Assisted dying: law and practice around the worldBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4481 (Published 19 August 2015) Cite this as: BMJ 2015;351:h4481
- Correspondence to: C White (Europe) ; O Dyer (North America) ; A García Rada (South America)
Voluntary euthanasia and assisted suicide (see box for definitions) remain a crime here, but, since 2002, doctors who end a life on request or who help a patient die can no longer be prosecuted, provided that they have met the statutory “due care” criteria. These include that the request is voluntary; the patient’s physical or mental suffering is unbearable with no prospect of improvement; the patient is fully informed about the prognosis; and doctor and patient have jointly concluded that no other reasonable solution exists.
At least one other doctor must be consulted and must state in writing that due care was fully discharged. The Royal Dutch Medical Association has set up a network of independent medical assessors for this purpose. The attending doctor must also report the death to the appropriate regional euthanasia review committee. In theory, non-residents can ask for help in ending their life, but the law requires a close doctor-patient relationship.
People with dementia are eligible, as are mentally competent minors (aged 12 to 17), but only if an advance directive has been made. The parents or guardians must also agree in cases of 12 to 15 year olds, and parents must be involved in discussions in cases of 16 to 17 year olds. Under the Groningen Protocol (2005) doctors can end the lives of newborns in specific circumstances.
Reported cases of assisted suicide/euthanasia totalled 4829 in 2013, up from 2636 in 2009.1 Some 78.5% of assisted deaths have occurred at home, 9% in nursing or care homes, and 6% in hospices. In five cases from the most recent year the doctor was judged not to have complied with statutory due care criteria, accounting for 0.1% of cases.
In 2002 Belgium legalised voluntary euthanasia by lethal injection for patients who are mentally competent and have an incurable condition, including mental illness, that causes them constant and unbearable physical or mental suffering.2 Sodium thiopental has been used. In 2014 the law was extended to children of any age, but only with parental consent. Assisted suicide is not explicitly permitted in law.
Doctors’ legal obligations are similar to those in the Netherlands. But, if the patient is not in the final stages of illness, the doctor must consult a second independent medical specialist, and at least a month must elapse between the patient’s written request and the act of euthanasia.
The Federal Control and Evaluation Commission reports every two years on compliance with the law. From 2010 to 2014, reported cases almost doubled from 953 to 1807, and Dutch speakers comprised 80% of them.3 A recent study in JAMA Internal Medicine found that an increasing number of requests are made by patients with diseases other than cancer, those older than 80, and nursing home residents.4 Some 44% of assisted deaths have occurred in hospital, 43% at home, and 11% in care or nursing homes.
Euthanasia and assisted suicide were legalised in 2009. Only mentally competent adults with a severe and incurable terminal condition, causing constant and unbearable physical or psychological suffering without prospects of improvement, are eligible.
Doctors must fulfil statutory due care criteria, which include consulting another independent medical specialist, as well as the patient’s medical team and a “person of trust” appointed by the patient. Doctors must also check with the National Commission for Control and Assessment to see whether end of life provisions have been registered for that patient and must then notify the commission of the death within eight days. Thiopental is used. Non-residents can ask for help to die, but the terms of the legislation require a close doctor-patient relationship. To date, 34 people have used the law.5 Of these 34 cases, six deaths were at home, 22 in hospital, and six in care or nursing homes.6
Voluntary euthanasia is not legal here. But article 115 of the Swiss Penal Code permits assisted suicide if the person assisting does so for “unselfish reasons.” It does not require a doctor to be involved. And assisted suicide is not restricted to people with terminal illness or to Swiss residents. Oral drugs including sodium pentobarbital have been used. In 2012 the Canton of Vaud allowed nursing homes and hospitals to carry out assisted suicide in their facilities.
Four of the six right to die organisations in Switzerland allow foreign nationals to use their services. Some 611 non-residents were helped to die from 2008 to 20127; German (268) and UK (126) nationals made up almost two thirds of the total.
Oregon’s law permitting physician assisted dying is the world’s oldest, dating from 1997, and is also a model for the Assisted Dying Bill soon to be debated by the UK House of Commons.8 The law in Oregon permits the prescription of lethal drugs to adult state residents of sound mind with a disease judged to be terminal, who have a life expectancy of six months or less.9 The prescribing physician must refer the patient to a consulting physician for confirmation of this diagnosis. If either concludes that a psychiatric condition such as depression is impairing the patient’s judgment, the process is put on hold and the patient is referred for counselling. The prescribing physician is free to attend the death or not.
Two other states, Washington in 2009 and Vermont in 2013, have passed substantially identical legislation permitting assisted dying. Montana bars the prosecution of doctors who assist terminally ill patients to die since a 2009 court ruling determined that such prosecutions would violate the state’s constitution. A New Mexico court issued a similar ruling last year, but it was reversed on appeal this month, returning the number of states that permit assisted dying to just four.10
About 13 million people live in one of those four states, but the number of actual physician assisted deaths taking place across the United States is fewer than 300 a year, a fraction of the figures seen in Belgium and the Netherlands. Even in jurisdictions that permit assisted dying, finding willing physicians can be a challenge. Data from Oregon11 and Washington,12 the two most populous states and the ones issuing detailed reports, show that, in more than half of cases, the relationship between a prescribing physician and patient lasted less than a year, suggesting that many patients had sought help elsewhere after failing to obtain cooperation from their usual doctor.
Since 1998 in Oregon 1327 lethal prescriptions have been written, and 859 patients have used them to die.11 Six have reawakened after taking the dose, mostly dying within days. The most common method is ingestion of secobarbital. Uptake has increased slightly year on year, offset by a bigger reduction in unassisted health related suicides.
The median patient age in Oregon was 71, with a slight preponderance of men. Educational levels among these patients were above average. Some 95% of deaths took place in the patient’s home, and, while a “healthcare provider” was present during half of these assisted deaths, the actual prescribing physician was recorded as being present in only 16% of cases.
State medical associations have been prominent among opponents of legalising assisted dying, along with religious institutions, disabled groups, and hospice associations. When Vermont’s governor signed assisted dying legislation into law in 2013, most of the state’s hospitals announced that they would opt out, as they were not ready to implement it. In Oregon, many hospitals have Catholic affiliations and will not participate. Some practitioners are opposed on principle, and a larger number have expressed worry about potential disciplinary action by the state medical board, although all three US Death with Dignity statutes specifically rule out such action.
US doctors are less supportive of physician assisted dying than the general public. A poll of US physicians by Medscape found a clear majority of 54% in support for the first time in 2014, compared with 46% in 2010.13 Polls this year by Gallup14 and Ipsos Mori15 found 68% and 63%, respectively, of the US public in favour. Gallup’s annual tracking showed that this matched a previous high from 2001, after a dip in public support that coincided with the passage of the Affordable Care Act and its opponents’ many references to “death panels.”
No fewer than 23 new assisted dying bills have been tabled in state legislatures so far in 2015. If history is any guide, most of them will fail. The issue remains contentious, and even voters in liberal states may still reject assisted dying in direct referendums, as in Massachusetts in 2012. In California, the most populous state, a Superior Court judge last month found the state’s ban on assisting death to be constitutional and said that the issue required legislation.
A bill has cleared California’s senate but stalled before the State Assembly, and it is now unlikely to be put forward again until next year. The California Medical Association recently became the first state association in the country to drop its opposition to assisted dying, opting instead for neutrality.
In February, Canada ruled out prosecution of physicians for helping mentally competent, seriously ill patients to die. Canada’s criminal law against such assistance was struck down by the Supreme Court after a six year legal battle. The two original plaintiffs, both women with terminal illnesses, did not live to see the result.
No Canadian province except Quebec had assisted dying legislation in place when that court ruled. Quebec’s law, passed in 2014, will come into force this December.16 Although derived in principle from the Dutch and Belgian experience, the final Quebec law closely mirrors Oregon’s, with assisted dying available to adult residents of sound mind, in whom two physicians diagnose a “grave and incurable” malady characterised by “advanced and irreversible decline of capacities” causing unbearable constant physical and psychological suffering that cannot be alleviated by means that the patient judges tolerable. However, no six month maximum life expectancy applies. As in the US, the prescribing physician is not obliged to attend the death, and any physician may refuse to participate.
The Supreme Court of Canada’s ruling did not take immediate effect this February, but it gave the federal government a year to draft its own legislation that incorporates a physician’s right to assist death by prescribing lethal drugs. If the Ottawa parliament fails to act within that time limit, physician assistance in dying will be legal throughout Canada and unregulated outside Quebec.
Ottawa’s parliament has strongly rejected assisted dying in past votes, most recently in 2014, and the Conservative federal government remains opposed. A constitutional escape clause could theoretically allow the federal government to set aside the court’s decision, but assisted dying would then become an issue in the looming federal election, with the sitting government firmly on the wrong side of public opinion.
Colombia is the only country to allow assisted dying in Latin America. Although in 1997 the Colombian Constitutional Court decriminalised “mercy homicide,” it was not until April 2015 that the Ministry of Health specified how it could occur.19 20
Intravenous life ending drugs are administered by doctors in hospital.21 This voluntary euthanasia is eligible only to adult patients with a terminal disease that produces severe pain and suffering that cannot be relieved. The patient must consciously request an assisted death, and authorisation and supervision are needed from a medical specialist, a lawyer, and a psychiatrist or clinical psychologist.
Carmenza Ochoa, director of the Colombian Foundation for the Right to Die with Dignity (Fundación Pro Derecho a Morir Dignamente), told The BMJ that she estimates that some 20 cases of illegal voluntary euthanasia were performed a year before the law changed.22
Ovidio González, aged 79, who had vestibular cancer, was the first person to have a legal assisted death in Latin America, on 3 July 2015. “I want to die while I’m alive and not once I am dead,” he said after a first attempt was cancelled on 26 June, just 15 minutes before the scheduled time, after a doctor at the clinic raised fresh concerns.23 González’s son, the Colombian cartoonist Julio César González (“Matador”), illustrated the events.24
At least four other patients have had assisted deaths, says Ochoa. Current legislation does not forbid such assistance to foreigners, but Ochoa was not aware of any such cases.
Definitions and dispute25
Proponents and opponents do not all agree on the terminology used to describe the process.
Assisted dying—Proponents of the current Assisted Dying Bill in England and Wales and others argue that this term best describes prescribing life ending drugs for terminally ill, mentally competent adults to administer themselves after meeting strict legal safeguards. Assisted dying, as defined like this, is legal and regulated in the US states of Oregon, Vermont, and Washington and is what the bill in England and Wales proposes.
Assisted suicide—This term is used to describe giving assistance to die to disabled and other people who are not dying, in addition to patients with terminal illness. Drugs are self administered. Some opponents of the Assisted Dying Bill in England and Wales do not accept “assisted dying” as distinctly different. Assisted suicide, as defined like this, is permitted in Switzerland.
Voluntary euthanasia—This term describes a doctor directly administering life ending drugs to a patient who has given consent. Voluntary euthanasia is permitted in the Netherlands and Belgium.
Cite this as: BMJ 2015;351:h4481
Competing interests: None.
Provenance and peer review: Commissioned; not externally peer reviewed.