, Rana suffered a traumatic brain injury after falling from the fourth floor of his accommodation in 2013 and developed quadriplegia and was in a permanent vegetative state sustained through a PEG tube for over a decade. His parents sought a medical board to consider passive euthanasia, but in 2024 the Delhi High Court rejected the plea, reasoning that withdrawal would amount to starvation since Rana was not on mechanical ventilation. Medical boards later found his condition irreversible and withdrawal in his best interests, leaving the Supreme Court to decide: is artificial food and water always basic care, or can it become futile treatment that may lawfully be withdrawn?

A landmark shift, still incomplete

The Supreme Court reversed the High Court, holding that CANH requires clinical judgment and ongoing management of complications, and is therefore medical treatment rather than basic nursing care, falling within the Common Cause framework, a distinction previously echoed by the English House of Lords in Airedale NHS Trust v Bland. It also clarified the best interests test: the inquiry cannot be confined to whether treatment can biologically prolong life, but must weigh prognosis, the burdens and benefits of treatment, and the patient’s dignity as a whole. Crucially, withdrawal does not mean withdrawal of care, and the Court directed Rana’s admission to palliative care at AIIMS under a supervised plan.

This tracks the World Health Organization’s view that palliative care is core to the right to health under Article 12 of the ICESCR. In India, that promise remains largely unmet: nearly 7-8 million people require palliative care, but less than 4% can access it, and coverage stays concentrated in states such as Kerala while much of central and eastern India has almost none. A right to a dignified death, without accessible palliative care, risks becoming a right in name only.

Harish Rana transforms this right from principle into an operational one, yet the architecture remains incomplete. India still has no dedicated statute governing end-of-life decisions, and withdrawal rests on judicial safeguards rather than legislation. Implementation remains uneven, with several states yet to constitute the required medical boards. Thus, the Court has urged the Parliament to legislate, echoing decades-old recommendations.

Health rights are understood as requiring the state to preserve life, but Harish Rana shows the harder dimension: dignity sometimes requires recognising when treatment should end. Ensuring withdrawal is accompanied by palliative care rather than abandonment, the Court has placed dignity at the centre of end-of-life medicine, an obligation that, once medicine can no longer cure, becomes one of ensuring life’s final stage is governed by care and dignity.

To situate Ajay Malik, it must be read within the Court’s positive-obligations jurisprudence, under which fundamental rights may require affirmative State action, not merely non-interference. For instance, in Olga Tellis (1985) the Court read livelihood into Article 21 and in Unni Krishnan (1993), it recognised education as enforceable under Article 21. Read against this line of authority, Ajay Malik situates domestic workers’ vulnerability within constitutional commitments to dignity and livelihood (Article 21), equality  (Article 14), freedom from forced labour (Article 23), and humane conditions of work (Article 42), treating regulatory inaction as constitutionally relevant.

A Broken Legal Regime: Recognition Without Rights

Domestic workers in India, despite formal recognition under unorganised labour laws lack adequate protection. The Unorganised Workers’ Social Security Act, 2008 and the Code on Social Security include domestic workers within the definition of unorganised workers and empower governments to frame schemes on social security. However, access depends on prior registration with state welfare boards, which remains sparse and uneven. Crucially, there is no comprehensive legislation governing wages, hours, contracts, or grievance redress for domestic work. Many labour statutes are triggered only where work is performed in a notified “establishment” or commercial “workplace”. Laws such as the Factories Act or state Shops and Establishments Acts regulate industrial or commercial premises, not private homes, leaving domestic work beyond regular inspection and minimum wage enforcement frameworks. Placement agencies frequently exacerbate vulnerability by withholding documents and limiting communication with workers families, to increase vulnerability and thus complicate the process of abuse and wage claims. Complaints of violence are often dismissed by the police as private family matters.

India has not ratified ILO Convention 189 which mandates enforceable contracts, fair wages, and social protection for domestic workers. Several other jurisdictions have adopted clearer regulatory frameworks: Brazil amended its Constitution in 2013 to extend labour rights to domestic workers; Philippines’ Batas Kasambahay mandates written contracts and social insurance and South Africa’s courts guarantee compensation for household injuries.

