Judicial Recognition and Procedural Facilitation of Altruistic Non‑Directed Living Kidney Donation under THOTA, 1994: Commentary on Dr Thankam Subramonian v. The Chairperson, HBAC, Karnataka High Court (25 Nov 2025)

1. Introduction

The decision of the Karnataka High Court in Writ Petition No. 29161 of 2025 (GM-RES), Dr Thankam Subramonian v. The Chairperson, Hospital Based Authorization Committee & Anr., delivered on 25 November 2025 by Hon’ble Mr. Justice Suraj Govindaraj, is a significant step in the evolving Indian jurisprudence on altruistic, non‑directed living organ donation.

The case is notable for at least three reasons:

• It directly addresses the permissibility and procedural handling of a living person’s desire to donate a kidney altruistically to an unknown recipient, i.e., without any prior relationship or identified donee.
• It clarifies the role and responsibilities of a Hospital Based Authorization Committee (HBAC) constituted under the Transplantation of Human Organs and Tissues Act, 1994 and the 2014 Rules (collectively, “THOTA/THOT Rules”).
• It affirms the importance of individual autonomy and informed choice in matters of organ donation, while preserving statutory safeguards against commercial dealings in human organs.

The judgment, though concise, sets a clear expectation that when an adult, informed and motivated donor offers an altruistic kidney donation, the statutory bodies and the hospital cannot simply decline or ignore the request on the basis of vague suspicion of potential commercial arrangements. Instead, they must process such applications diligently and expeditiously, strictly in accordance with the statutory framework.

2. Factual Background and Procedural History

2.1 The Parties

• Petitioner: Dr. Thankam Subramonian, a 58‑year‑old medical doctor, residing in Bengaluru, who volunteered to donate one of her kidneys altruistically.
• Respondent No. 1: The Chairperson, Hospital Based Authorization Committee (HBAC) established under the Transplantation of Human Organs and Tissues Act, 1994 and the 2014 Rules, functioning at Manipal Hospital, Bengaluru.
• Respondent No. 2: Manipal Hospital, represented by its authorized signatory, being the transplant centre where the donation and transplantation were proposed to be carried out.

2.2 The Petitioner’s Request

The petitioner approached the hospital and the HBAC with a highly unusual request: she sought to donate one of her kidneys “altruistically to any deserving patient” at the respondent hospital, expressly stating that:

• she did not seek any monetary or other compensation, and
• she did not wish to choose or identify the donee; the recipient could be selected by the hospital, provided the medical compatibility tests were satisfied.

In other words, this was a case of non‑directed altruistic donation by a living person: the donor was willing to part with an organ for the benefit of a stranger whose identity she did not know and did not wish to influence.

2.3 The Respondents’ Inaction and Misconception

The petitioner’s application, however, was not considered by the HBAC. The Court records that this was:

“probably under the misconception that, without the Respondents knowing about it, the Petitioner and the donee may have entered into any kind of transaction or arrangement.”

In effect, the HBAC and/or the hospital seem to have proceeded on the presumptive suspicion that any unrelated donation, particularly one without a specified recipient, might conceal a commercial transaction or an impermissible arrangement, and therefore chose not to process the application.

2.4 Writ Petition before the High Court

Faced with inaction, the petitioner invoked the jurisdiction of the High Court under Articles 226 and 227 of the Constitution of India, seeking:

1. a writ of certiorari or other appropriate direction to the respondents to grant approval to her to donate one of her kidneys altruistically to any deserving patient at the respondent hospital; and
2. such other orders as the Court deemed fit in the interests of justice and equity.

During the proceedings, the petitioner was present, and her counsel made it clear that:

• she claimed no right to choose the recipient;
• the recipient could be identified by the hospital from among patients in need;
• subject to all requisite medical tests and compatibility checks, she had no objection to the donation being made without compensation.

On the Court’s prompting, the respondents carried out preliminary examinations and filed a memo reporting that they had identified five unrelated patients who were potentially compatible to receive the donor’s kidney, though further tests (anticipated to take 3–4 weeks) were still required.

