Medical Ethics: Euthanasia and Assisted Suicide

JJZ Polaris, Yale Law School, New Haven, CT, USA

LS Lehmann, Harvard Medical School, Boston, MA, USA
r 2016 Elsevier Ltd. All rights reserved.

Abstract

This chapter explores the various options that individuals may consider at the end of life. The ethics of
assisted suicide and euthanasia are discussed. Many see assisted dying as an opportunity for individuals to
avoid suffering and exercise their autonomy in the dying process. Those who object to the practice raise
concerns over the sanctity of life, the integrity of the medical profession, changing norms at the end of life,
and the risk of abuse. Finally, the current legal landscape of assisted dying is reviewed. The topic remains
controversial in the medical community and the public at large.

Introduction
Discussions about the end of life can be challenging for
patients, family members, and providers. Death and
dying are emotionally fraught subjects, and people vary
immensely in their outlook based on personal tempera-
ment and cultural background. Medicine has tradition-
ally concerned itself with the preservation and
prolongation of life, but in recent decades, some patients
have begun to prioritize other goals in their care.
This chapter explores assisted dying, an umbrella
term that we use to encompass two distinct methods
by which another person (the ‘assister’) plays a role in
ending an individual’s life. Assisted suicide involves
passive assistance: the assister provides the individual
with the means by which he may end his own life. A
doctor may prescribe a lethal dose of medication, for
example, but the patient must take and swallow the pill
on his own. In euthanasia, on the other hand, the assister
performs the final action in ending the individual’s life,
such as by administering a lethal injection.
This chapter begins with the historical background on
end-of-life decision making and palliative care (section
Background: Autonomy and Dying). After outlining the
various options individuals may consider at the end of
life (section The Spectrum of Options at the End of Life),
the chapter turns to the ethical debate over assisted
dying (section The Ethical Debate over Assisted Dying).
Many see assisted dying as an opportunity for indi-
viduals to avoid suffering and exercise their autonomy
in the dying process. Those who object to the practice
raise concerns over the sanctity of life, the integrity of
the medical profession, changing norms at the end of
life, and the risk of abuse. The topic remains contro-
versial in the medical community and the public at large.
Finally, the legal considerations of assisted dying are
discussed (section Legal Considerations in Assisted
Dying). Most countries prohibit assisted dying of any
kind. In places where it is legally permissible, there
is extensive variation in the precise details of what is
permitted and how that legal status was achieved. A few
countries and states in the United States have legalized
certain assisted dying practices (see Table 1), but many
others have considered the issue in the courts or the
legislatures in recent years and maintained the status
quo of prohibition. Anecdotal and empirical evidence
suggests, however, that some physicians and family
members choose to assist patients with suicide or
euthanasia even where such practices are illegal (Meier
et al., 1998; Maitra et al., 2005; Jamison, 1996).
A note on terminology: We will be referring through-
out to ‘patients’ who consider various options to end their
lives. Assisted dying is often discussed in the context of
terminally ill patients, and some jurisdictions have legal-
ized end-of-life options exclusively for that population. In
addition, many forms of medicalized assisted dying in-
volve a physician who prescribes medication or adminis-
ters an injection, so the recipient is a patient at least within
that relationship. We recognize, however, that individuals
with nonterminal diseases or no medical problems at
all may wish to voluntarily end their lives, and some
jurisdictions permit them to do so (see Table 1).
Background: Autonomy and Dying
Technological Advancement and the ‘Burden’ of Care
The last 150 years have produced tremendous advances
in medical science. The revolution in patient care
includes curative medicine such as antibiotics, preventive
techniques such as antiseptic surgical precautions, and
life-sustaining technologies such as ventilators and
feeding tubes. It was not so long ago that doctors were
relatively powerless to address many types of common
diseases and injuries; by the 1960s, however, the death
of a patient came to be seen as a failure of medicine
rather than an inevitable result of life’s misfortunes.
During this period of rapid scientific progress, the
driving goal was to keep patients alive and healthy for as

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322 Medical Ethics: Euthanasia and Assisted Suicide

Table 1 Details on countries where assisted dying is legal

Country or state/territory What form of assisted How and when was it Details: eligibility requirements, procedural safeguards, and
dying is legal? (Assisted legalized? other notes
suicide, euthanasia, or
both)