Some States have tried to fill this void. Kerala’s draft law proposes binding standards like an eight-hour workday and social security. Tamil Nadu and Maharashtra offer contributory welfare board benefits, and Karnataka and Telangana have notified sector-specific minimum wages. Yet registration under these schemes is limited and enforcement of notified minimum wages remains patchy, underscoring how geography still determines whether domestic workers receive any tangible protection.

Ajay Malik and the Unfinished Constitutional Project

Intervention of the Court in Ajay Malik draws constitutional attention to domestic workers in three ways. First, it recognises them as a vulnerable workforce within the unorganised sector, largely women from marginalised communities requiring stronger legal protection. Second, it acknowledges the regulatory hurdles posed by private homes as worksites and the resulting gaps in oversight. Third, it directs the Union Government, through the Ministries of Labour and Employment; Social Justice and Empowerment; Women and Child Development; and Law and Justice, to constitute an expert committee within six months to examine conditions and recommend legislative reform, placing responsibility with the executive and Parliament.

To actualise this, a national system of domestic workers must entail registered agreements (wages, hours, rest, and guarantees) to document claims, portable social security (health insurance, maternity benefits, and pensions through collective contributions) and rights to form unions and collective bargaining; and enforcement controls with consequences in case of abuse (confinement, sexual harassment, child labour), with privacy protections and traceability data structures. Domestic workers have long sustained India’s households and it is now time to recognise them fully as workers, extending legal protections into private homes.

In January 2025, India’s Supreme Court went a step further. In S Rajaseekaran v Union of India, it ruled that access to trauma care during the golden hour is not simply a matter of policy but a constitutional right under Article 21 (the right to life). The Court directed the Union Government to roll out a nationwide cashless treatment scheme for accident victims by March 14, 2025, warning that non-compliance would attract contempt of court. For the first time, trauma care became an enforceable fundamental right.

Failures of the Existing Framework

India’s road safety crisis underlines the urgency. In 2024, nearly 180,000 people died in traffic accidents, a 9% increase from the previous year. This implies that every 3 minutes, India faces a road fatality. Many of these deaths were preventable.

Yet only about 20% of accident victims reach medical care within the golden hour, and ambulance coverage is as low as one vehicle per 80,000–100,000 people—far below the WHO’s recommended one per 50,000. The Motor Vehicles Act already contained legal tools – Section 162 mandating golden hour treatment and Section 164-B creating a Motor Vehicle Accident Fund – but they remained dormant. In practice, police, not paramedics, are often the first responders, making survival a matter of chance rather than law.

Constitutionalising the Golden Hour

Indian constitutional jurisprudence on emergency care began with Parmanand Katara v Union of India (1989), where the Court declared that “preservation of human life is paramount,” requiring every doctor, public or private, to treat emergencies without delay.

Subsequent rulings deepened this framework: Consumer Education & Research Centre (1995) recognised the right to health for workmen as integral to Article 21; Paschim Banga Khet Mazdoor Samity (1996) held that denial of emergency care violates Article 21 and directed states to establish referral protocols, designated hospitals, and budgetary measures; and SaveLIFE Foundation v Union of India (2016) gave binding force to Good Samaritan protections, encouraging bystander assistance.

These precedents gradually shifted responsibility from individual doctors to the State. But the 2025 Rajaseekaran ruling [1]-[8] transformed this duty into a comprehensive state-funded trauma care system. The Court explicitly tied dormant statutory provisions (Sections 162 and 164-B of the Motor Vehicles Act) directly to constitutional obligation and laid out strict timelines: a nationwide cashless treatment scheme with direct hospital payments, integration with national insurance and accident reporting systems, real-time digital platforms for registration and claims, streamlined documentation and audits, extension of coverage beyond seven days, strengthened ambulance standards, and completion of a national trauma registry. Most importantly, any administrative, financial, or procedural delay was declared a constitutional violation, enforceable with contempt powers. The Court’s detailed directions moved India from fragmented statutory measures to a unified, rights-based and accountable trauma care infrastructure.

The ruling also resonates with international law. Article 12 of the International Covenant on Economic, Social and Cultural Rights requires states to realise the highest attainable standard of health. The WHO’s Global Emergency and Trauma Care Initiative urges universal trauma systems, while SDG 3.6 calls for halving road traffic deaths by 2030. India’s constitutionalisation of the golden hour aligns its domestic law with these global mandates.