A further factual nuance is the urgency highlighted by the petitioner: she had a family history of diabetes, which could, in the near future, compromise her kidney function and thus make her otherwise altruistic donation medically unviable.

3. Issues before the Court

While the Court did not formally frame issues, the core legal and practical questions emerging from the order can be articulated as follows:

1. Permissibility of Altruistic Non‑Directed Living Donation:
   Under THOTA and the 2014 Rules, can an adult living person validly offer to donate a kidney to an unknown, undesignated recipient, purely on altruistic grounds and without compensation?
2. Duties of HBAC and Hospital:
   What are the obligations of the HBAC and the hospital when confronted with such a request? Can they refuse or indefinitely delay considering the application merely because of a speculative apprehension of a commercial transaction?
3. Balancing Autonomy and Anti‑Commercialisation Safeguards:
   How should the law and the courts balance:
   • the donor’s bodily autonomy and informed consent, and
   • the State’s obligation to prevent commercial dealings in human organs?
4. Scope of Judicial Directions:
   Can the High Court, in writ jurisdiction, direct the hospital and HBAC to process and expedite such an altruistic donation and lay down timelines for decision‑making?

4. Summary of the Judgment

The High Court ultimately allowed the writ petition and issued a set of focused directions aimed not at bypassing the statutory framework, but at activating and expediting it.

4.1 Key Factual Findings

The Court records the following critical aspects:

• The petitioner is a doctor by profession, major in age, and is fully aware of the medical and legal implications of kidney donation.
• She has offered the donation of her own free will and volition, without seeking any compensation.
• She relinquishes any choice in identifying the recipient; the donee is to be identified by the hospital, subject to compatibility.
• The respondents have already identified five possible unrelated recipients, with further tests to be conducted over 3–4 weeks.
• There is an element of time‑sensitivity because of the petitioner’s family history of diabetes, potentially impacting her kidneys in the future.

4.2 Holding and Directions

Justice Suraj Govindaraj holds that when an adult, informed donor voluntarily offers a kidney donation without compensation, such a request “has to be given due credence and accepted and put in action.”

The operative directions are:

1. Writ petition allowed.
2. Direction to the Respondent Hospital:
   The hospital is directed to:
   • carry out all required medical tests on the possible donees to determine who would be a suitable recipient of the petitioner’s kidney, ensuring that:
     • the kidney is medically compatible, and
     • the recipient’s body is likely to accept the kidney “without rejection.”
   • upon completion of tests, place the test results and relevant documentation before Respondent No. 1 (the HBAC).
3. Direction to the HBAC (Respondent No. 1):
   The HBAC must:
   • consider the case and the materials placed before it “in terms of this direction”, and
   • pass necessary orders within one week of receiving the hospital’s submission.
4. Compliance with Statutory Procedures:
   The Court clarifies that:
   • all remaining steps must be carried out in accordance with the “applicable procedure”, and
   • as “mandated by Respondent No. 1,” i.e., in conformity with THOTA and the Rules framed thereunder, as implemented by the HBAC.

Notably, the Court does not directly grant or compel “approval” of the transplant. Rather, it mandates that the statutory approval process must be meaningfully and promptly engaged, and must culminate in a decision within a specific time frame.

5. Detailed Analysis

5.1 Precedents Cited and Legal Framework

5.1.1 Absence of Explicit Case‑Law Citations

The judgment does not explicitly cite any prior judicial precedents. It is a short, focused order dealing with a live factual situation and relying essentially on:

• the text and scheme of THOTA and the 2014 Rules, and
• the Court’s understanding of constitutional values of autonomy, informed consent, and public interest in organ donation.

Therefore, the “precedents cited” in the strict sense are none. However, the reasoning fits within a broader trajectory of Indian case‑law upholding individual autonomy in medical decision‑making and interpreting THOTA to enable legitimate, non‑commercial organ donation.

5.1.2 Statutory Framework: THOTA, 1994 and 2014 Rules

The Hospital Based Authorization Committee is described as being “constituted under relevant provisions of the Transplantation of Human Organs and Tissues Act, 1994 and Rules, 2014.” This implicitly invokes the following legal structure:

• Objective of THOTA: To regulate the removal, storage, and transplantation of human organs and tissues for therapeutic purposes, and to prevent commercial dealings in human organs.
• Living Donor Provisions: THOTA primarily permits organ donation by:
  • near relatives (such as spouse, parents, children, siblings), and
  • non‑relatives if specific statutory safeguards and committee approvals are satisfied.
• Authorization Committees (including HBACs):
  These are bodies mandated to:
  • scrutinize living donor–recipient pairs,
  • ensure that the donation is voluntary and uncoerced, and
  • specifically verify that there is no commercial transaction or exploitation involved.
• Hospital Based Authorization Committees:
  For certain recognized transplant centres, the Rules allow the creation of hospital‑based committees, which function under the overarching statutory and regulatory scheme but operate within the hospital to process approvals more efficiently.

This case concerns an unrelated donor and recipient scenario, and moreover, a non‑directed donation: the donor did not propose any specific recipient. The HBAC's role, therefore, is to:

• assess the voluntariness and motivation of the donor,
• exclude any signs of coercion or financial inducement, and
• ensure medical fitness and compatibility through the hospital’s clinical protocols.

The Court’s direction that “the rest of the procedures [are] to be carried out in terms of the applicable procedure” is a clear reaffirmation that THOTA’s safeguards remain fully operative; the Court does not undermine or dilute them.

5.1.3 Broader Jurisprudential Context (Not Cited, But Relevant)

Although not cited in the order, this judgment resonates with:

• Constitutional jurisprudence on bodily autonomy and privacy, where superior courts have affirmed that competent adults are generally entitled to make informed decisions regarding their own bodies, including in medical contexts.
• Earlier judicial approaches to living organ donation, where courts have scrutinized the actions of Authorization Committees to ensure that they neither permit commercial trafficking nor arbitrarily obstruct genuine voluntary donations.

This decision extends that narrative to explicitly recognize and facilitate non‑directed altruistic living donation, which has been relatively rare and often administratively misunderstood in India.

5.2 Court’s Legal Reasoning

5.2.1 Central Concept: Voluntary, Informed, Altruistic Donation

The Court’s core reasoning turns on the donor’s:

• capacity (she is an adult),
• professional background (she is a doctor, hence medically informed),
• understanding of risks (she is “knowing all the aspects relating to the donation”), and
• absence of improper motive (she seeks no compensation and declines to select the recipient).

On these facts, the Court concludes:

“I am of the considered opinion that when she has come forward for donating her kidney of her own free will and volition, being aware of all the aspects relating thereto, her request has to be given due credence and accepted and put in action.”

This is a powerful articulation of the principle that:

• voluntary, informed altruistic donation by a competent adult is prima facie legitimate, and
• statutory and administrative bodies must engage with such requests constructively, not obstruct them on the basis of mere conjecture.

5.2.2 Rejection of Presumptive Suspicion

The HBAC’s inaction appears to have been motivated by a general suspicion that any unrelated organ donation might conceal a commercial transaction. The Court acknowledges this, noting a “misconception” that:

“…without the Respondents knowing about it, the Petitioner and the donee may have entered into any kind of transaction or arrangement.”

While THOTA rightly seeks to prevent organ trafficking, the Court implicitly draws a line between:

• vigilant scrutiny based on evidence or specific red flags, and
• blanket presumption of illegality attached to all unrelated or altruistic donations.

The Court’s approach indicates that:

• Authorization Committees must investigate and verify the absence of commercial dealings, but they cannot refuse to even consider the application merely because such dealings are conceivable in the abstract.
• In a case where the donor is demonstrably informed, disinterested in compensation, and relinquishes the right to choose the recipient, the presumption must be in favour of engaging the statutory process, not ignoring it.

5.2.3 Time‑Sensitivity and Medical Pragmatism

Another important ingredient in the Court’s reasoning is the urgency arising from the petitioner’s family history of diabetes. This could render her kidney unsuitable for donation in the foreseeable future.

The Court therefore recognizes:

• the medical window of opportunity within which the donation can be safely and effectively performed; and
• the public interest in ensuring that a scarce resource (a healthy kidney) is not wasted due to administrative delay or inertia.