Australia: Northern Both (not legal anymore) By statute in 1995, The repealed law had the following provisions:
Territory repealed in 1997 Eligibility: Competent adults with terminal illness
Procedural safeguards: The patient must make multiple
requests for assisted dying. Three physicians must certify
the patient, including a specialist in the patient’s condition
and a psychiatrist who checks for depression
Belgium Euthanasia By statute in 2002 Eligibility: Competent adults and emancipated minors who
have ‘unbearable suffering’ (no terminal illness required);
children with terminal illness and ‘unbearable suffering’
Procedural safeguards: Standarda
Canada Assisted suicide By judicial decision in In Carter v. Canada, the Supreme Court of British Columbia
2013 (not final) struck down the Criminal Code provision that prohibited
physician-assisted suicide. At the time of writing, the
Supreme Court of Canada had agreed to hear the case later
in 2014
Eligibility: Competent adult with terminal illness
Procedural safeguards: Standarda
Colombia Euthanasia (see details) By judicial decision in Colombia’s Penal Code criminalizes euthanasia, but the
1997 Colombia Constitutional Court found a constitutional right
to euthanasia in certain circumstances. The Congress of
Colombia has considered and rejected bills to formally
legalize euthanasia by statute, leaving the ultimate legal
status somewhat undefined
Eligibility: Competent adults with terminal illness
Procedural safeguards: A physician must administer the
injection
England and Wales Assisted suicide (see By issuance of The UK has not formally legalized assisted suicide. The
details) prosecutorial guidelines simply specify a set of factors that make
guidelines in 2010 prosecution less likely, such as:

• The person was not a competent adult

• The person did not make a voluntary request for assisted
suicide
• The assister was not acting in a medical capacity
• The assister was motivated by compassion
• The assister provided the means of suicide without
advocating for the suicide itself
• The assister reported the suicide to law enforcement
authorities
Note: England, Wales, and Germany are the only jurisdictions
where the law permits nonmedical assisted suicide but
discourages medical-assisted suicide

Germany Assisted suicide Lack of prohibition on Suicide is legal in Germany, so it is not a crime for an
suicide assister to provide the means by which another person
commits suicide. The suicide may not be coerced, and the
assister may not violate other laws on possession of
controlled substances, firearms, etc.
Eligibility: Competent adults
Note: England, Wales, and Germany are the only jurisdictions
where the law permits nonmedical assisted suicide but
discourages medical-assisted suicide

Luxembourg Both By statute and Eligibility: Competent adults with terminal illness
constitutional Procedural safeguards: Standarda
amendment in 2009
(passed in 2008)
(Continued )
 Medical Ethics: Euthanasia and Assisted Suicide 323

Table 1 Continued

Country or state/territory What form of assisted How and when was it Details: eligibility requirements, procedural safeguards, and
dying is legal? (Assisted legalized? other notes
suicide, euthanasia, or
both)

Netherlands Both By several court Eligibility: Individuals with severe physical or psychological
decisions starting in suffering (no terminal illness required). Competent adults
1973, then codified by may request on their own; teenagers aged 12–16 years
statute in 2002 may request with parental consent; parents may request on
behalf of newborns with severe conditions
Procedural safeguards: Standarda
Switzerland Assisted suicide By update to the criminal Switzerland only criminalizes assisting a suicide for ‘selfish’
code effective 1942 reasons. Both medical and nonmedical assisted suicide are
thus permitted
Eligibility: No requirements. (Note: Switzerland is the ONLY
country where assisted dying is available to nonresidents.)
Private organizations will typically only assist competent
adults
Procedural safeguards: To guard against prosecution, private
organizations often require a written request from the
patient and then have a physician certify the patient’s
hopeless/terminal condition before providing the lethal pills
United States: Montana Assisted suicide By judicial decision in The Montana Supreme Court’s 2009 decision in Baxter v.
2009 Montana provided that any physician who faces criminal
prosecution for providing lethal medication to a terminally
ill patient may raise the affirmative defense of consent.
Montana has not formally codified the legality of assisted
suicide by statute
Eligibility: Competent adults with terminal illness
Procedural safeguards: Physician must provide the lethal
pills
United States: Oregon Assisted suicide By ballot initiative in Eligibility: Competent adults with terminal illness who are
1994 expected to die within 6 months
Procedural safeguards: Standarda
United States: New Assisted suicide By judicial decision in A New Mexico state district court’s 2014 decision in Morris
Mexico 2014 (not final) v. Brandenberg found a constitutional right to assisted
dying, striking down the state statute prohibiting the
practice. At the time of writing, the decision had not been
appealed, nor had the state taken any legislative action
Eligibility: Competent adults with terminal illness
Procedural safeguards: Physician must provide the lethal
pills
United States: Vermont Assisted suicide By statute in 2013 Eligibility: Competent adults with terminal illness who are
expected to die within 6 months
Procedural safeguards: Standarda
United States: Assisted suicide By ballot initiative in Eligibility: Competent adults with terminal illness who are
Washington State 2008 expected to die within 6 months
Procedural safeguards: Standarda
a
Standard procedural safeguards shared by many nations: The patient must make multiple separate requests for assisted dying. Two physicians must certify the patient’s
condition. A psychologist must screen the patient if there are doubts about competency. A physician must administer the pills/injection and report the death.