Towards a Landmark Transformation

The government has already moved from promise to practice. In May 2025, India launched a nationwide cashless emergency treatment scheme for accident victims, covering expenses up to ₹1.5 lakh  (around $1,800) for the first seven days. Hospitals empanelled under the program—including those in the country’s largest public insurance network (Ayushman Bharat)—are paid directly, eliminating upfront costs for patients. Registration, verification, and claims are processed through digital platforms (eDAR, an accident reporting portal, and the National Health Authority’s TMS system). A dedicated budget of ₹272 crore (about $33 million) has been earmarked for 2025–26 to cover uninsured and hit-and-run victims.

These measures show that the Court’s directions are being translated into operational guarantees: cashless treatment, digital transparency, and financial backing. It ensures that survival after trauma no longer depends on luck or bureaucratic delay. The golden hour is now a constitutional mandate, backed by enforceable rights and state accountability.

This incident exposes the structural abuse faced by persons with disabilities (PwDs), especially from marginalised backgrounds, violating Article 21 of the Constitution, and India’s obligations under the UNCRPD (including rights to life, health, and data collection). Despite the landmark ruling of the Supreme Court of India in Rajive Raturi v Union of India which reinforces the rights of PwDs to dignified care and protection from inhuman treatment, disability institutions in India remain sites of invisible suffering. This blog argues that unless India begins to count, record, and publicly review every institutional death, the neglect of PwDs will remain hidden and unaddressed.

When Deaths Aren’t Counted, They Don’t Count

Section 176(1A) of the Criminal Procedure Code and the National Human Rights Commission (NHRC) guidelines mandate prompt reporting, post-mortems examinations and independent Judicial inquiries in all cases of custodial deaths. However, no parallel framework exists for deaths occurring within state-run or non-profit institutions housing PwDs despite India’s enactment of The  Rights of Persons with Disabilities Act, 2016 (RPwD Act).

Sections 3, 6, and 25 of the RPwD Act guarantee the right to dignity and healthcare, yet these provisions till date have remained toothless. Families are not timely notified of a resident’s death, no investigation is conducted to determine the cause of death, and no central registry exists to track such fatalities, amounting to zero accountability even when deaths recur. Such a vacuum renders disability institutions as zones of statistical invisibility and consequently legal and societal apathy.

Similar tracking in other avenues has helped India address long-standing issues. Maternal Death Review and Health Management Information System helped identify high-risk districts where maternal deaths were concentrated, prompting targeted interventions such as increased institutional deliveries, deployment of skilled birth attendants, and improved emergency obstetric care, thus, reducing maternal mortality from 130 to 97 maternal deaths per 100,000 live births. Similarly, the Poshan Tracker used real-time data to flag malnourished children, enabling customised nutritional supplementation. Lack of a similar measure in case of mortalities in disability institutions leaves the problem of systemic neglect undiscovered and therefore unspoken.

International Practice: Where Deaths Trigger Review

Several countries treat deaths in disability institutions as triggers for mandatory reviews, audits, and public reporting – essential for early warning, accountability, and reform.

In the United Kingdom, the Learning Disabilities Mortality Review Programme (LeDeR), established by NHS England, mandates structured, multi-agency reviews of all deaths of persons with learning disabilities In the United States, Medicare and Medicaid-certified care homes are mandated to report all deaths via the Minimum Data Set (MDS) to the Centre for Medicare & Medicaid Services (CMS), which uses this data to flag unsafe facilities and trigger inspections or de-certification. Similarly, a national death review program with independent oversight for all deaths in disability residential services was also suggested by Australia’s Royal Commission. Even the European Court of Human Rights in Nencheva v. Bulgaria, has affirmed that states have a positive duty to protect life and investigate institutional deaths.

Thus, the message on the global scale is clear: counting deaths is the first step toward preventing them.

Towards a National Disability Mortality Registry (NDMR)

To address this legal black hole surrounding deaths in institutional care, India urgently needs a National Disability Mortality Registry (NDMR) to enforce a comprehensive oversight system. First, a Mandatory Dual Notification Protocol should require written and verbal communication of every institutional death within 48 hours to both the next of kin and the relevant regulatory authority. Second, independent medical audits must verify the cause of death and detect negligence. Third, a tiered reporting framework should be put in place: a single death would trigger routine reporting and audit; more than three deaths in thirty days would mandate an automatic state-level inquiry, and any indication of systemic neglect would lead to emergency inspections and temporary suspension of admissions. To ensure transparency, the NDMR should maintain a public dashboard with anonymised data, and penalties, including de-licensing of institutions, must be imposed for non-compliance.

