What the Karnataka Hysterectomy Case Reveals About Reproductive Rights of Disabled Women

The recent Karnataka high court judgment permitting the parents of a 23-year-old woman with severe intellectual disability to go ahead with her hysterectomy has reopened one of the most difficult debates in disability rights: who should decide when a person cannot provide informed consent? Is it the family, the medical profession, the courts, or the state? More fundamentally, how can society reconcile respect for bodily autonomy with the realities of profound intellectual disability?

These questions have no easy answers. Yet the Karnataka case deserves attention not merely because of the decision the court reached, but because it exposes the inadequacies of India's legal and policy framework governing the reproductive rights of women with disabilities. The judgment is not simply about one young woman or one medical procedure. It reveals the tensions between autonomy and protection, between rights and care, and between constitutional ideals and the lived realities of persons with disabilities and their families.

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On its facts, the case appears compelling. A multidisciplinary medical board comprising specialists in psychiatry, psychology, neurology, obstetrics and gynaecology, radiology and anaesthesiology concluded that the young woman had profound intellectual and developmental disabilities, cerebral palsy and a seizure disorder. Her developmental age was assessed at approximately five years and four months, and her IQ at 36.

The board unanimously concluded that she lacked the capacity to provide informed consent, could not independently manage menstrual hygiene and suffered recurrent medical complications. It recommended hysterectomy as being in her best interests. Exercising its parens patriae jurisdiction, the high court accepted the recommendation.

The court was careful to distinguish the case from forced sterilisation or eugenic practices. It repeatedly emphasised that the decision arose from medical necessity rather than disability itself and that it had carefully considered the irreversible nature of the procedure. The parents, themselves advancing in age, expressed concern about recurring infections and their diminishing ability to provide lifelong care for their daughter. Read narrowly, the judgment appears humane, cautious and procedurally rigorous.

Yet the larger questions remain. The real issue is not whether the Karnataka high court acted responsibly. It is why courts continue to be asked to decide questions that ought to be governed by clear legislation, comprehensive public policy and robust community support systems. Judicial discretion, however conscientious, cannot substitute for a coherent rights-based framework.

A history that cannot be forgotten

The concerns surrounding hysterectomy and sterilisation of women with disabilities do not arise in a historical vacuum. Across the world, women with intellectual and psychosocial disabilities have disproportionately been subjected to irreversible medical procedures without their knowledge or meaningful consent. Such interventions have often been justified in the name of hygiene, institutional convenience, protection from sexual abuse or prevention of pregnancy.

In reality, they reflect deeply entrenched assumptions that women with disabilities are incapable of exercising reproductive autonomy or that their reproductive lives matters less than those of other women.

India has witnessed its own disturbing examples. The most notorious remains the 1994 Shirur Home incident in Pune, where eleven women with psychosocial disabilities underwent hysterectomies while ten others escaped the procedure only after women's organisations exposed the practice.

A delegation led by the late Ahilya Rangnekar, former Communist Party of India (Marxist) (CPI(M)) MP and a leader of the All India Democratic Women's Association (AIDWA), intervened with the then Maharashtra chief minister Sharad Pawar, bringing the exercise to an end.

The episode exposed how easily institutions could override the bodily integrity of women with disabilities in the name of care and convenience. Menstruation was viewed as an administrative burden rather than a natural biological process requiring appropriate support. Institutional inadequacies became medical justifications, while the voices of the women themselves were almost entirely absent.

It is this history that explains why disability rights organisations continue to approach such cases with caution. Their concern is not that every hysterectomy is inherently illegitimate. Rather, it is that disabled women have historically borne a disproportionate burden of irreversible interventions justified by paternalism, prejudice or institutional neglect.

Rights on paper, contradictions in practice

The legal framework has undoubtedly evolved since the Shirur incident. Section 10(2) of the Rights of Persons with Disabilities Act, 2016 (RPwD Act, 2016) explicitly prohibits medical procedures resulting in infertility without the free and informed consent of the person concerned. The provision represents an important affirmation that reproductive autonomy forms part of the dignity guaranteed to persons with disabilities.

Even before the enactment of the RPwD Act, the Supreme Court in Suchita Srivastava v. Chandigarh Administration (2009) recognised reproductive choice as an integral aspect of personal liberty protected under Article 21 of the constitution. Drawing upon constitutional principles and international human rights standards, including the UN Convention on the Rights of Persons with Disabilities (UNCRPD), the court held that a woman with intellectual disability could not be compelled to terminate her pregnancy merely because others considered it to be in her best interests. The judgment was rightly hailed as an affirmation that disability does not extinguish reproductive autonomy.

