Assisted suicide

Suicide

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Organizations Compassion & Choices Death with Dignity National Center Dignitas Exit International Final Exit Network Hemlock Society

Assisted suicide is suicide committed with the aid of another person, sometimes a physician.^[1] The term is often used interchangeably with physician-assisted suicide (PAS), which involves a doctor "knowingly and intentionally providing a person with the knowledge or means or both required to commit suicide, including counseling about lethal doses of drugs, prescribing such lethal doses or supplying the drugs."^[2] Assisted suicide is prohibited by common law or criminal statute in all U.S. states.

By contrast, medical aid in dying is specifically authorized in six U.S. states: Oregon, Washington, Vermont, Montana, California, and Colorado. The Oregon, Washington, Vermont, California and Colorado laws expressly say that, "actions taken in accordance with [the Act] shall not, for any purpose, constitute suicide, assisted suicide, mercy killing or homicide, under the law." This distinguishes the legal act of medical aid in dying from the act of assisting in a suicide. On November 1, 2016, the DC council was granted approval to allow terminally ill patients with less than six months to live the chance to be prescribed a lethal dose of medication if they choose to end their life early. There are now six states in the United States that medical aid in dying.^[3]

Countries other than the U.S. allow physicians to physically assist in the death of patients including Canada, Belgium, the Netherlands, Luxembourg, and Switzerland.

Assisted suicide and euthanasia are sometimes combined under the umbrella term "assisted dying". Other related terms include "physician-assisted dying", "physician-assisted death, "aid in dying", "death with dignity", "right to die", "compassionate death", "compassionate dying", "end-of-life choice", and "medical assistance at the end of life".

Physician-assisted suicide is often confused with euthanasia (sometimes called "mercy killing"). In cases of euthanasia the physician administers the means of death, usually a lethal drug. In physician-assisted suicide (PAS) the patient self-administers the means of death.^[4]

There has been a 26% rise in assisted suicide from 2013 to 2014 and almost double that from 2009.^[5]

Arguments in support of medical aid in dying (AiD) and responses to criticism

Due to the recent election November 8, there have many people debating the newly passed Colorado End of Life Options Act. The new law is usually compared to the Death With Dignity Act that has been in place in the state of Oregon for 20 years. While it passed by a vote of two thirds, that still leaves on third of the state's voters that did not wish to see it pass. A few common reasons that have come up, include: religious beliefs, fear of abuse, and the worry that some won't make the decision if they are given better care in their final days. Most supporters believe that it is their right to make this difficult decision on their own and wish to have the choice, despite opposing reasons. They view their choice for aid-in-dying as an end to their suffering, and the end of their life is only a result of the illness.

Personal autonomy

Medical decisions are personal and should be made by individuals and their families without interference from a third party—like the federal or state government. Libertarians strongly support AiD legislation for this reason.

Reducing suffering

One argument for assisted suicide or medical aid in dying is that it reduces prolonged suffering in those with terminal illnesses. When death is imminent (6 months or less) patients can choose to have aid in dying as a medical option to shorten an unbearable dying process.. The three most frequently mentioned end‐of‐life concerns reported by Oregon residents who took advantage of the Death With Dignity Act in 2015 were: decreasing ability to participate in activities that made life enjoyable (96.2%), loss of autonomy (92.4%), and loss of dignity (75.4%) ^[6]

Washington vs. Glucksberg

Assisted suicide is a very controversial topic, and has not always been legal in the 6 U.S. states that it is now legal in. In Washington, it did not become legal until 2008.^[7] In 1997, four Washington physicians, and three deathly ill patients brought forth a lawsuit that would challenge the ban on physician assisted suicide that was in place at the time. This lawsuit was first part of a district court hearing, where it ruled in favor of Glucksberg,^[8] which was the group of physicians and terminally ill patients. The lawsuit was then affirmed by the ninth circuit.^[9] Thus, it was taken to the supreme court, and there the supreme court decided to grant Washington certiorari. Eventually, the supreme court decided, with a unanimous vote, that physician assisted suicide was unconstitutional.^[10] The laws and arguments on this topic are often argued and changed depending on legal evaluation and decision.

Oregon Statistics

A study of hospice nurses and social workers in Oregon reported that symptoms of pain, depression, anxiety, extreme air hunger and fear of the process of dying were more pronounced among hospice patients who did not request aid-in-dying medication.^[11]

A Journal of Palliative Medicine report on patterns of hospice use noted that Oregon was in both the highest quartile of hospice use and the lowest quartile of potentially concerning patterns of hospice use. A similar trend was found in Vermont, where AiD was authorized in 2013.^[12]

In Oregon, in hospital death rates are at the lowest in the nation, at home death rates are at the highest in the nation, and violent suicide among hospice patients has been reduced significantly.^[12]

In February 2016, Oregon released a report on their 2015 numbers. During 2015, there were 218 people in the state who were approved and received the lethal prescription medicines to end their own life. Of that 218, 132 terminally ill patients ultimately made the decision to ingest the medication, resulting in their death. According to the state of Oregon Public Health Division’s survey, the majority of the participants, 78%, where 65 years of age or older and predominately Caucasian, 93.1%. 72% of the terminally ill patients who opted for ending their own lives had been diagnosed with some form of cancer. In the state of Oregon’s 2015 survey, they asked the terminally ill who were participating in the physician-assisted suicides, what their biggest end-of-life concerns were: 96.2 percent of those people mentioned the loss of the ability to participate in activities that once made them enjoy life, 92.4 percent mentioned the loss of autonomy, or their independence of their own thoughts or actions, and 75.4 percent stated loss of their dignity (Oregon Death With Dignity Act).