By requiring the HBAC to decide within one week of receiving the test results, the Court underscores that:

• statutory compliance must be balanced with promptness, especially when the donor’s medical eligibility is time‑bound; and
• undue delay can defeat the very purpose of donation and may indirectly amount to denying both the donor’s autonomy and the recipient’s right to life‑saving treatment.

5.2.4 Respect for Statutory Structure and Separation of Functions

Importantly, the Court stops short of directly authorizing the transplant itself. Instead, it:

• leaves the final decision to the HBAC, as mandated under THOTA;
• directs the hospital only to perform its clinical and logistical functions (testing and identification of a suitable donee); and
• reaffirms that the “rest of the procedures” must be in accordance with the “applicable procedure” and as mandated by Respondent No. 1.

This respects:

• the separation of roles between the judiciary and specialized committees; and
• the integrity of the regulatory scheme under THOTA, which vests the HBAC with the primary role in deciding authorization applications.

Thus, the Court exercises its writ jurisdiction in a facilitative and supervisory manner, ensuring that:

• the statutory machinery is actually set in motion, and
• decisions are taken within a reasonable, fixed timeframe, but without substituting the Court’s judgment for that of the HBAC on medical or factual assessments.

5.3 Directions and Their Legal Significance

5.3.1 Duty to Act on Altruistic Requests

The most important implication of the directions is that:

• Hospitals and HBACs must treat altruistic, non‑directed living donation requests as cognizable under the existing legal framework.
• They cannot refuse to entertain such applications on the ground that the donor has no pre‑existing relationship with the recipient or that the recipient is not yet identified when the donor approaches.

The High Court’s order effectively recognises that:

Non‑directed altruistic living kidney donation is not per se prohibited by THOTA; it must be processed with due care and statutory safeguards.

5.3.2 Procedural Timelines and Avoidance of Administrative Paralysis

By directing the HBAC to pass “necessary orders within one week” of receiving the test results, the Court:

• guards against administrative delay and paralysis, which can effectively nullify a donor’s wish and deny potential recipients a life‑saving opportunity;
• sets a benchmark for reasonable expedition in processing such sensitive and time‑critical applications.

Though this time limit directly applies only to this case, it can serve as persuasive guidance in future situations involving:

• living organ donations with medical time constraints, and
• instances where the donor’s eligibility may change due to progression of disease or age.

5.3.3 Reinforcing Non‑Commercialization without Chilling Legitimate Donations

The decision strikes a delicate balance:

• It does not dilute THOTA’s prohibition on commercial dealings in human organs.
• At the same time, it cautions against an over‑broad, paralyzing suspicion that could chill or effectively bar genuinely altruistic donations.

In this sense, the Court is implicitly saying that:

Safeguards against exploitation must be robust, but they must not be converted into obstacles that make lawful altruistic donation practically impossible.

6. Potential Impact on Organ Transplantation Law and Practice

6.1 Recognition of Non‑Directed Altruistic Living Donation

The judgment is a strong judicial acknowledgment that non‑directed altruistic kidney donation by a living person is legally cognizable under the Indian statutory framework, provided:

• the donor is competent and fully informed,
• the donation is voluntary and uncoerced, and
• there is no financial or material consideration involved.

This has the potential to:

• encourage other potential altruistic donors to come forward, knowing that courts can and will ensure that their applications are processed properly;
• prompt hospitals and HBACs to formulate clear internal protocols for handling altruistic, non‑directed donations.

6.2 Administrative Guidance for HBACs and Hospitals

While not framed as a general policy directive, this decision is likely to be read as persuasive guidance across:

• HBACs in Karnataka (and possibly elsewhere, by analogy), and
• transplant centres dealing with similar requests.

Key operational takeaways for such bodies include:

• Do not ignore or summarily reject altruistic donation applications by non‑related donors.
• Ensure that medical evaluation and compatibility testing are initiated promptly.
• Maintain vigilance against commercial motives, but base any refusal on concrete findings or red flags, not on abstract suspicion.
• Decide applications within a reasonable, preferably fixed timeframe, especially when medical urgency exists.