However, the Karnataka case reveals the limits of existing law. The principle of informed consent presupposes that the individual has the capacity to understand the nature, risks and consequences of a medical intervention. But what happens when a person's disability is so profound that such understanding is impossible?

The law rightly rejects unilateral decisions by doctors or guardians. Yet it offers little guidance on how decisions should be made when consent cannot realistically be obtained. The result is that families, hospitals and judges are left to navigate an ethical and legal vacuum on a case-by-case basis.

The contradictions within Indian law become even more apparent when one examines the interaction between the RPwD Act and the Medical Termination of Pregnancy Act. While the RPwD Act prohibits procedures leading to infertility without informed consent, Section 92 contains a troubling exception permitting termination of pregnancy in severe cases of disability with guardian consent and the opinion of a registered medical practitioner. This broad proviso weakens the protective principle contained elsewhere in the legislation and leaves considerable scope for subjective interpretation.

The distinction drawn under the MTP Act between mental illness and intellectual disability creates further anomalies. A woman with mental illness may undergo termination of pregnancy with the written consent of her guardian. However, guardian consent is not recognised for women with intellectual disabilities, whose own consent remains legally indispensable even when they lack the capacity to provide it. The resulting legal inconsistency has repeatedly generated confusion for medical practitioners and courts alike.

The experience of Z v. State of Bihar (2017) illustrates these contradictions starkly. A destitute woman with mild intellectual disability and HIV, who had become pregnant following rape, sought medical termination of pregnancy. Despite her willingness, the government hospital delayed the procedure while insisting upon consent from her estranged husband or father. By the time the matter reached the Supreme Court, the statutory time limit had expired and she was forced to continue the pregnancy. While the Court criticised the authorities and awarded compensation, the damage had been done.

These decisions demonstrate that India's legal framework remains internally inconsistent. Courts have rightly sought to protect reproductive autonomy, yet they continue to struggle when autonomy cannot be exercised in conventional ways.

Yet the Karnataka judgment also raises a larger question that extends beyond the inconsistencies of Indian law. Is the traditional "best interests" test itself an adequate safeguard for protecting the rights of persons with disabilities?

For decades, courts across the world have relied upon the "best interests" principle when deciding matters involving persons unable to exercise legal capacity. While the doctrine is undoubtedly well intentioned, disability rights movements have increasingly challenged its underlying assumptions. Decisions made in another person's "best interests" often reflect the values, anxieties and social prejudices of those making the decision rather than the wishes of the individual concerned.

This shift in thinking is reflected in the UN Convention on the Rights of Persons with Disabilities (UNCRPD), which marks a fundamental departure from traditional approaches to legal capacity. Article 12 recognises that persons with disabilities enjoy legal capacity on an equal basis with others and obliges States to provide the support necessary for individuals to exercise that capacity. Article 17 protects the physical and mental integrity of persons with disabilities, while Article 23 recognises their equal rights in matters relating to marriage, family and reproduction.

The UN Committee on the Rights of Persons with Disabilities has gone further in its interpretation of Article 12 through General Comment No. 1. It argues that substituted decision-making based solely on another person's assessment of "best interests" should gradually give way to supported decision-making, in which every effort is made to understand and respect an individual's own will and preferences, however they may be expressed.

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This approach does not eliminate difficult cases such as the Karnataka one. Some persons with profound intellectual disabilities may never be able to communicate informed choices in ways recognised by conventional legal standards. Nevertheless, the Convention changes the starting point of the enquiry. Instead of immediately asking what others believe to be in a person's best interests, it asks whether every reasonable effort has been made to understand that person's preferences and whether less restrictive alternatives have been exhausted.

Indian law is yet to fully incorporate this shift. The result is that judges continue to shoulder responsibilities that properly belong to a comprehensive statutory framework informed by contemporary disability rights principles.