U.S. Polls

A poll conducted by National Journal and Regence Foundation found that both Oregonians and Washingtonians were more familiar with the terminology "end-of-life care" than the rest of the country and residents of both states are slightly more aware of the terms palliative and hospice care.^[13]

A survey from the Journal of Palliative Medicine found that family caregivers of patients who chose medical AiD were more likely to find positive meaning in caring for a patient and were more prepared for accepting a patient's death than the family caregivers of patients who didn’t request AiD.^[14]

Safeguards to protect vulnerable populations

Many current assisted suicide or aid in dying laws contain oversight and investigative processes to ensure that the law is used only in eligible scenarios and within the confines of the law.

This includes stringent eligibility and qualification processes, mandatory state reporting by the medical team, and medical board oversight. In Oregon and other states, two doctors and two witnesses must attest that a person's request for aid in dying medication wasn’t coerced or under undue influence.

"Slippery slope" fears not realized

The state of Oregon provides nearly two decades of data on their Death with Dignity Act.

An October 2007 study, published in the Journal of Medical Ethics, found that "rates of assisted dying in Oregon and in the Netherlands showed no evidence of heightened risk for the elderly, women, the uninsured (inapplicable in the Netherlands, where all are insured), people with low educational status, the poor, the physically disabled or chronically ill, minors, people with psychiatric illnesses including depression, or racial or ethnic minorities, compared with background populations. The only group with a heightened risk was people with AIDS."^[15]

Organizations in support of assisted suicide

Listed below are some major organizations that support assisted suicide:

Death with Dignity National Center

The Death with Dignity National Center is a nonprofit organization that has been in existence since 1993. This organization is most notably associated with the original writing and continued advocating of the Oregon Death with Dignity Law that was enacted on October 27, 1997.^[16] Oregon, Washington, and Vermont laws state that mentally competent, and terminally ill adult patients can determine if they want to receive prescription medication so they can die in a humane and peaceful way.^[17]

Dignitas (Switzerland)

Dignitas helps Swiss nationals and foreigners to commit suicide by providing advice and lethal drugs. The legal pre-requisites are that a person must have either a terminal illness, an unendurable incapacitating disability or unbearable and uncontrollable pain.^[18] However, in practice they also accept mentally ill patients^[19] or those without a medical diagnosis. 25% of people in Switzerland who take advantage of assisted suicide do not have a terminal illness but are "tired of life," ^[20] for example the retired British art teacher who killed herself on 27 March 2014 "in part because she had become fed up with the modern world of emails, TVs, computers and supermarket ready meals."^[21]

Dignity in Dying

Dignity in Dying is a voluntary^[22] located in London.^[23]

Disabled Activists for Dignity in Dying

DADID^[24] is a campaign group in the UK for disabled people in association with Dignity in Dying, led by disabled people who support a change in the law to allow terminally ill, mentally competent adults the choice of an assisted death within upfront safeguards. Disability is an issue claimed both by activists and opponents in support of their arguments. Most court cases appealing for assisted suicide have been brought by disabled persons. A Yougov poll^[25] in the U.K. suggested that 80% of disabled persons support a change in the law, such as Lord Falconer's Bill^[26] to allow some form of assisted suicide.

Exit

Exit is a Scottish organization that supports a permissive model of right-to-die legislation^[27] based on published research and recommendations from Glasgow University using an 'exceptions to the rule' (against euthanasia) format to facilitate transparency and open safeguards.^[28] Exit published the world's first guide on assisted suicide, called How to Die With Dignity (1980); followed by Departing Drugs (1993), and the Five Last Acts series.^[29]^[30] Exit also publishes a Blog with broad-ranging analysis of assisted-suicide related issues.^[31]

Exit International

Exit International is the publisher of the assisted dying guidebook The Peaceful Pill Handbook by Dr. Philip Nitschke and Dr. Fiona Stewart.^[32] Founded in 2006 by Nitschke and based in Bellingham, Washington,^[33] Exit International is a pro-choice assisted dying organization with an online membership of around 18,000 internationally. The organization holds meetings and workshops in the US, Canada, the UK and Ireland, Australia and New Zealand.

Final Exit Network

Final Exit Network, Inc. is a nonprofit organization founded in 2004 for the purpose of serving as a resource to individuals seeking information and emotional support in committing suicide as a means to end suffering from chronically painful—though not necessarily terminal—illness.

World Federation of Right to Die Societies

The World Federation of Right to Die Societies was founded in 1980 and encompasses thirty-eight right to die organizations in twenty-three different countries.^[34]

Arguments against assisted suicide

Potential for abuse of vulnerable people

Opponents of assisted suicide laws argue that they will already vulnerable populations, like the disability community, those in poverty, and historically marginalized racial groups.

Some members of the disabled community express concern that people with disabilities will be coerced into assisted suicide by discriminatory or ill-prepared institutions or family members. Since the law can’t protect against these cases, assisted suicide shouldn’t be legal.

Medical ethics

Hippocratic Oath

Some doctors argue that physician-assisted suicide is contrary to the original Hippocratic Oath of 400 B.C.E., stating "I will give no deadly medicine to anyone if asked, nor suggest any such counsel".^[35]^[36] The original oath however has been modified many times and, contrary to popular belief, is not required by most modern medical schools,^[37] although some have adopted modern versions that suit many in the profession in the 21st century.

The Declaration of Geneva

The Declaration of Geneva is a revision of the Hippocratic Oath, first drafted in 1948 by the World Medical Association in response to forced euthanasia, eugenics and other medical crimes performed in Nazi Germany. It contains, "I will maintain the utmost respect for human life."

