In the UK our end of life choices for those who wish to take some control of the timing of their death are currently limited, (described here). We do not have the option of the type of peaceful, medically assisted death we might like.
Currently, voluntary euthanasia and/or doctor-assisted suicide is legally available in parts of Australia, Belgium, Canada, Colombia, Luxembourg, The Netherlands, Switzerland, and several US States.
In Switzerland, assisting suicide has not been a crime since suicide was decriminalised during the enlightenment. In 1918 the Swiss government pointed out that if assistance was done with selfish motives, it should be punished. Examples given were pressurising someone to take their own life with the aim of inheriting earlier than with a natural death, or having the intention of no longer needing to support a family member – clearly, immoral motives. The Swiss Federal Criminal Code was finalised in 1937 and came into force on 1 January 1942, the relevant article 115 states:
Inciting and assisting suicide:
Any person who for selfish motives incites or assists another to commit or attempt to commit suicide is, if that other person thereafter commits or attempts to commit suicide, liable to a custodial sentence not exceeding five years or to a monetary penalty.
The legal consequence of this is that assisting a suicide is legal as long as the person who assists does not have selfish motives. The person being assisted must be an adult, fully competent and doing the last act which brings about death themself. Voluntary euthanasia, (by someone administering a lethal injection, for example), is prohibited in Switzerland.
From the 1980s onwards, the law was interpreted as legal permission to establish non-profit member’s societies to enable assisted/accompanied suicide for mentally-competent adults and other services such as setting up health care advance directives. Today, there are two large organizations, both called Exit, based in Geneva and Zurich, which are for Swiss nationals only, and another two which are mainly for foreigners: Dignitas, near Zurich, and Lifecircle, in Basel. In this respect Switzerland is unique as the only country which offers assistance to die to foreign nationals. In 2011 two votes in the Canton of Zürich showed strong support to continue both to permit assisted suicide, and to accept foreigners.
In general, those who are eligible for an assisted suicide are adults who are terminally ill, who are suffering from a severe disability, and elderly persons whose lives have become too arduous as a result of medical conditions related to old age. Despite such assistance being a practice for several decades, today, still only about 1.5% of Swiss deaths are due to assisted suicide.
A document published by Dignitas in August 2017 explains some important but little known aspects of their work, including the counselling they provide; their campaigning activities; and their support for people unable to pay their normal fees.
In The Netherlands, since 1981, both voluntary euthanasia and doctor-assisted suicide have been accepted for those who were experiencing unbearable suffering without the prospect of improvement. Although not legalised until 2002, the practices were initially tolerated under guidelines prepared by the main national legal and medical organizations. In practice, very few Dutch nationals choose doctor assisted suicide, preferring euthanasia. There is no requirement to be “terminally ill”, nor is there any mandatory waiting period.
While the great majority of Dutch doctors support the law (figures up to 90% have been quoted), only about 60% have ever performed euthanasia. At present, about 3% of all deaths are due to voluntary euthanasia – and, all such deaths have to be reported. Cancer accounts for at least 70% of all euthanasia deaths; presently, another 4% are due to dementia (in the early stages of this disease when the patient is still mentally competent to make a request, or in an advanced stage if a patient has made a detailed request for euthanasia in an advance decision), and about 3% are elderly individuals without a serious disease. In The Netherlands, children as young as twelve, who are terminally ill, can request euthanasia, with parental consent (in fact, up to 2014, only five have died this way). Today, unlike a decade or so ago, the palliative care services in The Netherlands are considered to be among the best in Europe.
A description of the practice of euthanasia, written by a retired GP in the Netherlands is available here.
Voluntary euthanasia and doctor-assisted suicide have been legal in Belgium since 2002. The palliative care services and the option of medically-assisted dying are well integrated. As in The Netherlands, euthanasia (doctor-assisted suicide is rarely requested) can be provided to all competent adults who are suffering irreversibly – but, if a patient is not terminally ill, there is a one-month waiting period before euthanasia can be performed. All medically-assisted deaths are reported to a Control and Evaluation Commission. Since 2014, competent children can receive euthanasia if they are terminally ill and in great pain. About 4% of all deaths in Belgium are due to doctor-assisted dying.