long as possible. Eventually, though, some patients,
families, and physicians began to wonder whether an
intervention could be so burdensome that the costs
outweighed the benefits. At a deeper level, they began to
question the longstanding presumption that living longer
was always better. At first, medical providers resisted
requests to discontinue life-sustaining treatment. Such
action was seen as inconsistent with the Hippocratic
Oath’s mandate to ‘do no harm.’ Other providers feared
legal liability, and indeed, some law enforcement of-
ficials threatened to bring charges against doctors or
hospitals who ‘killed’ patients by discontinuing life-
sustaining interventions. The Supreme Court of New
Jersey’s 1976 decision in In re Quinlan was the first in a
324 Medical Ethics: Euthanasia and Assisted Suicide
series of cases that established patients’ legal right to
refuse treatment, even where doing so would lead to
their death.
Palliative Care
Legal cases about the right to refuse medical inter-
ventions helped frame a broader conversation about
end-of-life decision making in the United States. Modern
medicine had become effective enough at preserving life
to become burdensome to some patients; nevertheless,
the growing public faith in the marvels of medicine im-
pelled many seriously ill patients and their families to
fight death to the last breath, trying every possible
treatment even when the hope of success was slim. Pal-
liative care has responded to these concerns by trying to
refocus patient care at the end of life on comfort (Kelly
and Meier, 2010).
One of the primary goals of palliative care is simply
to manage the symptoms of a disease rather than attack
the disease itself, a mindset that emphasizes caring for
the patient rather than attempting to cure him. This
simple notion was quite provocative, acknowledging as
it did the limits of curative medicine and the real possi-
bility that patients may genuinely wish to trade off
the longest possible life in exchange for a more
comfortable and peaceful death. Palliative care offers
patients medical monitoring and pain management, as
well as psychosocial support to guide patients and their
families through the dying process.
Advance directives
With the advent of medical technology that can sustain
life and an increased emphasis on patient autonomy, the
medical profession developed the concept of advance
directives. An advance directive is a mechanism by
which patients can designate an individual to make de-
cisions on their behalf, and also allows patients to spe-
cify in advance their goals, values, and preferences for
medical care in the event that they are unable to com-
municate for themselves (White and Arnold, 2011). For
example, a patient may specify that she does not wish to
be resuscitated if she has a cardiac arrest. By clarifying
these difficult choices ahead of time, patients can avoid
leaving their family or clinical care team to guess about
what the patient would have wanted.
The Spectrum of Options at the End of Life
This section places assisted suicide and euthanasia in a
broader array of end-of-life options. Patients who wish
to expedite their own deaths may consider a number of
approaches, some of which are illegal in many juris-
dictions. These options exist on a spectrum, from those
that proceed entirely on the patient’s own initiative to
those with active involvement from an outside party. In
general, the level of public controversy and physician
opposition related to a given practice tends to escalate as
the role of outside actors becomes more prominent
(Curlin et al., 2008; Yun et al., 2011; Maitra et al.,
2005). For the most part, these approaches are con-
sidered by terminally ill patients who either do not have
the option of or have chosen not to pursue further life-
prolonging treatments.
More Passive: Hastening Death by Removing Medical
Treatment
Withholding and withdrawing treatment
Competent patients have the right to decline treatment,
including interventions that could significantly prolong
their lives. These decisions are generally not considered
‘suicide’ because the patient ultimately dies of his
underlying disease rather than an active intervention.
Some ethicists differentiate between refusing treatment
entirely and withdrawing it once it has already begun on
the grounds that the latter scenario involves an active
step that makes the patient worse off than before. The
more common view (and the view codified in law in
many jurisdictions) is that the two practices are ethically
equivalent.
Withholding and withdrawing nutrition
Some patients choose to end their lives by refusing
nutrition, relying on a combination of symptom man-
agement and limited hydration to keep them
comfortable until they slip into a coma and then pass
away. This option is most commonly exercised by
terminally ill patients, and is seen by many ethicists as
equivalent to refusing any other medical intervention.
The choice becomes more legally complicated in pa-
tients without a terminal illness, however, because it
may be construed as suicide, which most jurisdictions
either prohibit or consider grounds for involuntary
psychiatric commitment. Forced nutrition has been used
in psychiatric and prison settings (Crosby et al., 2007),
so relatively healthy individuals who choose to stop
eating may find themselves involuntarily kept alive and
referred for mental health services.
Incompetent Patients: Advance Directives and Surrogate
Decision Makers
There is an important qualification to the options dis-
cussed thus far: generally, they are only available to
patients who are competent to make medical decisions,
thereby excluding children and the mentally ill. These
same competent patients can use advance directives
(described in section Background: Autonomy and
Dying) to specify in advance how they would like their
care to proceed if they lose decision-making capacity
and are unable to communicate (White and Arnold,
2011).