This isn’t just a procedural reform – it is a constitutional obligation under Article 21, the RPwD Act, and India’s UNCRPD commitments. By recording age, gender, disability type, cause of death, and duration of stay, the NDMR can uncover patterns of systemic abuse and neglect, ensuring that institutional deaths are neither invisible nor ignored.

Rooted in Brahminical notions of purity and pollution, this practice assigns the task of handling human waste exclusively to Dalit communities. While caste has often been rationalized as division of labour, B.R. Ambedkar critiqued this functionalist view, arguing it was instead a “division of laborers.” The persistence of this practice, despite being banned under the Employment of Manual Scavengers and Construction of Dry Latrines (Prohibition) Act 1993 and reaffirmed by the Prohibition of Employment as Manual Scavengers and their Rehabilitation Act 2013 (The Act), reflects not just legal inadequacy but a larger societal failure.

Critical Gaps in the Legal Definition

Section 2(g) of the 2013 Act defines a “manual scavenger” restrictively, covering only those handling human excreta from insanitary latrines, open drains, railway tracks, or other premises notified by the government. If this work occurs elsewhere, or in locations not officially notified, it may fall outside the law’s protection.

The Act also fails to include other toxic environments like sewers and septic tanks, which are covered under the definition of hazardous activities under the Rules of the Act. This artificial distinction between hazardous workers and manual scavengers. The Supreme Court in Dr. Balram Singh v Union of India recognized the common origin of both the practices and sought to treat both equally in terms of rehabilitation. However, it held that it was powerless to address this issue since it was not specifically claimed by the parties. This differentiation has practical ramifications since manual scavengers are unable to get the benefit accorded to workers in hazardous employment and vice versa. For instance, workers cleaning septic tanks or sewers with inadequate gear are excluded from the benefits and safeguards intended for manual scavengers such as a One Time Cash Assistance for rehabilitation, skill development training for alternative employment, and access to scholarships for their children under central schemes. On the other hand, the provision of “protective equipment” as per the Rules are limited to workers engaged in hazardous activities and not to those cleaning insanitary latrines and open drains.

Moreover, as per the definition, if a person uses “devices and protective gear as notified by the government,” they are not considered a manual scavenger. In practice, however, the gear provided is often inadequate or outdated, and the law leaves it to the government to define adequacy – an area frequently exploited. For instance, the Railways circumvented the Act by providing workers with basic gear (gloves, masks) while continuing hazardous manual cleaning of tracks and septic tanks. This token compliance exploits the law’s silence on minimum safety standards, allowing employers to bypass accountability.

Due to these loopholes, despite constitutional bans under Articles 17 (abolition of untouchability) and 21 (right to life with dignity), manual scavenging continues unabated. Over 58,000 manual scavengers were identified as of 2018, with conviction rates for violations remaining negligible, causing the Supreme Court to recently order a total ban on manual scavenging in 6 states of India.

Pathway to Eradication

To combat the same, India’s manual scavenging laws must shift from method-oriented compliances to  outcome-oriented  protections,  prioritizing  whether  workers are exposed to hazardous waste over technicalities like tools or contractual status. Judicial precedents, such as Bangalore Water Supply v A. Rajappa wherein the Supreme Court redefined “industry” to protect labor rights and X v Principal Secretary which centered lived realities of unmarried women in abortion access, demonstrate that laws succeed when they align with dignity and ground truths. A revised definition of “manual scavenger” must thus read:

“A person engaged directly or indirectly in handling human excreta, sewage, sludge, or septic tank waste—regardless of decomposition stage, employment status, or location—without access to scientifically validated protective gear that fully eliminates exposure to health hazards.”

Further, long-term eradication demands eliminating human intervention through technology like Bandicoot robots and mechanized suction pumps. Concurrently, stricter penalties, including criminal liability for officials and contractors, should be imposed to deter complicity. Consequently, adopting such a reality-aligned definition along with such supplementary interventions would not only bridge critical legal loopholes but also reaffirm India’s constitutional commitment to human dignity and equality.