For further information see the 2014 MDMD lecture given by Prof Jan Bernheim and a Q&A paper published in the Journal of Bioethical Enquiry in Dec 2014 and an article from the Journal of Medical Ethics in July 2017 – in the last paper, it is recommended that, in legislations where “assisted dying” is legalized, the World Health Organization definition on palliative care (which presently specifies that this “intends neither to hasten or postpone death”) should be updated to include this option (as happens so successfully in Belgium).
In Luxembourg, legislation for voluntary euthanasia was passed in 2009. But, in this small country, up to 2015, less than fifty of its citizens had died this way.
In Colombia, where its Constitutional Court had approved the possibility of voluntary euthanasia in 1997, the first such death only occurred in 2015. This is the only jurisdiction that requires the prior approval of euthanasia requests by an independent committee.
The province of Quebec adopted legislation for doctor-assisted suicide in 2014, and the Federal Government took similar steps in 2016. Now, in this country, all competent, adult Canadians who suffer from a “grievous and irremediable condition” and whose death is “reasonably foreseeable” can receive medical assistance to die. This refusal, by a country so similar to the UK, to use a precise definition for a “terminal illness” (such as “expected to die within six months”) is to be welcomed. Canada uses the term MAiD (Medical Aid in Dying) to refer to the practice there. In 2019 practitioners started using the existing law to provide MAiD for those with early stage dementia, provided that they have mental capacity at the time of their assisted death. The working of the Canadian law is in the process of review with the possibility that it will be extended to cover those who are incurably suffering but not terminally ill. MDMD believe the developing Canadian model is a particularly useful one for the UK to consider.
Canada, excluding Quebec, allows either medically assisted suicide or euthanasia. In Quebec, only euthanasia is allowed. This is another interesting departure from the “Oregon model” used in the USA, and which has been used as the basis for recent UK proposals. Intravenous methods, whether administered by a doctor at the patient’s request, or controlled by patient themselves, avoids some of the possible complications of oral methods used in USA and elsewhere.
In 1997 Oregon became the first state to legalize doctor-assisted suicide for terminally-ill adults (those with a prognosis for survival of six months or less). Later, in 2008, Washington State adopted essentially the same law followed by Vermont (2013); California (2016); Colorado (2016); Washington DC (2017); Hawaii (2018); New Jersey (2019); and Maine (2019). In Montana, its Supreme Court, in 2009, agreed that doctor-assisted suicide could be allowed.
In these States, while a doctor has to write a prescription for the necessary medication, a healthcare professional need not be present when the terminally-ill patient decides to die. All these States require a fifteen-day period between two oral requests and a two-day waiting period between a final written request and the dispensing of the prescription.
All assisted suicide deaths must be reported in each of these States. Detailed annual reports are provided which indicate that the great majority of Americans deciding to die this way are already receiving extensive palliative care, and that they are usually well-educated individuals, with medical insurance coverage. In Oregon, where only 1% of doctors have written prescriptions for the necessary medication, less than 0.4% of all deaths are due to doctor-assisted suicide. Pain motivated only one-third of people to die this way, with most citing a loss of autonomy or dignity, or an inability to do things that made life enjoyable. One-third who receive the lethal medication never use it, but benefit from the knowledge that an end to their suffering is at hand, should they need it.
In Victoria assisted suicide became legal in 2019 for people who are terminally ill and having a life expectancy of 6 months or less, extended to 12 months or less in the case of neurodegenerative illnesses. A similar law has been passed for Western Australia.
For further information see:
Attitudes and Practices of Euthanasia and Physician-Assisted Suicide in the United States, Canada, and Europe, et. al., Journal of the American Medical Association, July 5 2016
and The Economist June 27th 2015 which has several articles and a leader on right-to-die legislation around the world.
Both articles provide source data for this page.