The International Code of Medical Ethics

The International Code of Medical Ethics, last revised in 2006, includes "A physician shall always bear in mind the obligation to respect human life" in the section "Duties of physicians to patients".^[38]

The Statement of Marbella

The Statement of Marbella was adopted by the 43rd World Medical Assembly Malta and editorially revised by the 44th World Medical Assembly in Marbella, Spain in 1992. It outlines guidelines for physicians when dealing with hunger strikers. Physician-assisted suicide is not explicitly prohibited, but could be seen as contrary to the principles of this statement. The first principle is, "Duty to act ethically. All physicians are bound by medical ethics in their professional contact with vulnerable people, even when not providing therapy." The second principle is "Respect for autonomy", meaning a physician is to respect that "food or treatment refusal is the individual's choice". The third principle is 'Benefit' and 'harm'. "Physicians must exercise their skills and knowledge to benefit those they treat...'Benefit' includes respecting individuals' wishes as well as promoting their welfare. Avoiding 'harm' means not only minimising damage to health but also not forcing treatment upon competent people nor coercing them to stop fasting. Beneficence does not necessarily involve prolonging life at all costs, irrespective of other values."^[39]

"Slippery slope" argument

Main article: Euthanasia and the slippery slope

There are many health care professionals, especially those concerned with bioethics, who are opposed to PAS due to the detrimental effects that the procedure can have with regard to vulnerable populations. This argument is known as the "slippery slope".^[40] This argument encompasses the apprehension that once PAS is initiated for the terminally ill it will progress to other vulnerable communities, namely the disabled, and may begin to be used by those who feel less worthy based on their demographic or socioeconomic status. In addition, vulnerable populations are more at risk of untimely deaths because, "patients might be subjected to PAS without their genuine consent".^[41]

Stances on assisted suicide by religion

Buddhism

Catholicism

The Roman Catholic Church is a vocal opponent of physician-assisted suicide, arguing that life is a God-given right and that humans should not interfere in the natural course of death. The Roman Catholic Church teaches its followers that the act of Euthanasia is a great sin, and will continue to be taught as such through the commandment "You shall not kill".^[42]

Judaism

While preservation of life is one of the greatest values in Judaism, there are rare instances of suicide and assisted suicide appearing in the Bible and Rabbinic literature.^[43] The medieval authorities debate the legitimacy of those measures and in what limited circumstances they might apply. The conclusion of the majority of later rabbinic authorities, and accepted normative practice within Judaism, is that suicide and assisted suicide can not be sanctioned even for a terminal patient in intractable pain.^[44]

Unitarianism

According to a 1988 General Resolution, "Unitarian Universalists advocate the right to self-determination in dying, and the release from civil or criminal penalties of those who, under proper safeguards, act to honor the right of terminally ill patients to select the time of their own deaths".^[45]

Mormonism

The Church of Jesus Christ of Latter-day Saints is against euthanasia. Anyone who takes part in euthanasia, including "assisted suicide", is regarded as having violated the commandments of God.^[46] However the Church recognizes that when a person is in the final stages of terminal illness there may be difficult decisions to be taken. The Church states that 'When dying becomes inevitable, death should be looked upon as a blessing and a purposeful part of an eternal existence. Members should not feel obligated to extend mortal life by means that are unreasonable.^[47]

Organizations opposed to assisted suicide

ADAPT – the American Disabled for Attendant Programs Today is a United States organisation that is active in the disability rights movement. They oppose the legalization of physician-assisted suicide, arguing that it is a "violation of the equal protection guaranteed by the Americans with Disabilities Act."^[48]
Agudath Israel of America^[49]
Autistic Self Advocacy Network
British Medical Association
Care Not Killing is a group based in the United Kingdom that combines a number of organisations opposed to assisted suicide under a common banner.^[50]
Christian Medical Fellowship
Disability Rights Education and Defense Fund^[51]
The Euthanasia Prevention Coalition International, founded in 1998 in Canada, is an international organisation opposed to euthanasia and assisted suicide.
Family First New Zealand^[52]
Family Institute of Connecticut^[53]
National Council on Disability
National Spinal Cord Injury Association
Not Dead Yet is a United States disability rights group that opposes assisted suicide and euthanasia for people with disabilities.^[54]
Orthodox Union is one of the oldest Orthodox Jewish organizations in the United States^[55]
Patients' Rights Action Fund
Royal College of General Practitioners
Royal College of Physicians^[56]
TASH is an international advocacy association of people with disabilities, their family members, other advocates, and people who work in the disability field. The mission of TASH is to promote the full inclusion and participation of children and adults with significant disabilities in every aspect of their community, and to eliminate the social injustices that diminish human rights.
The Russian Orthodox Church Canons consider any form of suicide, except suicides committed out of mental disturbances (insanity), a grave sin and a human fault: "A perpetrator of calculated suicide, who 'did it out of human resentment or other incident of faintheartedness' shall not be granted Christian burial or liturgical commemoration (Timothy of Alexandria, Canon 14).^[57]
The United States Conference of Catholic Bishops has stated its opposition to assisted suicide.^[58]
Voice for Life^[59]
The World Medical Association's official position is: "Physicians-assisted suicide, like euthanasia, is unethical and must be condemned by the medical profession. Where the assistance of the physician is intentionally and deliberately directed at enabling an individual to end his or her own life, the physician acts unethically. However the right to decline medical treatment is a basic right of the patient and the physician does not act unethically even if respecting such a wish results in the death of the patient."^[60]

Attitudes of physicians and healthcare professionals

It is widely acknowledged that physicians must play some role in the process of assisted suicide and euthanasia (as evident in the name "physician assisted suicide"), often putting them at the forefront of the issue. Just like the general public, physician and other healthcare professional opinions vary on the issue of assisted suicide.