6.3 Constitutional and Ethical Implications

At a broader level, the judgment reflects and reinforces:

• the constitutional value of bodily autonomy and the right of an adult to make informed, altruistic choices concerning their own body;
• an ethical recognition that gift‑based, non‑commercial organ donation is a deeply valuable social act that the law should facilitate, not frustrate, so long as exploitation and coercion are excluded;
• the notion that transplant law and policy should be designed to maximize legitimate, life‑saving donations, within robust safeguards against abuse.

7. Complex Concepts Simplified

7.1 Altruistic / Non‑Directed Living Kidney Donation

Altruistic donation means giving an organ purely out of a desire to help someone, without expecting any money, gift, or benefit. Non‑directed (or “unspecified”) means that:

• the donor does not specify who should receive the organ, and
• the hospital or transplant centre selects a recipient based on need and compatibility.

In this case, the petitioner was willing to donate her kidney to “any deserving patient” at the hospital, without naming or knowing the recipient.

7.2 Hospital Based Authorization Committee (HBAC)

An HBAC is a committee set up in certain hospitals that perform organ transplants, under the authority of THOTA and the 2014 Rules. Its main functions include:

• reviewing applications for organ donation by living persons,
• ensuring the donor is acting voluntarily and is not being paid or coerced,
• verifying that there is no commercial transaction involved, and
• authorizing or refusing the transplant based on legal and ethical criteria.

It acts as a safeguard to make sure living organ donations are ethical and legal.

7.3 Writ Petition under Articles 226 and 227

A writ petition is a way for a person to approach a High Court directly when they believe a public authority has:

• acted illegally, or
• failed to act when the law requires it to act.

Article 226 of the Constitution allows High Courts to issue orders to protect rights and ensure public authorities obey the law. Article 227 gives the High Court a supervisory power over lower courts and tribunals.

Here, the petitioner used this route to seek a direction that the HBAC and the hospital must properly consider and process her application to donate a kidney.

7.4 “Applicable Procedure” under the Act and Rules

When the Court says that:

“The rest of the procedures [are] to be carried out in terms of the applicable procedure and as mandated by Respondent No.1.”

it means:

• all remaining steps—counselling, documentation, consent forms, ethical checks, medical clearances—must be done strictly according to THOTA and the 2014 Rules, and any additional lawful guidelines of the HBAC.
• The Court is not relaxing or changing those requirements; it is simply ensuring that the process is actually used and not avoided.

8. Conclusion: Significance in the Broader Legal Context

The Karnataka High Court’s decision in Dr Thankam Subramonian v. The Chairperson, HBAC marks an important development in Indian transplant law and constitutional jurisprudence.

The key takeaways are:

• Altruistic, non‑directed living kidney donation is legally cognizable under THOTA, provided statutory safeguards against commercialisation and coercion are observed.
• Hospitals and Authorization Committees have a duty to process such applications in a fair, expeditious, and legally compliant manner. Mere suspicion or generalised concern about organ trade cannot justify refusal to even consider the request.
• The Court centres the donor’s autonomy and informed choice, especially where the donor is an adult, medically knowledgeable, and acts without expectation of gain.
• At the same time, the Court respects the statutory scheme by not usurping the HBAC’s decision‑making role, but rather ensuring that the statutory process is triggered and completed within a reasonable time.
• The judgment sends a clear policy signal: while combating organ trafficking is crucial, the law must not erect insurmountable barriers for genuine altruistic donors whose actions may save or greatly improve the lives of strangers.

In practical and normative terms, this judgment can be seen as:

• a judicial endorsement of altruistic gift‑based organ donation within the existing legal framework, and
• a reminder to regulatory bodies that they must act with both vigilance and empathy—protecting against exploitation, yet honouring the autonomy and generosity of individuals willing to donate organs for the benefit of others.

As India continues to grapple with chronic organ shortages and ethical concerns about transplantation, this decision provides an important reference point for courts, hospitals, and policymakers seeking to design systems that enable legitimate altruism while preventing abuse.