Assisted suicide

Assisted suicide, also known as assisted dying, is suicide undertaken with the aid of another person.[1] The term usually refers to physician-assisted suicide (PAS), which is suicide that is assisted by a physician or other healthcare provider. Once it is determined that the person's situation qualifies under the physician-assisted suicide laws for that place, the physician's assistance is usually limited to writing a prescription for a lethal dose of drugs.

Suicide

In many jurisdictions, helping a person die by suicide is a crime.[2] People who support legalizing physician-assisted suicide want the people who assist in a voluntary death to be exempt from criminal prosecution for manslaughter or similar crimes. Physician-assisted suicide is legal in some countries, under certain circumstances, including Canada, Belgium, the Netherlands, Luxembourg, Colombia, Switzerland, and parts of the United States and Australia (Victoria).[3] In most of those states or countries, to qualify for legal assistance, individuals who seek a physician-assisted suicide must meet certain criteria, including having a terminal illness, proving they are of sound mind, voluntarily and repeatedly expressing their wish to die, and taking a specified, lethal dose of drugs themselves.

Terminology
Secobarbital is one of the most commonly prescribed drugs for physician assisted suicide in the United States.[4]

Suicide is the act of killing oneself. Assisted suicide is when another person materially helps an individual person die by suicide, such as providing tools or equipment, while Physician-assisted suicide involves a physician (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".[5]

Assisted suicide is contrasted to Euthanasia, sometimes referred to as mercy killing, where the person dying does not directly bring about their own death, but is killed in order to stop the person from experiencing further suffering. Euthanasia can occur with or without consent, and can be classified as voluntary, non-voluntary or involuntary. Killing a person who is suffering and who consents is called voluntary euthanasia. This is currently legal in some regions.[6] If the person is unable to provide consent it is referred to as non-voluntary euthanasia. Killing a person who does not want to die, or who is capable of giving consent and whose consent has not been solicited, is the crime of involuntary euthanasia, and is regarded as murder.

Right to die is the belief that people have a right to die, either through various forms of suicide, euthanasia, or refusing life-saving medical treatment.

Assisted dying vs assisted suicide

Some advocates for assisted suicide strongly oppose the use of "assisted suicide" and "suicide" when referring to physician-assisted suicide, and prefer the phrase "assisted dying". The motivation for this is to distance the debate from the suicides commonly performed by those not terminally ill and not eligible for assistance where it is legal. They feel those cases have negatively impacted the word "suicide" to the point that it bears no relation to the situation where someone who is suffering irremediably seeks a peaceful death.[7][8]

Physician-assisted suicide

Support

Arguments for

Arguments in support of assisted death include respect for patient autonomy, equal treatment of terminally ill patients on and off life support, compassion, personal liberty, and transparency.[9] When death is imminent (half a year or less) patients can choose to have assisted death as a medical option to shorten what the person perceives to be an unbearable dying process. Pain is mostly not reported as the primary motivation for seeking physician-assisted suicide in the United States;[3] 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%).[10]

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 a lethal prescription for barbiturates, the drug used for physician assisted death.[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 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 drugs to end their own life. Of that 218, 132 terminally ill patients ultimately made the decision to ingest drugs, resulting in their death. According to the state of Oregon Public Health Division's survey, the majority of the participants, 78%, were 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 medical aid in dying, what their biggest end-of-life concerns were: 96.2% of those people mentioned the loss of the ability to participate in activities that once made them enjoy life, 92.4% mentioned the loss of autonomy, or their independence of their own thoughts or actions, and 75.4% stated loss of their dignity.[13]

Washington State statistics

An increasing trend in deaths caused from ingesting lethal doses of medications prescribed by physicians was also noted in Washington: from 64 deaths in 2009 to 202 deaths in 2015.[14] Among the deceased, 72% had terminal cancer and 8% had neurodegenerative diseases (including ALS).[14]

U.S. polls

Polls conducted by Gallup dating back to 1947 positing the question, "When a person has a disease that cannot be cured, do you think doctors should be allowed to end the patient's life by some painless means if the patient and his family request it?" show support for the practice increasing from 37% in 1947 to a plateau of approximately 75% lasting from approximately 1990 to 2005. When the polling question was modified as such so the question posits "severe pain" as opposed to an incurable disease, "legalization" as opposed to generally allowing doctors, and "patient suicide" rather than physician-administered voluntary euthanasia, public support was substantially lower, by approximately 10% to 15%.[3]

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.[15]

A survey from the Journal of Palliative Medicine found that family caregivers of patients who chose assisted death 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 assisted death.[16]

Safeguards

Many current assisted death laws contain provisions that are intended to provide oversight and investigative processes to prevent abuse. This includes 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 assert that a person's request for a lethal prescription wasn't coerced or under undue influence.

These safeguards include proving one's residency and eligibility. The patient must meet with two physicians and they must confirm the diagnoses before one can continue; in some cases, they do include a psychiatric evaluation as well to determine whether or not the patient is making this decision on their own. The next steps are two oral requests, a waiting period of a minimum of 15 days before making the next request. A written request which must be witnessed by two different people, one of which cannot be a family member, and then another waiting period by the patient's doctor in which they say whether they are eligible for the drugs or not ("Death with Dignity").

The debate about whether these safeguards work is debated between opponents and proponents.

Religious stances
Unitarian Universalism

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".[17]

Support organizations

Listed below are some major organizations that support medical aid in dying:

Compassion and Choices

Compassion and Choices is a nonprofit organization in support of end-of-life care and claims to be the biggest nonprofit in the United States to do so. Created over 30 years ago, the group provides patients with legal assistance as well as advice and information about medical aid in dying.[18]

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 27 October 1997.[19] 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.[20]

Dignitas (Switzerland)

Dignitas helps Swiss nationals and foreigners to die 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.[21] However, in practice they also accept mentally ill patients[22] or those without a medical diagnosis. 25% of people in Switzerland who use assisted death do not have a terminal illness but are "tired of life",[23] 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".[24]

Dignity in Dying

Dignity in Dying Is a United Kingdom-based campaign group for the right to die, supporting members with advice and information relating to palliative care, and other end of life options. The organization frequently campaigns for the right of adults to make choices about their end of life options. The group was founded in 1935 and has since then been one of the bigger organizations to openly support assisted death in the UK. Their main goal is for the choice to choose how they die and to have a completely free choice to their end of life options.[25]

Disabled Activists for Dignity in Dying

DADID[26] is a campaign group created by Dignity in Dying for disabled people who share the group's perspective on assisted death in the UK. A Yougov poll undertaken by the National Secular Society,[27] which supports assisted death, suggested that 80% of disabled persons support a change in the law, such as Lord Falconer's Bill[28] to allow some form of assisted death. A 2015 Populus poll showed that 86% of disabled people support the introduction of assisted dying law in the UK.[29]

Exit

Exit is a Scottish organization that supports a permissive model of right-to-die legislation[30] based on published research and recommendations from Glasgow University using an 'exceptions to the rule' (against voluntary euthanasia) format to facilitate transparency and open safeguards.[31] Exit published the world's first guide on medical aid in dying, called How to Die With Dignity (1980); followed by Departing Drugs (1993), and the Five Last Acts series.[32] Exit also publishes a Blog with broad-ranging analysis of assisted-death related issues.[33]

Exit International

Exit International is the publisher of the assisted dying guidebook The Peaceful Pill Handbook by Dr. Philip Nitschke and Dr. Fiona Stewart.[34] Founded in 2006 by Nitschke and based in Bellingham, Washington,[35] 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.

Friends At The End

Friends At The End (FATE) is a Scottish charity and UK membership organisation. Friends at the End formed as a voluntary society in 2000 and achieved charitable status in 2018. They sponsor the Cross Party Group on End of Life Choices in the Scottish Parliament and have worked with MSPs to bring two Bills before the Scottish Parliament - the End of Life Assistance (Scotland) Bill 2010 and the Assisted Suicide (Scotland) Bill 2015. Their policy on assisted dying extends to those who are terminally ill or those living with an incurable condition with no time limits.

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 dying medically as a means to end suffering from chronically painful—though not necessarily terminal—illness.

Humanists UK

Humanists UK is a British charity that promotes humanism. They support the right of those who are suffering incurably to have access to an assisted death,[36] and they have supported various court cases to this effect.[37] In contrast to Dignity in Dying, they do not think assisted dying should only be the right of the terminally ill.

My Death My Decision

My Death My Decision is a British organisation that believes those who suffer incurably and have a quality of life below which is acceptable to them should have access to an assisted death.[38] Similar to Humanists UK, they do not think assisted dying should only be the right of the terminally ill.

Pegasos Swiss Association

Pegasos Swiss Association is a Switzerland-based located in Basel. They also have an office in Melbourne, Australia.[39] Pegasos Swiss Association was founded in August 2019 by Ruedi Habegger. Pegasos aims to provide assisted suicide with much less bureaucracy than other similar organizations.[40]

Right to Die Ireland

Right to Die Ireland was founded by Tom Curran, the partner of the assisted suicide campaigner Marie Fleming who lost her legal bid to decriminalise assisted suicide in Ireland in 2013.[41][42]

World Federation of Right to Die Societies

The World Federation of Right to Die Societies was founded in 1980 and encompasses 38 right-to-die organizations in 23 different countries.[43]

Opposition

Medical ethics
Code of Ethics

The most current version of the American Medical Association's Code of Ethics states that physician-assisted suicide is prohibited. It prohibits physician-assisted suicide because it is "fundamentally incompatible with the physician’s role as healer" and because it would be "difficult or impossible to control, and would pose serious societal risks". [44]

Hippocratic Oath

Some doctors[45] remind that physician-assisted suicide is contrary to the Hippocratic Oath, which is the oath historically taken by physicians. It states "I will give no deadly medicine to anyone if asked, nor suggest any such counsel".[46][47] The original oath however has been modified many times and, contrary to popular belief, is not required by most modern medical schools, nor confers any legal obligations on individuals who choose to take it.[48] There are also procedures forbidden by the Hippocratic Oath which are in common practice today, such as abortion.[49]

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 (involuntary) euthanasia, eugenics and other medical crimes performed in Nazi Germany. It contains, "I will maintain the utmost respect for human life."[50]

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".[51]

Statement of Marbella

The Statement of Marbella was adopted by the 44th World Medical Assembly in Marbella, Spain, in 1992. It provides that "physician-assisted suicide, like voluntary euthanasia, is unethical and must be condemned by the medical profession."[52]

Concerns of expansion to people with chronic disorders
Main article: Euthanasia and the slippery slope

A concern present among health care professionals who are opposed to PAS, are the detrimental effects that the procedure can have with regard to vulnerable populations. This argument is known as the "slippery slope".[53] 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".[54]

Religious stances
Catholicism

The Roman Catholic Church acknowledges the fact that moral decisions regarding a person's life must be made according to one's own conscience and faith.[55] Catholic tradition has said that one's concern for the suffering of another is not a sufficient reason to decide whether it is appropriate to act upon voluntary euthanasia. According to the Catechism of the Catholic Church, "God is the creator and author of all life." In this belief system God created human life, therefore God is the judge when to end life.[55] From the Roman Catholic Church's perspective, deliberately ending one's life or the life of another is morally wrong and defies the Catholic doctrine. Furthermore, ending one's life deprives that person and his or her loved ones of the time left in life and causes enormous grief and sorrow for those left behind.[56]

Pope Francis[57] is the current dominant figure of the Catholic Church. He affirms that death is a glorious event and should not be decided for by anyone other than God. Pope Francis insinuates that defending life means defending its sacredness.[58] The Roman Catholic Church teaches its followers that the act of euthanasia is unacceptable because it is perceived as a sin, as it goes against the Ten Commandments, "Thou shalt not kill. (You shall not kill)" As implied by the fifth commandment, the act of assisted suicide contradicts the dignity of human life as well as the respect one has for God.[59]

As an alternative to the physician-assisted suicide and in order to alleviate pain, the Catholic Church proposes that terminally ill patients focus on religion and making peace with the Creator while receiving the love and mercy of their families and caregivers.[56] Additionally, the Roman Catholic Church recommends that terminally ill patients should receive palliative care, which deals with physical pain while treating psychological and spiritual suffering as well, instead of physician-assisted suicide.[60]

Judaism

While preservation of life is one of the greatest values in Judaism, there are instances of suicide and assisted suicide appearing in the Bible and Rabbinic literature.[61] 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.[62]

The Church of Jesus Christ of Latter-day Saints

The Church of Jesus Christ of Latter-day Saints (LDS Church) is against euthanasia. Anyone who takes part in euthanasia, including "assisted suicide", is regarded as having violated the commandments of God.[63] 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.[64]

Organizations opposed

Listed below are organizations opposed to medical aid in dying:

Neutrality

There have been calls for organisations representing medical professionals to take a neutral stance on assisted dying, rather than a position of opposition. The reasoning is that this would better reflect the views of medical professionals and that of wider society, and prevent those bodies from exerting undue influence over the debate.[81][82][83]

The UK Royal College of Nursing voted in July 2009 to move to a neutral position on assisted dying.[84]

The California Medical Association dropped its long-standing opposition in 2015 during the debate over whether an assisted dying bill should be introduced there, prompted in part by cancer sufferer Brittany Maynard.[85] The California End of Life Option Act was signed into law later that year.

In December 2017, the Massachusetts Medical Society (MMS) voted to repeal their opposition to physician-assisted suicide and adopt a position of neutrality.[86]

In October 2018, the American Academy of Family Physicians (AAFP) voted to adopt a position of neutrality from one of opposition. This is contrary to the position taken by the American Medical Association (AMA), who oppose it.[87]

In January 2019 the British Royal College of Physicians announced it would adopt a position of neutrality until two-thirds of its members thinks it should either support or oppose the legalisation of assisted dying.[88]

Attitudes of healthcare professionals

It is widely acknowledged that physicians must play some role in the process of assisted suicide and voluntary euthanasia (as evident in the name "physician-assisted suicide"), often putting them at the forefront of the issue. Decades of opinion research shows that physicians in the US and several European countries are less supportive of legalization of PAS than the general public.[89] In the US, although "about two-thirds of the American public since the 1970s" have supported legalization, surveys of physicians "rarely show as much as half supporting a move".[89] However, physician and other healthcare professional opinions vary widely on the issue of physician-assisted suicide, as shown in the following tables.

StudyPopulationWilling to Assist PASNot Willing to Assist PAS
Canadian Medical Association, 2011[90]Canadian Medical Association (n=2,125)16% 16
 
44% 44
 
Cohen, 1994 (NEJM)[91]Washington state doctors (n=938)40% 40
 
49% 49
 
Lee, 1996 (NEJM)[92]Oregon state doctors (n=2,761)46% 46
 
31% 31
 
StudyPopulationIn favor of PAS being legalNot in favor of PAS being legal
Medscape Ethics Report, 2014[93]U.S.-based doctors54% 54
 
31% 31
 
Seale, 2009[89]United Kingdom physicians (n=3,733)35% 35
 
62.2% 62.2
 
Cohen, 1994 (NEJM)[91]Washington state doctors (n=938)53% 53
 
39% 39
 

Attitudes toward PAS vary by health profession as well; 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 showed that opposition to voluntary euthanasia and PAS was highest among Palliative Care and Care of the Elderly specialists, with more than 90% of palliative care specialists against a change in the law.[89]

In a 1997 study by Glasgow University's Institute of Law & Ethics in Medicine found pharmacists (72%) and anaesthetists (56%) to be generally in favor of legalizing PAS. 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".[94] A report published in January 2017 by NPR suggests that the thoroughness of protections that allow physicians to refrain from participating in the municipalities that legalized assisted suicide within the United States presently creates a lack of access by those who would otherwise be eligible for the practice.[95]

A poll in the United Kingdom showed that 54% of General Practitioners are either supportive or neutral towards the introduction of assisted dying laws.[96] A similar poll on Doctors.net.uk published in the BMJ said that 55% of doctors would support it.[97] In contrast the BMA, which represents doctors in the UK, opposes it.[98]

An anonymous, confidential postal survey of all General Practitioners in Northern Ireland, conducted in the year 2000, found that over 70% of responding GPs were opposed to physician-assisted suicide and voluntary active euthanasia.[99]

Legality
See also: Legality of euthanasia

Voluntary euthanasia was legalized in the Netherlands (in 2002), Belgium (in 2002), Luxembourg (in 2008),[100] and Canada (in 2016).[101] Physician-assisted suicide is legal in Canada, the Netherlands, Luxembourg, Switzerland, the Australian state of Victoria and parts of the United States. In the United States there are assisted dying laws, or court rulings, restricted to terminally ill adults in Oregon, Montana,[102][103] Washington, Vermont, Maine (eff. 1 January 2020), New Jersey, Hawaii, California, Colorado and Washington D.C.[104] The laws require that the patient's attending physician certify mental competence. Oregon was the first United States state to legalize assisted suicide, which was achieved through popular vote. The Act was a citizens' initiative passed twice by Oregon voters. The first time was in a general election in November 1994 when it passed by a margin of 51% to 49%. An injunction delayed implementation of the Act until it was lifted on 27 October 1997. In November 1997, a measure was placed on the general election ballot to repeal the Act. Voters chose to retain the Act by a margin of 60% to 40%.[105]

Australia
Main article: Euthanasia in Australia

Laws regarding assisted suicide in Australia are a matter for state governments, and in the case of the territories, the federal government. Physician-assisted suicide is currently legal in the state of Victoria[106] and Western Australia. In all other states and territories it remains illegal.

Under Victorian law, patients can ask medical practitioners regarding voluntary assisted dying and doctors, including conscientious objectors, should refer to appropriately trained colleagues who do not conscientiously object.[107] Health practitioners are restricted from initiating conversation or suggesting voluntary assisted dying to a patient unprompted.

Voluntary euthanasia was legal in the Northern Territory for a short time under the Rights of the Terminally Ill Act 1995, until this law was overturned by the Federal Government who also removed the ability for territories to pass legislation relating to assisted dying. The highly controversial 'Euthanasia Machine', the first invented voluntary assisted dying machine of its kind, created by Philip Nitschke, utilised during this period is presently held at London's Science Museum.[108]

Belgium

The Euthanasia Act legalized voluntary euthanasia in Belgium in 2002,[109][110] but it did not cover physician-assisted suicide.[111]

Canada
Main article: Euthanasia in Canada

Suicide was considered a criminal offence in Canada until 1972. Physician-assisted suicide has been legal in the Province of Quebec since 5 June 2014.[112] It was declared legal across the country through the Supreme Court of Canada decision Carter v. Canada (Attorney General) of 6 February 2015.[113] After a lengthy delay, the House of Commons passed a Bill[114] in mid-June 2016 that allows for physician-assisted suicide. Between 10 December 2015 and 30 June 2017, 2,149 medically assisted deaths were documented in Canada. Research published by Health Canada illustrates physician preference for physician-administered voluntary euthanasia, citing concerns of effective administration and prevention of the potential complications of self-administration by patients.[115]

China

In China, assisted suicide is illegal under Articles 232 and 233 of the Criminal Law of the People's Republic of China.[116] In China, suicide or neglect is considered homicide and can be punished by three to seven years in prison.[117] In May 2011, Zhong Yichun, a farmer, was sentenced two years' imprisonment by the People's Court of Longnan County, in China's Jiangxi Province for assisting Zeng Qianxiang to commit suicide. Zeng suffered from mental illness and repeatedly asked Zhong to help him commit suicide. In October 2010, Zeng took excessive sleeping pills and lay in a cave. As planned, Zhong called him 15 minutes later to confirm that he was dead and buried him. However, according to the autopsy report, the cause of death was from suffocation, not an overdose. Zhong was convicted of criminal negligence. In August 2011, Zhong appealed the court sentence, but it was rejected.[117]

In 1992, a physician was accused of murdering a patient with advanced cancer by lethal injection. He was eventually acquitted.[117]

Colombia

In May 1997 the Colombian Constitutional Court allowed for the voluntary euthanasia of sick patients who requested to end their lives, by passing Article 326 of the 1980 Penal Code.[118] This ruling owes its success to the efforts of a group that strongly opposed voluntary 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".[119]

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.[120]

Denmark

Assisted suicide is illegal in Denmark. Passive euthanasia, or the refusal to accept treatment, is not illegal. One survey found that 71% of Denmark's population was in favor of legalizing voluntary euthanasia and physician-assisted suicide.[121]

France

Assisted suicide is not legal in France. The controversy over legalising voluntary euthanasia and physician-assisted suicide is not as big as in the United States because of the country's "well developed hospice care programme".[122] 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".[122] 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 two 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".[123]

Germany

Killing somebody in accordance with their demands is always illegal under the German criminal code (Paragraph 216, "Killing at the request of the victim; mercy killing").[124]

Assisting suicide 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").[125] 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,[126] 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".[125]

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 reincarnated 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.[127] (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:

  1. if the person is under 14
  2. if the person has "one of the mental diseases listed in §20 of the German Criminal Code"[125]
  3. 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").[128] 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, they do not do everything in their power to revive the subject.[125] In other words, if someone assists a person in committing suicide, leaves, but comes back and finds the person unconscious, they must try to revive them.[125]

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.

Travel to Switzerland

Between 1998 and 2018 around 1250 German citizens (almost three times the number of any other nationality) travelled to Dignitas in Zurich, Switzerland for an assisted suicide, where this has been legal since 1918.[129][130] Switzerland being one of the few countries that permits assisted suicide for non-resident foreigners.[131]

Physician-assisted suicide

Physician-assisted suicide was formally legalised on 26 February 2020 when Germany's top court removed the prohibition of "professionally assisted suicide".[132]

Iceland

Assisted suicide is illegal.[133]

Ireland

Assisted suicide is illegal. "Both euthanasia and assisted suicide are illegal under Irish law. Depending on the circumstances, euthanasia is regarded as either manslaughter or murder and is punishable by up to life imprisonment."[134]

Luxembourg

After again failing to get royal assent for legalizing voluntary euthanasia and physician-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.[135] Voluntary euthanasia and physician-assisted suicide were legalized in the country in April 2009.[136]

The Netherlands
Main article: Euthanasia in the Netherlands

Netherlands was the first country in the world to formally legalise voluntary euthanasia.[137] Physician-assisted suicide is legal under the same conditions as voluntary 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 patients who are suffering "unbearably without hope"[138] are allowed to grant a request for an assisted suicide. The Netherlands 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 voluntary euthanasia and physician-assisted suicide. Owing to the underdeveloped 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 voluntary euthanasia when it became legalized in the country.[139] 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 [...]".[139]

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. On 6 December 2016 the Supreme Court of Appeal overturned the High Court ruling.[140]

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.[141] The relevant provision of the Swiss Criminal Code[142] 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.[143] 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 they 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.[144] 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.

Switzerland is one of only a handful of countries in the world which permits assisted suicide for non-resident foreigners,[131] causing what some critics have described as suicide tourism. Between 1998 and 2018 around 1'250 German citizens (almost three times the number of any other nationality) travelled to Dignitas in Zurich, Switzerland for an assisted suicide. During the same period over 400 British citizens also opted to end their life at the same clinic.[129][130]

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 84% of voters, while 78% voted to keep services open should overseas users require them.[145]

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 patient's 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. About 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".[23]

Publicized cases

In January 2006 British doctor Anne Turner took her own life in a Zurich clinic having developed an incurable degenerative disease. Her story was reported by the BBC and later, in 2009, made into a TV film A Short Stay in Switzerland starring Julie Walters.

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.[146]

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).[147]

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 voluntary 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, 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.

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."[148]

United Kingdom
Main article: Assisted suicide in the United Kingdom

England and Wales

Deliberately assisting a suicide is illegal.[149] Between 2003 and 2006 Lord Joffe made four attempts to introduce bills that would have legalised physician-assisted suicide in England & Wales—all were rejected by the UK Parliament.[150] 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.[151] These have not been tested by an appellate court as yet[152] 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.[153] However, in a free vote on 11 September 2015, only 118 MPs were in favour and 330 against, thus defeating the bill.[154]

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 physician-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.[155][156]

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.

Northern Ireland

Health is a devolved matter in the United Kingdom and as such it would be for the Northern Ireland Assembly to legislate for assisted dying as it sees fit. As of 2018, there has been no such bill tabled in the Assembly.

Assisted Dying Coalition

A coalition of assisted dying organizations working in favour of legal recognition of the right to die was formed in early 2019.[157]

United States
Main article: Assisted suicide in the United States
State laws regarding assisted suicide in the United States
  Legal
  Legal under court ruling1
  Illegal
1 In some states assisted suicide is protected through court ruling even though specific legislation allowing it does not exist.

Assisted death is legal in the American states of California (via the California End of Life Option Act of 2015, enacted June 2016),[158] Colorado (End of Life Options Act of 2016), Hawaii (Death with Dignity Act of 2018), Oregon (via the Oregon Death with Dignity Act, 1994),[159] Washington (Washington Death with Dignity Act of 2008), Washington DC (District of Columbia Death with Dignity Act of 2016), New Jersey (New Jersey Dignity in Dying Bill of Rights Act of 2019), Maine[160] (eff. 1 January 2020 - Maine Death with Dignity Act of 2019) and Vermont (Patient Choice and Control at End of Life Act of 2013). In Montana, the Montana Supreme Court ruled in Baxter v. Montana (2009) that it found no law or public policy reason that would prohibit physician-assisted dying.[103] Oregon and Washington specify some restrictions. It was briefly legal in New Mexico from 2014, but this verdict was overturned in 2015. Maine is the most recent state that has legalized physician-assisted suicide, with a bill passed by the state assembly in June and approved by the Governor on 12 June 2019. The law went into legal effect on 1 January 2020.

Oregon requires a physician to prescribe drugs and they must be self-administered. In order 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 six 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 months. It is up to the attending physician to determine whether these criteria have been met.[105] 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 drugs.[161]

The law was passed in 1997. As of 2013, a total of 1,173 people had DWDA prescriptions written and 752 patients had died from ingesting drugs prescribed under the DWDA.[162] In 2013, there were approximately 22 assisted deaths per 10,000 total deaths in Oregon.[162]

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.[161]

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.[163]

In January 2014, it seemed as though New Mexico had inched closer to being the fifth state in the United States to legalize physician-assisted suicide via a court ruling.[164] "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 11 August 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".[165]

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.

The punishment for participating in physician-assisted death (PAD) varies throughout many states. The state of Wyoming does not "recognize common law crimes and does not have a statute specifically prohibiting physician-assisted suicide". In Florida, "every person deliberately assisting another in the commission of self-murder shall be guilty of manslaughter, a felony of the second degree".[166]

States currently considering physician-assisted suicide laws

Alaska, Arizona, Connecticut, Delaware, Indiana, Iowa, Kansas, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, New Hampshire, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Utah, and Wisconsin.

Washington vs. Glucksberg

In Washington, physician-assisted suicide did not become legal until 2008.[167] In 1997, four Washington physicians and three terminally ill patients brought forth a lawsuit that would challenge the ban on medical aid in dying that was in place at the time. This lawsuit was first part of a district court hearing, where it ruled in favor of Glucksberg,[168] which was the group of physicians and terminally ill patients. The lawsuit was then affirmed by the Ninth Circuit.[169] 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 medical aid in dying was not a protected right under the constitution as of the time of this case.[170] The laws and arguments on this topic are often argued and changed depending on legal evaluation and decision.

Brittany Maynard

A highly publicized case in the United States was the death of Brittany Maynard in 2014. After being diagnosed with terminal brain cancer, Maynard decided that instead of suffering with the side effects the cancer would bring, she wanted to choose when she would die. She was residing in California when she was diagnosed, where assisted death was not legal. She and her husband moved to Oregon where assisted death was legal, so she could take advantage of the program. Before her death, she started the Brittany Maynard fund, which works to legalize the choice of ending one's life in cases of a terminal illness. Her public advocacy motivated her family to continue to try and get assisted death laws passed in all 50 states.[171]

Films

Television

In the American television series House, physician-assisted suicide is mentioned multiple times. In "Known Unknowns", Dr. Wilson, an oncologist, reveals he indirectly provided a patient dying from cancer the code to increase his morphine level to a lethal amount leading to the patient's death. In "The Dig", Thirteen reveals she assisted her brother in his suicide who was suffering from advanced symptoms of Huntington's disease and that was she was sent to prison for overprescribing. In the same episode, House promises to assist her in killing herself once her own Huntington's symptoms get too bad.

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See also

Notes

    References
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