For incompetent patients, a designated healthcare
agent or surrogate must make these important decisions.
The process is straightforward when there is someone
legally designated to make decisions on the patient’s
behalf, such as a legal guardian or someone with durable
power of attorney.
Without a clear decision maker under the law, med-
ical teams may defer to family members with strong
evidence of what the patient would have wanted. In
some cases, however, there may be disputes among po-
tential deciders such as family members and close
friends. Decision makers (legally designated and other-
wise) may also disagree with clinicians over how to
proceed, pushing for treatment the medical team views
as futile or ill advised. Such disputes may be referred to
an institutional ethics committee for discussion, and may
ultimately involve legal action. The highly publicized
case of Terri Schiavo, for example, involved several
rounds of litigation between Ms. Schiavo’s spouse and
parents to determine whether her feeding tube could be
withdrawn (Schwarz and Coyle, 2006).
More Active: Providing or Administering the Means of Death
Palliative sedation
Our understanding of pain management has improved
in recent decades, but some patients nonetheless ex-
perience severe chronic pain or discomfort that cannot
be addressed by conventional palliative strategies.
Terminally ill patients with severe pain may request
palliative sedation (also called terminal sedation), where
a physician induces a coma using powerful narcotics.
Most patients who receive palliative sedation are not
kept alive with life-sustaining technologies like venti-
lators and artificial nutrition, and some have argued that
the practice is equivalent to a slow form of euthanasia
(ten Have and Welie, 2014; Jansen and Sulmasy, 2002).
The heightened doses of medication used in palliative
sedation risk reducing patients’ expected life span, but
the practice is permitted under the law in many countries
because it is seen as a pain-management strategy.
Assisted suicide
Assisted suicide is precisely what the name suggests:
another person (the ‘assister’) provides the means by
which an individual takes his or her own life. Medical-
assisted suicide involves a physician prescribing a lethal
dose of medication to be self-administered by the pa-
tient. This practice has been legalized in several countries
and US states (see Table 1). More generally, assisted
suicide may include the provision of prescription medi-
cations, illegal drugs, or a weapon with the under-
standing that the recipient plans to commit suicide. Most
jurisdictions outlaw these types of actions.
The literature suggests that even in jurisdictions that
prohibit assisted suicide, patients with terminal illnesses
or severe chronic disability request assistance in ending
Medical Ethics: Euthanasia and Assisted Suicide 325
their own lives. Despite the legal consequences, some
doctors, family members, and friends choose to provide
lethal doses of medication or other means to help pa-
tients end their life (Meier et al., 1998; Maitra et al.,
2005; Jamison, 1996).
Euthanasia
In euthanasia, the assister moves from passively pro-
viding the means of death to actively causing the death
itself. Medical euthanasia typically involves a lethal in-
jection (similar to the injections used in capital punish-
ment). Nonmedical euthanasia may involve more violent
methods like a gunshot or smothering, which can be
traumatic for the assister, even when performed at the
patient’s request (Jamison, 1996).
Most jurisdictions prohibit euthanasia of any kind.
Those that permit it (see Table 1) may require an explicit
request by the patient, or may allow physicians to pro-
ceed with euthanasia where they deem it to be in a pa-
tient’s best interests.
The Ethical Debate over Assisted Dying
Assisted dying is a controversial subject that raises
deeply personal questions at the intersection of medical
technology, ethics, and spirituality. In this section, we
explore the main arguments advanced to support legal-
ization of assisted dying and the main ethical objections
raised by those in opposition.
Arguments in Favor of Permitting Assisted Dying
Autonomy and dying
Assisted dying is predicated on the notion that patients
have the right to control their own dying process. Some
patients want dying to be something they do rather than
something that happens to them. They have the right to
withhold or withdraw life-saving treatment, but that is
an inherently reactive form of autonomy: the option to
choose death is triggered by an acute condition (e.g.,
refusing resuscitation for cardiac arrest) or a particular
kind of chronic care (e.g., discontinuing artificial
nutrition).
Some patients with a terminal illness face neither
an immediate health threat nor dependence on life-
sustaining technology. As a further distinction, assisted
suicide by a self-administered pill is not an option for
patients who cannot swallow or self-administer medi-
cation, such as those with advanced amyotrophic lateral
sclerosis or quadriplegia. Given the existing right to re-
fuse treatment, some claim that prohibitions on assisted
suicide and euthanasia draw arbitrary lines, allowing
certain types of patients to control the time and manner
of their death and leaving others to wait until their
illness takes its toll.
326 Medical Ethics: Euthanasia and Assisted Suicide
Physical and emotional suffering
Patients may seek assisted dying for many different
reasons that span the physical, emotional, existential,
and spiritual aspects of their lives. Individual patients
