Assisted suicide


Assisted suicide, also commonly referred to as physician-assisted suicide is the process by which a person, with the assistance of a medical professional, takes actions to end their life.
This practice is strictly regulated by the laws and rules of the state or country that a person lives in. The physician's assistance is usually limited to writing a prescription for a lethal dose of drugs. This practice falls under the concept of the medical right to die.
While assisted suicide is not legal in all countries, it is legal under certain circumstances in some countries including Austria, Belgium, Canada, Germany, Luxembourg, parts of Australia, the Netherlands, Portugal, Spain, Switzerland, and parts of the United States. The constitutional courts of Colombia, Estonia and Italy have legalized assisted suicide, but their legislatures have not yet legislated or regulated the practice.

Terminology

This practice is referred to using a wide range of terminologies. These include:
However, all of these terminologies refer to the same medical practice, in which a physician indirectly assists another person to end their own life. It involves a physician "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". This is a regulated practice in which the patient must meet strict criteria in order to receive medical assistance in dying.

Related terms

occurs when somebody directly brings about the death of another. It can occur with or without consent, and can be classified as voluntary, non-voluntary or involuntary.

Concerns about use of the term "assisted suicide"

Some advocates for assisted dying strongly oppose the terms "assisted suicide" and "suicide", and prefer terms such as "medical aid in dying" or "assisted dying". The motivation for this is to distance the debate from suicides commonly performed by those not terminally ill, as they believe that the use of "suicide" is not an accurate representation of the medical practice.
In November 2022 at its biannual Annual General Meeting, the World Federation of Right to Die Societies discussed and adopted the phrase "voluntary assisted dying" as the preferred terminology for this medical practice.

Restrictions and criteria

To qualify for medical aid in dying, individuals must typically meet strict criteria, which may include:
  • they have a terminal or incurable illness or disability,
  • they are of sound mind,
  • they voluntarily and repeatedly express their wish to die,
  • they take the specified, lethal dose by their own hand.
Laws vary in scope from place to place. In the United States, medical aid in dying is limited to those who have a prognosis of less than six months to live. Additionally, it is required in the United States that a physician offer alternative methods to limit a patient's suffering or discomfort, such as hospice or palliative care, before allowing them to agree to medical aid in dying.
In Canada and many European countries, eligibility also includes 'unbearable suffering'. Switzerland has some of the least restrictive criteria for medical aid in dying. In order to qualify, a medical diagnosis is not required. Any person of sound mind can seek assistance to commit suicide. The Federal Supreme Court affirmed in 2023 that in case of mental illness, several intensive discussions with the individual, questioning the patient's relatives and obtaining a medical second opinion is sufficient for a doctor to prescribe a lethal drug to a mentally ill person. An opinion written by a psychiatric specialist is not necessary. The Swiss association Dignitas requires that the person:
  • have a disease which will lead to death, and/or an unendurable incapacitating disability, and/or unbearable and uncontrollable pain,
  • be of sound judgement,
  • be able to commit the last stage – to swallow, administer the gastric tube or open the valve of the intravenous access tube – by themselves.

    Methods

Ingestion method

In the majority of cases, medical aid in dying is performed through the ingestion of pills that are swallowed, with the patient becoming unconscious after a few minutes and then dying within about two hours.

Intravenous method

In some places such as Canada, the medications may be taken by intravenous infusion, with dying normally occurring within a few minutes.

Inhalation method

Ingestion of nitrogenous gas has been used in a few cases in Switzerland.

Medications commonly used

Other medications and medication combinations have been considered, and typically vary by state or country.
In Canada, a sequence of midazolam, propofol and rocuronium is used.
In Oregon, in 2022, more than 70% of ingestions used the drug combination DDMAPh, and 28% used the drug combination DDMA. These medication combinations have largely replaced the use of individual medications in previous years. Over 2001–22, the median time to death for DDMAPh was 42 minutes and for DDMA 49 minutes. Other US states also use similar drug combinations to facilitate medical aid in dying.
In the Netherlands, very high-dose barbiturates have been recommended by the Netherlands' Guidelines for the Practice of Euthanasia. In the Dignitas program in Switzerland, after taking an anti-emetic, the person ingests sodium pentobarbital, usually 15 grams. This is normally swallowed with water, but may be ingested by gastric tube or intravenously. In the Swiss Pegasos program, sodium pentobarbital is taken intravenously.

Witnessing the act

Medical staff or volunteers

In most countries, medical staff such as doctors or nurses are permitted to accompany the patient and serve as a witness, so long as the patient is the only person who handles and ingests the medication on their own.
Other witnesses are also typically allowed, such as friends, family, or community volunteers. In Oregon in 2022, it was found that a medical staff or volunteer was present in 28% of cases when medications were ingested, and in 55% of cases at time of death.

Duo-euthanasia

Some countries, such as the Netherlands, allow duo-euthanasia, in which partners die together. In 2023, 66 people chose to die by duo-euthanasia. Former Dutch prime minister Dries van Agt and his wife passed away by doing this.

Legality by country and region

Australia

Laws regarding assisted suicide in Australia are a matter for state and territory governments. Physician assisted suicide is currently legal in all Australian states: New South Wales, Victoria, South Australia, Western Australia, Tasmania and Queensland. It remains illegal in all Australian territories, however the Australian Capital Territory plans to legalise this by 2024, and the Northern Territory is holding an investigation due to report in 2024.
Under Victorian law, patients can ask medical practitioners about assisted suicide, and doctors, including conscientious objectors, should refer to appropriately trained colleagues who do not conscientiously object. Health practitioners are restricted from initiating conversation or suggesting VAD to a patient unprompted.
Physician assisted suicide 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 Parliament which also removed the ability for territories to pass legislation relating to assisted dying, however this prohibition was repealed in December 2022 with the passing of Restoring Territory Rights Act 2022. 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.

Austria

In December 2020, the Austrian Constitutional Court ruled that the prohibition of assisted suicide was unconstitutional. In December 2021, the Austrian Parliament legalized assisted suicide for those who are terminally ill or have a permanent, debilitating condition.

Belgium

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

Canada

In Canada, physician-assisted suicide was first legalized in the province of Quebec on 5 June 2014. It was declared nationally legal by the Supreme Court of Canada on 6 February 2015, in Carter v. Canada .
National legislation formalizing physician-assisted suicide passed in mid-June 2016, for patients facing an estimated death within six months. Eligibility criteria have been progressively expanded over time. As of March 2021, individuals no longer need to be terminally ill in order to qualify for assisted suicide. Legislation allowing for assisted suicide for mental illness was expected to come into force on 17 March 2023, but has since been postponed until 2027.
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 about effective administration and prevention of the potential complications of self-administration by patients.

China

In China, assisted suicide is illegal under Articles 232 and 233 of the Criminal Law of the People's Republic of China. In China, suicide or neglect is considered homicide and can be punished by three to seven years in prison.
In May 2011, Zhong Yichun, a farmer, was sentenced to two years imprisonment by the People's Court of Longnan County, in China's Jiangxi Province for assisting Zeng Qianxiang to die by suicide. Zeng had a mental illness and repeatedly asked Zhong to help him die by 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.
In 1992, a physician was accused of murdering a patient with advanced cancer by lethal injection. He was eventually acquitted.