Where can you choose to end your life?

Campaigners stand outside the US Supreme Court in 2005. REUTERS

The importance of confronting mortality and the right to make autonomous decisions are modern mantras – both within medicine and wider society. The decriminalisation of suicide in England and Wales in 1961 is an early example that life choices may also include making a choice to end one’s own life. Since then a number of jurisdictions have introduced legislation which provides assistance for those who choose to end their lives.

Given the repeatedly unsuccessful attempts to introduce any such legislation in the UK, it is interesting to look to other regimes that have overcome challenges and hurdles to introduce assisted dying legislation. The number of these jurisdictions is still growing, albeit slowly – California is the most recent addition to the list: the state’s End of Life Option Act will come into effect on June 9 2016.

Terminology remains paramount in any legislative provision – and rightly so when it may be used to determine matters of life and death. While the words “euthanasia” and “assisted suicide” are often interchangeably used, there is an important distinction between the two when it comes to who is doing the killing.

In euthanasia, the responsibility for overseeing the death rests with a person other than the one who wishes to end their life. In assisted suicide, the assistance may be provided by another, but it is the person who wishes to die who has the responsibility to bring about their own death. The term “assisted dying” is increasingly being incorporated into legislative proposals to mean assistance which is being provided to those who are terminally ill.

For me, the phrase “right to die” is a misnomer. As human beings we are all mortal, which brings with it a certainty that we are all going to die. We don’t need a “right” for this to happen – it is rather a matter of when rather than if.

If it is a “right” that is being requested then it may more accurately be described as the right to exercise autonomy, or self-determination about choices in our lives – including the ending of that life. Recent high-profile, highly emotive cases – such as that of Dianne Pretty – in the UK courts appear to support this position.

Assisted-suicide clinic Dignitas, in the industry area of Pfaeffikon near Zurich. REUTERS/Christian Hartmann

Where can you choose to die?

The Netherlands is perhaps the best-known place where a person can choose to end their life in this way. The country introduced guidelines following a court case in 1973 and enacted subsequent legislation in 2001. It was followed by Belgium in 2002 and Luxembourg in 2009. All three countries permit both euthanasia and assisted suicide.

Belgium is often cited as having the most “liberal” physician-assisted suicide laws. Last year it extended the right to a physically healthy 24-year-old woman who was suffering from depression. Similarly, The Netherlands does not restrict euthanasia to those with terminal illnesses, but rather some clinics have allowed patients with “unbearable suffering” to die. This includes a man who had been diagnosed with borderline dementia and a woman who had incurable tinnitus.

Switzerland has permitted assisted suicide since 1942 but not euthanasia. Unlike other jurisdictions, the law does not require any involvement from a medical practitioner nor does it require the recipient to be a Swiss national. The country is unique in this respect – and this latter aspect has led to many high-profile and poignant cases of individuals travelling from their home country to Switzerland, in a practice referred to as “suicide tourism”.

Though the Colombian Supreme Court ruled in 1997 that doctors should be allowed to end the lives of patients by euthanasia, it was not until 18 years later that formal guidelines were approved. The practice has faced strong opposition from the country’s catholic church, however, which has threatened to close its hospitals in the country if the government forces its doctors to offer euthanasia.

Right to die campaigner Brittany Maynard makes a passionate plea before her death by assisted suicide in 2015.

In the United States, California has become the fifth State and most recent jurisdiction to enact legislation which will permit an individual, who must be terminally ill, to receive “assistance” to end their life. The four other US States: Oregon (1994), Washington (2008), Montana (2009) and Vermont (2014) have the terminally ill criteria in their death-with-dignity laws, although they have enacted the rules in various ways.

The California law was signed by the governor, Jerry Brown, in the aftermath of high-profile campaigning by Brittany Maynard, a 29-year-old woman who was diagnosed with terminal brain cancer. In her last few months, she lobbied for the legalisation of the right to die, eventually moving to Oregon from her home in California to end her life.

Legislation on physician-assisted suicide is expected to be introduced this month in Canada. The change in law follows a 2015 human rights-based Supreme Court decision, which overturned the ban on doctor-assisted suicide.

Physician-assisted suicide has been legal in Quebec since 2014. However, a requirement that two doctors must assess a patient’s suitability for medically assisted suicide has reportedly caused problems after physicians were reluctant to come forward.

Choosing the right

Even if we accept that what is being sought is a right to exercise choices concerning how we end our lives, it is worth noting that most legislation which has been enacted does not actually confer a personal right to seek assistance to die. It is arguably broader than that, creating a framework, where – subject to certain conditions – it is lawful for that help to be provided.

For those countries and states which are still hesitant about introducing similar legislation, turning the focus away from death and instead focusing about choices in life could be a way forward. The distinction may be a fine one but it is fundamental – for it is only when we are alive that we can express what is important to us and make our wishes and values known. UK Supreme Court judge, