By Bob Roehr
Assisted dying goes by a variety of names from country to country.1 These are often chosen to shape public discourse, and the weight of different factors varies by country.
The practice is less likely in places and cultures that look more to family and society to make healthcare decisions, often to the point of shielding a patient from knowledge of a diagnosis and treatment options. Even in the western world, it’s not that long ago that patients were sometimes not told that they had terminal cancer.
The cost of care is often part of the debate: in many high income countries the government, or patients themselves through insurance, bear most or at least part of the direct costs of care. Religion is another: some religious groups are among the most potent foes of the right to die, and in countries where such groups provide a significant part of medical care they can wield an effective veto over such legislation.
The first person in the world to die under a specific law on the right to die was Bob Dent, in 1995 in Darwin, northern Australia. Two years later the Australian parliament took the highly unusual step of overturning the territorial law that had allowed the procedure.
In 2017 the state of Victoria passed a law on voluntary assisted dying based on the “Oregon model” that had emerged in the US (see “United States” below). Western Australia passed a similar law in 2018 that is now in effect, followed more recently by Tasmania (in 2019, to take effect in October 2022) and South Australia (in June 2021, with regulations and a start date yet to be decided).
Advocates expect that Queensland will vote for similar legislation in September 2021. New South Wales, which has about a third of the country’s population, “will be a tough nut to crack” because of the strong influence of religious forces in the state, says Marshall Perron, a political leader who sponsored the initial legislation in the Northern Territory.
The Medical Assistance in Dying law2 in Canada sprang from a 2015 high court ruling that assisted dying was a basic human right under the Canadian Charter of Rights and Freedoms, which forms part of the national constitution. It ordered the legislature to decriminalise assisted dying and create an implementation structure, much of which would reside in the provinces as administrators of healthcare. The initial 2016 law faced immediate legal challenges for being too restrictive, and in 2021 the court again referred the matter back to the legislature for remedy.
A major element of the new law is allowing medical assistance in dying on the basis of mental health issues. It gives jurisdictions until March 2023 to create regulatory mechanisms for requests based solely on mental health issues.
In 1997 the Colombian Supreme Court set out the rights of a terminally ill person to engage in voluntary euthanasia. The health ministry issued guidelines in July 2021 that require a voluntary request, which may be through an advance directive, and a procedure for review.
The situation in Germany over the past decade has been confusing. In 2014 its courts declared that “passive euthanasia” was legal, but a year later the legislature also criminalised “assisted suicide,” with little clarity over the difference.
Then in February 2020, Germany’s highest court ruled that a person’s right to self-determination allowed for the right to die. As a part of this, assistance is allowed for altruistic motives, but concern has focused on assisted dying becoming a treatment option that could become a business.
How all of this will be regulated is still subject to much debate and may depend on the outcome of federal elections this autumn.
The legal status of both euthanasia and withholding treatment at the end of life are ill defined under the law in Japan. In July 2020 two doctors were charged with murder for helping a woman with amyotrophic lateral sclerosis to end her life.
The pair were later separately charged with murder for the earlier death of one of the men’s fathers, who had been terminally ill. The arrests and pending trials have revived discussion of a “death with dignity” bill in the legislature.
In 2001 the Netherlands passed a law that broadly allows voluntary euthanasia. A doctor must certify that the patient is suffering “unbearably without hope” from a physical or mental condition. It is allowed for people as young as 12 years of age. Regulations have been tightened to assure that patients are competent to make such decisions.
Neighbouring countries have since brought in similar policies: Belgium followed in 2002 by legalising voluntary euthanasia but not physician assisted suicide. In Luxembourg both practices have been active since 2009 despite initial royal objections.
The End of Life Choice Bill was enacted by the New Zealand parliament in 2019 and ratified by a public referendum in 2020, with 65.2% of the vote. The bill will take effect in November 2021.3<
The legislature in Portugal passed a bill in March 2021 permitting assisted dying, and the president asked the constitutional court to rule on its legitimacy before signing it. However, the court found the measure imprecise and thus unconstitutional. The legislature is considering revision of the bill’s language to fall within guidance offered by the court.
Since 2002 a series of laws and public cases in Spain have expanded the rights of patients to refuse and discontinue treatment, dubbed “passive suicide.” Facing opposition from the Catholic Church and many medical professional organisations, but with overwhelming public support, the legislature passed a law allowing “physician assisted suicide,” which took effect in July 2021 and is largely modelled on the Netherlands’ approach.4
A 2015 law gave patients in Sweden the right to participate in any medical decision, while physicians may not legally object to any procedure, including assisted dying. However, the legal ambiguity arising from a lack of regulations has contributed to there being few assisted deaths in the country.
Switzerland has no specific legislation outlawing or permitting assisted dying, but the practice has generally been allowed since 1937 under the Swiss Criminal Code, which allows for it under a person’s constitutional right so long as the people providing the assistance don’t have “selfish motives.” A physician must evaluate the candidate to assure soundness of mind, but there is no requirement of terminal illness.
Switzerland remains one of the few countries that allow foreigners to gain access to assisted dying, and a handful of groups have emerged to assist locals and foreigners in the process. One established provider says that about 60% of its foreign users come from Germany and 30% from the UK, paying $7500-$12 000 (£5440-£8700; €6330-€10 120) depending on the services provided.
Assisted dying (or “medical aid in dying,” as it’s generally referred to in US legislation) came into effect in the state of Oregon in 1997.
“The laws require the person to be an adult, mentally capable and/or have a terminal prognosis of six months or less, and to self-ingest the medication, so they can change their mind at any time in the process,” says Sean Crowley, a spokesman for Compassion & Choices, which led the struggle in Oregon and is a leading voice nationally.
The Oregon model has been followed in eight other states—California, Colorado, Hawaii, Maine, New Jersey, New Mexico, Vermont, and Washington—as well as in Washington, DC. A Montana court struck down restrictions on assisted suicide, but no implementing regulations have been created.5
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