United States

2014 Medscape Survey

The Medscape Ethics Report of 2014 found that 54% of U.S. based doctors surveyed agreed that physician-assisted suicide should be allowed. 31% disagreed. Support for the measure has increased 8 percentage points since 2010.^[61]

1997 study

A 1997 anonymous mail study directed by David A. Asch MD, MBA and Michael L. DeKay, Ph.D,^[62] sent out surveys to 1,560 United States critical care nurses, and 73% responded about their feelings about euthanasia and physician-assisted suicide. Some of the critical care nurses were sympathetic towards euthanasia because "some...see euthanasia as a legitimate response to end human suffering".^[63] Other factors that influence health care professionals' attitudes towards euthanasia including religion, religiosity, and age.

1994 New England Journal of Medicine study

A study published in 1994 in the New England Journal of Medicine found that physicians’ attitudes toward physician assisted suicide and euthanasia were polarizing. 39% of the 938 participants polled agreed with the statement that physician assisted suicide is never ethically justified, 50% disagreed. 53% said physician assisted suicide should be legal in some cases, and 40% said they would be willing to assist a patient in committing suicide.^[64]

United Kingdom

2009 studies

An extensive survey of 3733 medical physicians was sponsored by the National Council for Palliative Care, Age Concern, Help the Hospices, Macmillan Cancer Support, the Motor Neurone Disease Association, the MS Society and Sue Ryder Care. It showed that the proportion against a change in the law was 66% against euthanasia and 65% against assisted suicide. Opposition to euthanasia and PAS was highest among Palliative Care and Care of the Elderly specialists, while more than 90% of palliative care specialists were against a change in the law.^[65]

Evidence shows that physicians already perform euthanasia and assisted suicide in the UK. In a 2009 survey of 8857 physicians, the proportion of UK deaths involving voluntary euthanasia (i.e. at the patient's request) was 0.21% (CI: 0–0.52), and involuntary euthanasia (i.e. without the patient's request) was 0.30% (0–0.60).^[66]

1997 Glasgow University Study

Glasgow University's Institute of Law & Ethics in Medicine surveyed UK medical practitioners and pharmacists and found that 54% were in favour of a change in the law to allow physician-assisted suicide to take place in specific circumstances, with only 36% against. 60% of the 1000 practitioners who responded had treated a patient who was considering suicide, 12% personally knew another health professional who had assisted a patient to kill themselves and 4% had themselves provided the means (such as drugs or information about lethal acts) to assist a patient to kill themselves. One finding of the second study was that most medical practitioners found physician-assisted suicide preferable to voluntary euthanasia (43% in comparison to 19%), especially in view of the findings of a first study by the University which showed the public's preference for voluntary euthanasia. There was little by way of differences in the percentages of hospital physicians, medical GPs, surgeons or psychiatrists favouring a change in the law – approximately 48% were in favour. This was in stark contrast to the percentage of pharmacists in favour (72%) and anaesthetists (56%). Pharmacists were twice as likely as medical GPs to endorse the view that "if a patient has decided to end their own life then doctors should be allowed in law to assist". (McLean, S., 1997, "Sometimes a Small Victory", Institute of Law and Ethics in Medicine, University of Glasgow.)

Legality by country

Australia

Main article: Euthanasia in Australia

Assisted suicide is currently illegal throughout Australia, but was for a time legal in the Northern Territory under the Rights of the Terminally Ill Act 1995.

Belgium

The "Euthanasia Act" legalized euthanasia in Belgium in 2002,^[71]^[72] but it didn't cover assisted suicide.^[73]

In 2006, Belgium partially legalized euthanasia with certain regulations:

The patient must be an adult and in a "futile medical condition of constant and unbearable physical or mental suffering that cannot be alleviated"^[74]
The patient must have a long-term history with the doctor, with euthanasia/physician assisted suicide only allowed for permanent residents
There need to be several requests that are reviewed by a commission and approved by two doctors.^[75]

As of November 2015, Belgium had the most liberal assisted suicide laws in the world.^[76]

In 2014, Belgium became the first country to authorize euthanasia for children, on request, if they have a terminal illness and understand the repercussions of their act.^[77]

Canada

Main article: Euthanasia in Canada

Suicide was considered a criminal offence in Canada until 1972, after which it was removed from the Criminal Code. Physician-assisted suicide has been legal in the Province of Quebec since the end of life care law (also referred to as "medical aid in dying") was passed by the provincial government on June 5, 2014.^[78] It was declared legal across the country because of the Supreme Court of Canada decision Carter v Canada (AG), of February 6, 2015. The court provided a 12-month suspension of the decision to provide time for the federal government to enact the necessary legislation to make "physician-assisted dying" legal across the country.^[79] Subsequently, the Court approved a four-month extension to this suspension following a request from the Federal government.^[80]

Until it is changed, the Criminal Code of Canada states in section 241(b) that

Every one who ....(b) aids or abets a person to commit suicide, whether suicide ensues or not, is guilty of an indictable offence and is liable to imprisonment for a term not exceeding fourteen years"^[81]

The reason behind this content was to prevent people from 'assisting in suicide' those that are not mentally capable of making the decision and because of the "value that society places on human life" which "in the eyes of the lawmakers, might easily be eroded if assistance in committing suicide were to be decriminalized."^[81]

In 1993, the Supreme Court of Canada heard a case (Rodriguez v. British Columbia (Attorney General)) in which Sue Rodriguez, a terminally ill woman, challenged the prohibition of assisted suicide as contrary to the Canadian Charter of Rights and Freedoms. In a 5 to 4 decision, the Court upheld the provision in the Criminal Code of Canada.