often cite multiple motivations across these domains
(Oregon Public Health Division, 2013; Dees et al., 2011;
Fischer et al., 2009).
Advances in palliative medicine have produced many
effective management strategies, but some patients
nonetheless experience chronic pain or simply express a
preference for death over continued existence. Many
terminally ill or disabled patients are dependent on
others for basic care, and may lose control of their
bodily functions. Those who pursue assisted dying ex-
plain that they suffer at this perceived loss of dignity,
declining independence, and inability to enjoy the ac-
tivities that give their life meaning. Others comment
on feelings of despair or hopelessness; living with a fatal
disease means accepting that their condition is only
going to continue getting worse until they die.
Some patients would prefer to decide when and how
that death will occur, to combat feelings of powerless-
ness in the face of disease and death by exercising their
own will in dying. Some patients find solace simply in
knowing that they have the option to determine their
own death. In Oregon, for example, a large minority of
patients who request and receive lethal medication never
use it (Oregon Public Health Division, 2013); they
ultimately die of their disease, but they found comfort in
knowing they had the option to take the medication at
any time if the suffering grew too great.
Objections to Assisted Dying
The sanctity of life
One of the main objections to assisted dying stems from
a belief that we undermine the sanctity of life by taking
actions to hasten death. Those who hold this belief may
view all forms of suicide as morally wrong, and they
often oppose other practices like withholding and with-
drawing treatment or nutrition. Across countries, op-
position to various forms of assisted dying is correlated
with strongly held religious beliefs (Curlin et al., 2008;
Yun et al., 2011; Smets et al., 2011; Lee et al., 2009;
Maitra et al., 2005; Lisker et al., 2008). In political de-
bates over legalization of assisted dying, religious groups
are often among the most vocal opponents.
One variation of the argument about the sanctity of
life applies specifically to those living with disability. As
discussed above, a primary motivation for seeking as-
sisted dying is the suffering arising from loss of auton-
omy and dignity: some patients with impaired mobility
or severe medical symptoms would rather end their
life than persist in such a state. Many people with dis-
abilities, however, live with those same types of bodily
limitations and symptoms. They argue that allowing
patients to kill themselves because they have physical
limitations can be interpreted as endorsing the view
that a life with a disability is a life not worth living
(Behuniak, 2011). Legally sanctioning assisted suicide
thus implicitly denigrates all the similarly disabled peo-
ple who nonetheless manage to live rich and full lives.
The role of the medical profession
Many physicians see their role as one of healing and
preserving life. They view assisted dying as incompatible
with the Hippocratic Oath’s principle of ‘do no harm,’
just as many physicians and medical societies officially
oppose physician involvement in torture or executions.
Some doctors also worry that allowing assisted dying
may erode public trust in the medical profession. Other
doctors see assisted dying as consistent with medicine’s
broader goal to alleviate suffering. Nonetheless, the
medical profession overall typically opposes assisted
dying practices at a higher rate than the general popu-
lation, though in both groups, religious belief in a strong
predictor of opposition to assisted dying (Curlin et al.,
2008; Yun et al., 2011; Smets et al., 2011; Lee et al.,
2009; Maitra et al., 2005; Lisker et al., 2008). Medical
professional societies are often vocal players in debates
over legalization of assisted dying practices.
Uncertainties of medical prognostication
In many jurisdictions, assisted dying is only available for
patients who are terminally ill. Critics of assisted dying
argue that prognoses at the end of life are often in-
accurate and fear that patients may cut their lives short
based on a grim prognosis when they might have lived
much longer than expected (Glare et al., 2003; Twomey
et al., 2008).
The risk of abuse
Critics of assisted dying express concerns over the effects
of legalization on patients themselves. Patients may feel
pressured by family members or physicians into choos-
ing a premature death, whether because of explicit co-
ercion or out of a desire not to be a burden on others.
These fears are particularly acute as applied to margin-
alized groups like patients who are elderly or less edu-
cated, since they may be more susceptible to outside
influence in their medical decision making. Patients with
mental illnesses such as depression may be more likely to
request assisted dying, but are not permitted to do so in
many jurisdictions; however, their disease may be dif-
ficult to recognize, particularly in the emotionally
fraught context of terminal illness (Ganzini et al., 2008).
There is also the question of how to handle requests for
assisted dying made on behalf of incompetent patients
by family members or guardians.
Jurisdictions that have legalized assisted dying often
did so with strict procedural safeguards in place to guard
against these types of concerns (see section Legal Con-
siderations in Assisted Dying). The data suggest that
those who choose assisted dying tend to be more affluent