The National Platform for the Rights of the Disabled (NPRD) recognised these concerns while the Rights of Persons with Disabilities Bill was being examined by parliament. In its memorandum to the Parliamentary Standing Committee in 2014, the organisation argued that hysterectomy should never be performed on girls or women with disabilities unless a multidisciplinary team, including a gynaecologist and psychiatrist, concluded that preservation of the uterus was medically inadvisable because of incurable pathological conditions. It also sought the removal of provisions permitting irreversible medical procedures on the basis of guardian consent and the opinion of a single medical practitioner.

Those recommendations were not accepted. The resulting legislation continues to contain ambiguities that leave room for inconsistent interpretation and place considerable responsibility upon judges confronted with exceptionally difficult cases.

International evidence reinforces the need for caution. A systematic review published in Epidemiologic Reviews in 2026 found that women with disabilities were consistently more likely to undergo hysterectomy than women without disabilities across several countries. Depending upon the study, women with disabilities were between 1.12 and 2.18 times more likely to have the procedure.

Importantly, the review did not conclude that these surgeries were necessarily inappropriate. Rather, it highlighted concerns that hysterectomy was sometimes recommended because of caregiver anxiety, difficulties associated with menstrual management or assumptions about quality of life rather than because of unavoidable medical necessity. It also noted that many healthcare professionals receive little or no disability-specific training, raising the possibility that unconscious biases influence clinical decision-making.

These findings resonate strongly in the Indian context. Families caring for persons with severe disabilities often confront overwhelming challenges in the absence of meaningful public support. The burden of lifelong care falls overwhelmingly upon parents, usually mothers, who themselves grow older while continuing to provide round-the-clock assistance.

Access to community-based support services remains limited. Personal assistance programmes are virtually non-existent. Respite care is scarce. Menstrual support services for women with severe disabilities receive almost no policy attention. Social security pensions remain inadequate, while disability-specific healthcare services are rare.

In such circumstances, decisions that appear to concern individual medical treatment are frequently shaped by structural failures of the welfare system.

This is why the Karnataka case should not be viewed simply as a contest between the reproductive rights of a disabled woman and the anxieties of her parents. Such a framing obscures the broader reality. Families are often making decisions within a context created by the State's failure to provide adequate social support. Ageing parents, fearful of what will happen to their daughters after they are gone, frequently confront choices that no family should have to make.

The answer therefore cannot lie either in uncritical paternalism or in a rigid conception of autonomy that ignores the realities of profound disability. Nor is judicial discretion, exercised on a case-by-case basis, a satisfactory long-term solution.

Judicial discretion can't substitute rights guaranteed through law

What India requires is a coherent legal and policy framework rooted in the principles of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). The contradictions between the RPwD Act and the Medical Termination of Pregnancy Act need to be addressed through legislative reform. Clear statutory guidance is required on supported decision-making, assessment of legal capacity and the limited circumstances in which irreversible procedures may be considered.

Every such case should involve independent multidisciplinary review, including disability rights expertise, while ensuring that all less restrictive and reversible alternatives have been fully explored. 

It also needs to be underlined that such procedures may also make the woman more vulnerable to sexual abuse. Additionally, such procedures have severe impact on hormones and thus behaviour, which is rarely accounted for.

Equally important, reproductive justice for women with disabilities cannot be secured through legal reform alone. It requires sustained public investment in community living, personal assistance services, respite care, accessible reproductive healthcare, caregiver support and social protection. Without these measures, rights guaranteed on paper will continue to be undermined by the practical realities confronting families.

The Karnataka high court while arriving at its decision under the existing legal framework took care to rely upon expert medical opinion, recognised the irreversible nature of hysterectomy and sought to ensure procedural safeguards. The judgment should therefore not be read as an endorsement of forced sterilisation or as a retreat from disability rights.

At the same time, the case serves as a reminder that judicial discretion cannot substitute for rights guaranteed through law and supported by public policy. More than three decades after the Shirur Home scandal, India continues to lack a comprehensive framework capable of protecting the bodily integrity and reproductive autonomy of women with disabilities while also responding to the genuine challenges faced by families and caregivers.

The Karnataka judgment did not create this dilemma; it merely exposed it. The unfinished task before policymakers is not simply to prevent another abuse, but to ensure women with disabilities are neither denied necessary medical care nor reduced to passive subjects of decisions taken on their behalf. A society committed to equality must strive for more than protection. It must create the conditions in which women with disabilities can exercise autonomy, live with dignity and enjoy reproductive justice as equal citizens.

Muralidharan is general secretary, National Platform for the Rights of the Disabled (NPRD). Views are personal.

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