On June 15, 2012, the British Columbia Supreme Court struck down the prohibition against physician-assisted suicide, calling the current law discriminatory, disproportionate and overbroad. Justice Lynn Smith suspended her ruling for a period of one year in order to give Parliament time to draft legislation with her ruling in mind.^[82] Within a month, the federal government announced it would appeal that ruling.^[83] On October 25, 2012, the federal government filed its 54-page legal argument, arguing inter alia that the purpose of the current legislation is "to protect the vulnerable, who might be induced in moments of weakness to commit suicide", that "it is a reflection of the state's policy that the inherent value of all human life should not be depreciated by allowing one person to take another's life", and that the B.C. Supreme Court had no right to attempt to overrule the Supreme Court of Canada's ruling in the 1993 Rodriguez case.^[84] On December 10, 2012, the British Columbia Court of Appeal announced that it had scheduled a hearing for the appeal in March, 2013.^[85]

On June 5, 2014, physician-assisted suicide became legal in the province of Quebec with the passing of the end of life care law (also referred to as "medical aid in dying") by the provincial government.^[86]

On February 6, 2015, The Supreme Court of Canada released their decision in the Carter v Canada (AG) case,^[87] a landmark ruling where the prohibition of assisted suicide was illegal and struck it down by a unanimous vote. The court found that section 241(b) and section 14 of the Criminal Code unjustifiably infringed on Section 7 of the Canadian Charter of Rights and Freedoms.^[88]

Following the 2015 Canadian federal election the new Minister of Justice and Attorney General of Canada, Jody Wilson-Raybould and Minister of Health, Jane Philpott changed the mandate of the External Panel on Options for a Legislative Response to Carter v. Canada by extending the deadline for their report to December 15, 2015 and instructing them to focus on the results of their consultations, rather than on the development of legislative options.^[89] The government subsequently requested a six-month extension for implementation; the arguments for this request were heard by the Supreme Court in January 2016.^[90] The Court approved a four-month extension to the law's implementation on January 15, 2016.^[80]

The court decision includes a requirement that there must be stringent limits that are "scrupulously monitored." This will require the death certificate to be completed by an independent medical examiner, not the treating physician, to ensure the accuracy of reporting the cause of death.^[91]

The Canadian Medical Association (CMA) reported that not all doctors were willing to help a terminally-ill patient die. However, the belief in late 2015 was that no physician would be forced to do so.^[90] By late 2015, the CMA had begun to offer educational sessions to members as to the process that would be used.^[90]

After a lengthy delay, the House of Commons passed a Bill (C-14) in mid June 2016 that would allow for doctor-assisted suicide. The bill was debated in the Senate. Initially, that "House of sober second thought" amended the bill, expanding the right to die. However, when it became apparent that the elected House of Commons would not accept the amendment, a final vote was held on June 18. At that time, a majority agreed with the restrictive wording provided by the House of Commons indicating that "only patients suffering from incurable illness whose natural death is 'reasonably foreseeable' are eligible for a medically assisted death," as summarized by the Toronto Star. Critics of the Bill indicate that the Supreme Court decision in Carter v Canada (AG) was broader, including desperately ill individuals and not only those who are terminally ill or near death. The House of Commons did accept a few Senate amendments, such as requiring that patients be counseled about alternatives, including palliative care and barring beneficiaries from acting.^[92]^[93] The bill will become law after approval by the Governor General of Canada which is only a formality.

China

An article in People's Daily reported that "Nine people from Xi'an City in China made news when they 'jointly wrote to local media asking for euthanasia, or mercy killings'".^[94] These people had uremia, a disease due to the failure of the kidneys, and expressed their "unbearable suffering and [an unwillingness] to burden their families any more".^[95] The article stated because it is illegal for doctors to help their patients die, all that could be done for them was to ask the doctors to ease their pain.^[94]

Colombia

Despite its strict Roman Catholic history, in May 1997 the Colombian Constitutional Court allowed for the euthanasia of sick patients who requested to end their lives, by passing Article 326 of the 1980 Penal Code.^[75] This ruling ows its success to the efforts of a group that strongly opposed euthanasia. When one of its members brought a lawsuit to the Colombian Supreme Court against it, the court issued a 6 to 3 decision that "spelled out the rights of a terminally ill person to engage in voluntary euthanasia."^[96]

In February 2015, the Supreme Court gave the government 30 days to create a comprehensive set of guidelines for doctors, to assist them in avoiding breaches of the law, as although technically legal, many physicians face lawsuits where they must prove that all legal requirements were met prior to the procedure. This fear of legal action has led many doctors to refuse to perform the procedure, in spite of its legality.^[97]

Though physician-assisted suicide is legal, the country has no way to document or set rules and regulations for doctors and patients who want to end their lives. Though it is opposed on religious grounds by many Colombians, many patients have still been able to find doctors to assist them in ending their lives.^[75]

Denmark

In Denmark, passive euthanasia, or the refusal to accept treatment is not illegal. But voluntary euthanasia when a patient actively tries to kill themselves is illegal. 71% of Denmark's population is in favor of legalizing assisted suicide.^[98]

France

The controversy over legalising euthanasia and physician assisted suicide is not as big as in the United States because of the country's "well developed hospice care programme".^[99] However, in 2000 the controversy over the topic was ignited with Vincent Humbert. After a car crash that left him "unable to 'walk, see, speak, smell or taste'", he used the movement of his right thumb to write a book, I Ask the Right to Die (Je vous demande le droit de mourir) in which he voiced his desire to "die legally".^[99] After his appeal was denied, his mother assisted in killing him by injecting him with an overdose of barbiturates that put him into a coma, killing him 2 days later. Though his mother was arrested for aiding in her son's death and later acquitted, the case did jump-start new legislation which states that when medicine serves "no other purpose than the artificial support of life" it can be "suspended or not undertaken".^[100]

In 2013 President Francois Hollande said that France should hold a national debate on the issue, and stated his intention to introduce a bill to parliament before the end of the year. Opinion polls in France show that the majority of the public are in favor of an assisted suicide law,^[101] however France's national ethics committee has advised against any change in the law.^[102]

Germany

Killing somebody in accordance with his demands is always illegal under the German criminal code (Paragraph 216, "Killing at the request of the victim; mercy killing").^[103]

Assisting with suicide by, for example, providing poison or a weapon, is generally legal. Since suicide itself is legal, assistance or encouragement is not punishable by the usual legal mechanisms dealing with complicity and incitement (German criminal law follows the idea of "accessories of complicity" which states that "the motives of a person who incites another person to commit suicide, or who assists in its commission, are irrelevant").^[104] Nor is assisting with suicide explicitly outlawed by the criminal code. There can however be legal repercussions under certain conditions for a number of reasons. Aside from laws regulating firearms, the trade and handling of controlled substances and the like (e.g. when acquiring poison for the suicidal person), this concerns three points:

Free vs. manipulated will

If the suicidal person is not acting out of his own free will, then assistance is punishable by any of a number of homicide offences that the criminal code provides for, as having "acted through another person" (§25, section 1 of the German criminal code,^[105] usually called "mittelbare Täterschaft"). Action out of free will is not ruled out by the decision to end one's life in itself; it can be assumed as long as a suicidal person "decides on his own fate up to the end [...] and is in control of the situation."^[104]

Free will cannot be assumed, however, if someone is manipulated or deceived. A classic textbook example for this, in German law, is the so-called Sirius case on which the Federal Court of Justice ruled in 1983: The accused had convinced an acquaintance that she would be re-incarnated into a better life if she killed herself. She unsuccessfully attempted suicide, leading the accused to be charged with, and eventually convicted of attempted murder.^[106] (The accused had also convinced the acquaintance that he hailed from the star Sirius, hence the name of the case).

Apart from manipulation, the criminal code states three conditions under which a person is not acting under his own free will:

if the person is under 14
if the person has "one of the mental diseases listed in §20 of the German Criminal Code"^[107]
a person that is acting under a state of emergency.

Under these circumstances, even if colloquially speaking one might say a person is acting of his own free will, a conviction of murder is possible.

Neglected duty to rescue

German criminal law obliges everybody to come to the rescue of others in an emergency, within certain limits (§323c of the German criminal code, "Omission to effect an easy rescue").^[108] This is also known as a duty to rescue in English. Under this rule, the party assisting in the suicide can be convicted if, in finding the suicidal person in a state of unconsciousness, he does not do everything in his power to revive him.^[109] In other words, if someone assists a person in committing suicide, leaves, but comes back and finds the person unconscious, he must try to revive him.^[110]

This reasoning is disputed by legal scholars, citing that a life-threatening condition that is part, so to speak, of a suicide underway, is not an emergency. For those who would rely on that defence, the Federal Court of Justice has considered it an emergency in the past.

Homicide by omission

German law puts certain people in the position of a warrantor (Garantenstellung) for the well-being of another, e.g. parents, spouses, doctors and police officers. Such people might find themselves legally bound to do what they can to prevent a suicide; if they do not, they are guilty of homicide by omission.

Iceland

Assisted suicide is illegal. "At the current time, there are no initiatives in Iceland that seek the legalization of euthanasia or assisted suicide. The discussion on euthanasia has never received any interest in Iceland, and both lay people and health care professionals seem to have little interest in the topic. A few articles have appeared in newspapers but gained little attention."^[111]

Luxembourg

In March 2003, a vote to legalise assisted suicide was lost by a single vote (at the time, assisted suicide was not illegal, as suicide was permitted under the criminal code, but a person assisting someone to take their own life could face prosecution).^[112] After again failing to get royal assent for legalizing euthanasia and assisted suicide, in December 2008 Luxembourg's parliament amended the country's constitution to take this power away from the monarch, the Grand Duke of Luxembourg.^[113] Euthanasia and assisted suicide were legalized in the country in April, 2009.^[114]

The Netherlands

Main article: Euthanasia in the Netherlands

Physician-assisted suicide is legal under the same conditions as euthanasia. Physician-assisted suicide became allowed under the Act of 2001 which states the specific procedures and requirements needed in order to provide such assistance. Assisted suicide in the Netherlands follows a medical model which means that only doctors of terminally ill patients are allowed to grant a request for an assisted suicide. The Netherlands only allows people over the age of 12 to pursue an assisted suicide when deemed necessary.

New Zealand

Main article: Euthanasia in New Zealand

Assisted suicide is illegal in New Zealand. Under Section 179 of the Crimes Act 1961, it is illegal to 'aid and abet suicide.'

South Africa

South Africa is struggling with the debate over legalizing euthanasia. Owing to the under-developed health care system that pervades the majority of the country, Willem Landman, "a member of the South African Law Commission, at a symposium on euthanasia at the World Congress of Family Doctors" stated that many South African doctors would be willing to perform acts of euthanasia when it became legalized in the country.^[115] He feels that because of the lack of doctors in the country, "[legalizing] euthanasia in South Africa would be premature and difficult to put into practice [...]".^[115]

On 30 April 2015 the High Court in Pretoria granted Advocate Robin Stransham-Ford an order that would allow a doctor to assist him in taking his own life without the threat of prosecution. The National Prosecuting Authority has stated their intention to appeal the ruling.^[116]

Switzerland

Main article: Euthanasia in Switzerland

Though it is illegal to assist a patient in dying in some circumstances, there are others where there is no offence committed.^[117] The relevant provision of the Swiss Criminal Code^[118] refers to "a person who, for selfish reasons, incites someone to commit suicide or who assists that person in doing so will, if the suicide was carried out or attempted, be sentenced to a term of imprisonment (Zuchthaus) of up to 5 years or a term of imprisonment (Gefängnis)."

A person brought to court on a charge could presumably avoid conviction by proving that they were "motivated by the good intentions of bringing about a requested death for the purposes of relieving "suffering" rather than for "selfish" reasons.^[119] In order to avoid conviction, the person has to prove that the deceased knew what he or she was doing, had capacity to make the decision, and had made an "earnest" request, meaning he/she asked for death several times. The person helping also has to avoid actually doing the act that leads to death, lest they be convicted under Article 114: Killing on request (Tötung auf Verlangen) - A person who, for decent reasons, especially compassion, kills a person on the basis of his or her serious and insistent request, will be sentenced to a term of imprisonment (Gefängnis). For instance, it should be the suicide subject who actually presses the syringe or takes the pill, after the helper had prepared the setup.^[120] This way the country can criminalise certain controversial acts, which many of its people would oppose, while legalising a narrow range of assistive acts for some of those seeking help to end their lives.

In July 2009, British conductor Sir Edward Downes and his wife Joan died together at a suicide clinic outside Zürich "under circumstances of their own choosing". Sir Edward was not terminally ill, but his wife was diagnosed with rapidly developing cancer.^[121]

In March 2010, the PBS FRONTLINE TV program in the United States showed a documentary called "The Suicide Tourist" which told the story of Professor Craig Ewert, his family, and Dignitas, and their decision to commit assisted suicide using sodium pentobarbital in Switzerland after he was diagnosed and suffering with ALS (Lou Gehrig's disease).^[122]

In May 2011, Zurich held a referendum that asked voters whether (i) assisted suicide should be prohibited outright; and (ii) whether Dignitas and other assisted suicide providers should not admit overseas users. Zurich voters heavily rejected both bans, despite anti-euthanasia lobbying from two Swiss social conservative political parties, the Evangelical People's Party of Switzerland and Federal Democratic Union. The outright ban proposal was rejected by eighty four percent of voters, while seventy eight percent voted to keep services open should overseas users require them.^[123]

In June 2011, The BBC televised the assisted suicide of Peter Smedley, a canning factory owner, who was suffering from motor neurone disease. The programme – Sir Terry Pratchett's Choosing To Die – told the story of Peter's journey to the end where he used The Dignitas Clinic, a euthanasia clinic in Switzerland, to assist him in carrying out the taking of his own life. The programme shows Peter eating chocolates to counter the unpalatable taste of the liquid he drinks to end his own life. Moments after drinking the liquid, Peter begged for water, gasped for breath and became red,^[124] he then fell into a deep sleep where he snored heavily while holding his wife's hand. Minutes later, Peter stopped breathing and his heart stopped beating.

In Switzerland non-physician assisted suicide is legal, the assistance mostly being provided by volunteers, whereas in Belgium and the Netherlands, a physician must be present. In Switzerland, the doctors are primarily there to assess the patients decision capacity and prescribe the lethal drugs. Additionally, unlike cases in the United States, a person is not required to have a terminal illness but only the capacity to make decisions. Interestingly, 25% of people in Switzerland who take advantage of assisted suicide do not have a terminal illness but are simply old or "tired of life."^[20]

Uruguay

Main article: Euthanasia in Uruguay

Assisted suicide, while criminal does not appear to have caused any convictions, as article 37 of the Penal Code (effective 1934) states: "The judges are authorized to forego punishment of a person whose previous life has been honorable where he commits a homicide motivated by compassion, induced by repeated requests of the victim."^[125]

United Kingdom

England and Wales, Northern Ireland

Deliberately assisting a suicide is illegal.^[126] Between 2003 and 2006 Lord Joffe made four attempts to introduce bills that would have legalised assisted suicide in England & Wales – all were rejected by the UK Parliament.^[127] In the meantime the Director of Public Prosecutions has clarified the criteria under which an individual will be prosecuted in England and Wales for assisting in another person's suicide.^[128] These have not been tested by an appellate court as yet^[129] In 2014 Lord Falconer of Thoroton tabled an Assisted Dying Bill in the House of Lords which passed its Second Reading but ran out of time before the General Election. During its passage peers voted down two amendments which were proposed by opponents of the Bill. In 2015 Labour MP Rob Marris introduced another Bill, based on the Falconer proposals, in the House of Commons. The Second Reading was the first time the House was able to vote on the issue since 1997. A Populus poll had found that 82% of the British public agreed with the proposals of Lord Falconer's Assisted Dying Bill.^[130] However, in a free vote on 11 September 2015, only 118 MPs were in favour and 330 against, thus defeating the bill.^[131]

Scotland

Unlike the other jurisdictions in the United Kingdom, suicide was not illegal in Scotland before 1961 (and still is not) thus no associated offences were created in imitation. Depending on the actual nature of any assistance given to a suicide, the offences of murder or culpable homicide might be committed or there might be no offence at all; the nearest modern prosecutions bearing comparison might be those where a culpable homicide conviction has been obtained when drug addicts have died unintentionally after being given "hands on" non-medical assistance with an injection. Modern law regarding the assistance of someone who intends to die has a lack of certainty as well as a lack of relevant case law; this has led to attempts to introduce statutes providing more certainty.

Independent MSP Margo MacDonald's "End of Life Assistance Bill" was brought before the Scottish Parliament to permit assisted suicide in January 2010. The Catholic Church and the Church of Scotland, the largest denomination in Scotland, opposed the bill. The bill was rejected by a vote of 85–16 (with 2 abstentions) in December 2010.^[132]^[133]

The Assisted Suicide (Scotland) Bill was introduced on 13 November 2013 by the late Margo MacDonald MSP and was taken up by Patrick Harvie MSP on Ms MacDonald's death. The Bill entered the main committee scrutiny stage in January 2015 and reached a vote in Parliament several months later; however the bill was again rejected.

United States

Main article: Assisted suicide in the United States

State laws regarding assisted suicide in the United States ----

Legal

Legal under court ruling¹

Prohibition upheld by state supreme court

Legislation currently under review²

Illegal

---- ¹ In some states assisted suicide is protected through court ruling even though specific legislation allowing it does not exist.
² Legislation regarding assisted suicide currently under consideration, or a notable court case on the issue is in progress.