and educated (Lindsay (2009). A lack of recorded in-
stances of specific patient abuse is a positive sign, but
there may nonetheless be instances of pressure on pa-
tients that go unreported and instances of patients with
depression who go undiagnosed.
Shifting social norms
Embedded within arguments about the sanctity of life
and the risk of abuse is a concern about the ‘slippery
slope,’ the fear that legalizing one controversial practice
will eventually lead to other, more problematic social
consequences by shifting the boundaries of what we
consider morally acceptable. Some view the current de-
bate over assisted suicide in many Western nations as an
inevitable result of the debate a few decades ago over
withdrawing life-saving treatment. They may fear that
legalizing assisted suicide will ultimately lead to the
legalization of voluntary or involuntary euthanasia.
Commentators point to euthanasia performed by the
Nazis as an indication of how disregard for human life
can contribute to greater atrocities.
There is also concern that legalization of assisted
dying will change our social norms and expectations,
such that the right to die could eventually start to feel
like a duty to die. Advocates worry that choosing to wait
for death from natural causes to occur would come to be
seen as a selfish use of resources, and that the elderly and
individuals with disabilities or terminal illnesses may feel
pressured to opt for assisted dying.
A related concern pertains to the state of palliative
care more generally: if patients have the option of ending
their lives due to great suffering, there may be less of
an incentive to push for advances in treating physical
and psychological pain. Thus far, however, experience
has shown that legalized assisted dying correlates with
greater overall investment in palliative services (Lindsay,
2009).
Legal Considerations in Assisted Dying
There is no single approach to legalizing assisted dying.
Jurisdictions have legalized different types of practices,
relied on different legal mechanisms to do so, and tar-
geted different groups of patients and assisters. This
section reviews the various legal considerations that
jurisdictions must grapple with, along with examples
from various countries that exemplify the different ap-
proaches. See Table 1 for an overview of each juris-
diction where some form of assisted dying is legal.
Mechanisms for Legalization
By statute or regulation
The most straightforward path to legalizing assisted
dying is for the government to pass a law, as Lux-
embourg’s parliament did in 2008. Official statutory
Medical Ethics: Euthanasia and Assisted Suicide 327
recognition may also be used to formally recognize and
clarify assisted dying rights that were legalized by other
mechanisms described in this section.
By judicial decision
In a jurisdiction where assisted dying is illegal, a person
may bring a lawsuit challenging the constitutionality of
that prohibition. The Montana Supreme Court’s 2009
opinion in Baxter v. Montana, for example, de-
criminalized assisted dying under the state constitution.
Courts in the Netherlands similarly decriminalized as-
sisted suicide and euthanasia in a number of decisions
issued through the 1970s and 1980s, and the legislature
codified those decisions with legislation in 2002.
By referendum
Some jurisdictions allow citizens to vote directly on
policy questions. In the US states of Oregon and
Washington, for example, assisted suicide was legalized
by successful citizen ballot initiatives.
Lack of prohibition
The 1942 version of the Swiss Criminal Code crimin-
alized assisted suicide for selfish motives, but said
nothing about assisted suicide for unselfish reasons.
That silence has been interpreted as legalization, and
assisted suicide has been practiced in Switzerland ever
since. Similarly, Germany does not criminalize suicide,
so assisted suicide is not a crime as long as the assister
does not coerce the decision.
Prosecutorial discretion
The United Kingdom has not formally legalized assisted
dying, but the Crown Prosecution issued guidelines in
2010 that permit prosecutorial discretion in cases of
assisted suicide in England and Wales (Scotland and
Ireland have not followed suit). The guidelines outline
various factors that make prosecution more or less likely
(see Table 1).
What Is Legalized?
Table 1 reviews the specific practices legalized by each
country or state.
Assisted suicide versus euthanasia
Some countries, like Luxembourg, have legalized both
assisted suicide and euthanasia. The Netherlands has
also legalized both practices, as well as permitting both
voluntary euthanasia (where a competent patient makes
the request) and nonvoluntary euthanasia (where a
physician or guardian decides on behalf of an in-
competent patient).
Other jurisdictions, like Switzerland and several US
states, have legalized assisted suicide while maintaining
prohibitions on euthanasia. In these jurisdictions, the
only legal methods of assisted dying are those that the
328 Medical Ethics: Euthanasia and Assisted Suicide
patient can administer himself. Belgium, on the other
hand, has legalized euthanasia but not assisted suicide.
Who is eligible?
Some jurisdictions tightly limit the option of assisted
dying. In Oregon, for example, assisted suicide is only
permitted for competent adults who are legal residents
of the state, diagnosed with a terminal illness, and ex-
pected to die within 6 months. Switzerland, meanwhile,
requires neither legal residency nor a terminal illness; it
has thus become a destination for ‘suicide tourism,’ since
anyone may travel to Switzerland and receive assisted
suicide. Belgium recently legalized euthanasia for term-
inally ill children. The Netherlands permits assisted
suicide and euthanasia for teenagers (with or without
terminal illness) who have parental consent, as well as
euthanasia of newborns with severe medical conditions
when requested by the parents.
Who can assist?
Most jurisdictions with legal assisted dying either re-
quire or emphasize a medical model: physicians perform
assisted suicide by prescribing a patient a lethal dose of
medication, and perform euthanasia by lethal injection.
Luxembourg and all relevant US states require medical
involvement in assisted dying. Switzerland does not
mandate the presence of a doctor, since any form of
unselfish assisted suicide is legal, though medical staff
are involved in most assisted deaths. England, Wales,
and Germany are outliers in that their prosecutorial
guidelines favor assisted suicide performed by a non-
medical person rather than a physician.
What Procedural Safeguards Are in Place?
Many jurisdictions impose procedural safeguards on
assisted dying to protect patients from abuse and to
ensure compliance with eligibility criteria.
The Netherlands was the first country to codify a set
of safeguards developed by the Royal Dutch Medical
Association. As other nations legalized assisted dying
practices, they looked to the Dutch model for guidance.
Oregon included many similar provisions in the Death
With Dignity Act in 1994, and that legislation has in
turn become the standard for other US states seeking to
legalize assisted suicide. As a result, though eligibility
criteria for assisted dying vary extensively across juris-
dictions, the procedural safeguards display a high degree
of consistency. (These common features are listed as
‘standard’ procedural safeguards in Table 1.)
Some critics of assisted dying, however, point to em-
pirical evidence that these safeguards are not always
followed (Pereira, 2011).
Written requests and waiting periods
It is not uncommon to require that a competent patient
make a written request for assisted dying. In Oregon, a
patient must make three requests with mandatory
waiting periods in between to ensure that the decision is
not a hasty one.
Additional medical certification
Several jurisdictions require that patients seeking as-
sisted dying must have their conditions certified by an
additional medical professional. Where assisted dying is
only permitted for terminally ill patients, the medical
professional must certify the diagnosis and potentially a
prognosis of death within a specified time period (e.g.,
6 months in Oregon). In Belgium, where the eligibility
criterion is not terminal illness but rather ‘unbearable
suffering,’ the medical professional must attest that the
patient meets that definition.
Mental health screening
Many jurisdictions require mental health screening for
any patient who is suspected of having a mental health
problem, whether because of medical history or recent
behavior. Sweden and the Netherlands permit some
mentally ill individuals to seek assisted dying, as long
as they are found to be competent to make medical
decisions. Jurisdictions like Oregon attempt to screen
out patients with conditions like depression or bipolar
disorder that may be affecting the choice to pursue
assisted dying.
Centralized reporting
Most jurisdictions require centralized reporting so they
can monitor details like the number of requests made,
the number of patients deemed ineligible and why, how
many patients actually ingested the medication (as op-
posed to dying from natural causes), where a patient
chose to die (home, hospice, hospital, etc.), and the
length of time from ingestion of the medication to un-
consciousness and death.
The Role of Private Organizations
In most jurisdictions with legalized assisted dying, pri-
vate organizations have been founded to provide edu-
cation and to help patients and clinicians meet the
necessary procedural requirements. The most prominent
examples include Exit (Switzerland), Dignitas (Switzer-
land), and Compassion and Choices (Oregon, USA).
These ‘right to die’ organizations may have been in-
volved in political activity that promoted the legalization
of assisted dying, and then shifted to an advisory and
support capacity for the practice of assisted dying. They
answer questions, assist with paper work, help patients
find doctors who are willing to participate in the process
by certifying medical conditions or prescribing lethal
medication, and facilitate the required data reporting
(Ziegler and Bosshard, 2007).

See also: Consent: Mental Capacity Assessment. Death
Investigation Systems: Murder, Manslaughter, Homicide, and
Attempts − Definitions. Deliberate Self-Harm Patterns: Patterns of
Injury. Deliberate Self-Harm Patterns: Psychology. Medical Ethics:
Advance Directives ('Living Will'). Medical Ethics: Principles of
Medical Ethics. Medical Ethics: Withholding or Withdrawing Life-
Sustaining Treatment. Murder−Suicide (Dyadic Death). Religious
Attitudes to Death. Suicide: Etiology, Methods, and Statistics.
Suicide: Self-Harm. Suicide: Youth Suicide
References
Baxter v. Montana, 224 P.3d 1211 (Mont. 2009).
Behuniak, S.M., 2011. Death with “dignity:” The wedge that divides the disability
rights movement from the right to die movement. Politics and Life Sciences 30,
17–32.
Crosby, S.S., Apovian, C.M., Grodin, M.A., 2007. Hunger strikes, force-feeding, and
physicians’ responsibilities. Journal of the American Medical Association 298,
563–566.
Curlin, F.A., Nwodim, C., Vance, J.L., Chin, M.H., Lantos, J.D., 2008. To die, to
sleep: US physicians’ religious and other objections to physician-assisted
suicide, terminal sedation, and withdrawal of life support. American Journal of
Hospice and Palliative Care 25, 112–120.
Dees, M.K., Vernooij-Dassen, M.J., Dekkers, W.J., et al., 2011. ‘Unbearable
suffering’: A qualitative study on the perspectives of patients who request
assistance in dying. Journal of Medical Ethics 37, 727–734.
Fischer, S., Huber, C.A., Furter, M., et al., 2009. Reasons why people in Switzerland
seek assisted suicide: The view of patients and physicians. Swiss Medicine
Weekly 139, 333–338.
Ganzini, L., Goy, E.R., Dobscha, S.K., 2008. Prevalence of depression and anxiety in
patients requesting physicians’ aid in dying: Cross sectional survey. British
Medical Journal 337, a1682.
Glare, P., Virik, K., Jones, M., et al., 2003. A systematic review of physicians’
survival predictions in terminally ill cancer patients. British Medical Journal
327, 195.
ten Have, H., Welie, J.V.M., 2014. Palliative sedation versus euthanasia: An
ethical assessment. Journal of Pain and Symptom Management 47, 123–136.
Medical Ethics: Euthanasia and Assisted Suicide 329
In re Quinlan, 355A.2d 647 (N.J. 1976).
Jamison, S., 1996. When drugs fail: Assisted deaths and not-so-lethal drugs.
Journal of Pain and Symptom Management 4, 223–243.
Jansen, L.A., Sulmasy, D.P., 2002. Sedation, alimentation, hydration and
equivocation: Careful conversation about care at the end of life. Annals of
Internal Medicine 136, 845–849.
Kelly, A.M., Meier, D.E., 2010. Palliative care − A shifting paradigm. New England
Journal of Medicine 363, 781–782.
Lee, W., Price, A., Rayner, L., Hotopf, M., 2009. Survey of doctors’ opinions of the
legalisation of physician assisted suicide. BMC Medical Ethics 10, 2.
Lindsay, R.A., 2009. Oregon’s experience: Evaluating the record. American Journal of
Bioethics 9, 19–27.
Lisker, R., del Rio, A.A., Villa, A.R., Carnevale, A., 2008. Physician-assisted death.
Opinions of a sample of Mexican physicians. Archives of Medical Research 39,
452–458.
Maitra, R.T., Harfst, A., Bjerre, L.M., Kochen, M.M., Becker, A., 2005. Do German
general practitioners support euthanasia? Results of a nation-wide questionnaire
survey. European Journal of General Practice 11, 94–100.
Meier, D.E., Emmons, C.A., Wallenstein, S., et al., 1998. A national survey of
physician-assisted suicide and euthanasia in the United States. New England
Journal of Medicine 338, 1193–1201.
Oregon Public Health Division, 2013. Oregon’s Death with Dignity Act annual report
− 2012. Available at: http://public.health.oregon.gov/ProviderPartnerResources/
EvaluationResearch/DeathwithDignityAct/Pages/index.aspx (accessed 08.03.14).
Pereira, J., 2011. Legalizing euthanasia or assisted suicide: The illusion of
safeguards and controls. Current Oncology 11, e38–e45.
Schwarz, J., Coyle, N., 2006. Can we know what Terri Schiavo would have wanted?
Palliative & Supportive Care 4, 129–133.
Smets, T., Cohen, J., Bilsen, J., et al., 2011. Attitudes and experiences of Belgian
physicians regarding euthanasia practice and the euthanasia law. Journal of Pain
and Symptom Management 41, 580–593.
Twomey, F., O’Leary, N., O’Brien, T., 2008. Prediction of patient survival by
healthcare professionals in a specialist palliative care inpatient unit: A
prospective study. American Journal of Hospice and Palliative Medicine 25,
139–145.
White, D.B., Arnold, R.M., 2011. The evolution of advance directives. Journal of the
American Medical Association 306, 1485–1486.
Yun, Y.H., Han, K.H., Park, S., et al., 2011. Attitudes of cancer patients, family
caregivers, oncologists and members of the general public toward critical
interventions at the end of life of terminally ill patients. Canadian Medical
Association Journal 183, E673–E679.
Ziegler, S., Bosshard, G., 2007. Role of non-governmental organisations in physician
assisted suicide. British Medical Journal 334, 295–298.