Medical aid-in-dying is legal in the American states of California (via the California End of Life Option Act),^[134] Oregon (via the Oregon Death with Dignity Act),^[135] Washington (Washington Death with Dignity Act), and Vermont (Patient Choice and Control at End of Life Act). In Montana (through the 2009 trial court ruling Baxter v. Montana), the court found no public policy against assisting suicide, so consent may be raised as a defense at trial. Oregon and Washington specify some restrictions. It was briefly legal in New Mexico from 2014, but this verdict was overturned in 2015.

Oregon requires a physician to prescribe medication but it must be self-administered. For the patient to be eligible, the patient must be diagnosed by an attending physician as well as by a consulting physician, with a terminal illness that will cause the death of the individual within 6 months. The law states that, in order to participate, a patient must be: 1) 18 years of age or older, 2) a resident of Oregon, 3) capable of making and communicating health care decisions for him/herself, and 4) diagnosed with a terminal illness that will lead to death within six (6) months. It is up to the attending physician to determine whether these criteria have been met.^[70] It is required the patient orally request the medication at least twice and contribute at least one (1) written request. The physician must notify the patient of alternatives; such as palliative care, hospice and pain management. Lastly the physician is to request but not require the patient to notify their next of kin that they are requesting a prescription for a lethal dose of medication. Assuming all guidelines are met and the patient is deemed competent and completely sure they wish to end their life, the physician will prescribe the medication.^[136]

The law was passed in 1997. As of 2013, a total of 1,173 people had had DWDA prescriptions written and 752 patients had died from ingesting medications prescribed under the DWDA.^[137] In 2013, there were approximately 22 assisted deaths per 10,000 total deaths in Oregon.^[137]

Washington's rules and restrictions are similar, if not exactly the same, as Oregon's. Not only does the patient have to meet the above criteria, they also have to be examined by not one, but two doctors licensed in their state of residence. Both doctors must come to the same conclusion about the patient's prognosis. If one doctor does not see the patient fit for the prescription, then the patient must undergo psychological inspection to tell whether or not the patient is in fact capable and mentally fit to make the decision of assisted death or not.^[136]

In May 2013, Vermont became the fourth state in the union to legalize medical aid-in-dying. Vermont's House of Representatives voted 75–65 to approve the bill, Patient Choice and Control at End of Life Act. This bill states that the qualifying patient must be at least 18, a Vermont resident and suffering from an incurable and irreversible disease, with less than six months to live. Also, two physicians, including the prescribing doctor must make the medical determination.^[138]

In January 2014, New Mexico inched closer to being the fifth state in the United States to legalize medical aid-in-dying via a court ruling.^[139] "This court cannot envision a right more fundamental, more private or more integral to the liberty, safety and happiness of a New Mexican than the right of a competent, terminally ill patient to choose aid in dying," wrote Judge Nan G. Nash of the Second District Court in Albuquerque. The NM attorney general's office said it was studying the decision and whether to appeal to the State Supreme Court. However, this was overturned on August 11, 2015 by the New Mexico Court of Appeals, in a 2-1 ruling, that overturned the Bernalillo County District Court Ruling. The Court gave the verdict: "We conclude that aid in dying is not a fundamental liberty interest under the New Mexico Constitution".^[140]

In November 2016, the citizens of Colorado approved Proposition 106, the Colorado End of Life Options Act, with 65% in favor. This made it the third state to legalize medical aid-in-dying by a vote of the people, raising the total to six states.

Brittany Maynard

A pivotal case in the United States was the death of Brittany Maynard in 2014. After being diagnosed with terminal brain cancer, the 29 year old decided that instead of suffering with the side effects the cancer would bring, she wanted to die a painless death and live her last days without suffering. She was residing in California when she was diagnosed, where the Death with Dignity was not legal. Her and her husband Dan, moved up to Oregon where Death with Dignity was legal, so she could take advantage of the program. Before her death, she started the Brittany Maynard fund which works to improve and expand the choice of ending one's life in cases of a terminal illness. In her final days she put a lot of work into the Brittany Maynard fund and Compassion and Choices, and her dying wish was to have her family continue to try and get the Dying with Dignity act passed in all fifty states.^[141]

Published research

A study approved by the Dutch Ministry of Health, the Dutch Ministry of Justice, and the Royal Dutch Medical Association reviewed the efficacy in 111 cases of physician-aided dying (PAD).^[142] This showed that 32% of cases had complications. These included 12% with time to death longer than expected (45 min – 14 days), 9% with problems administering the required drugs, 9% with a physical symptom (e.g. nausea, vomiting, myoclonus) and 2% waking from coma. In 18% of cases the doctors provided euthanasia because of problems or failures with PAD.

The Portland (Oregon) Veterans Affairs Medical Center and the Department of Psychiatry at the Oregon Health and Science University set out to assess the prevalence of depression in 58 patients who had chosen PAD.^[143] Of 15 patients who went to receive PAD, three (20%) had a clinical depression. All patients who participated in the study were determined in advance to be mentally competent. The authors conclude that the "...current practice of the (Oregon) Death with Dignity Act may fail to protect some patients whose choices are influenced by depression from receiving a prescription for a lethal drug".

In a Dutch study of patients with severe and persistent symptoms requiring sedation, the researchers found that only 9% of patients received a palliative care consultation prior to being sedated.^[144]

Resources for further reading

More research can be found on the website of Living and Dying Well UK, an organization who researches and analyzes evidence surrounding end-of-life issues.^[145]

Data on the practice of assisted suicide can also be found from the reports produced in the jurisdictions where it is legal. For example, the Oregon Health Authority publishes annual reports^[146] detailing the enactment of the Oregon Death with Dignity Act.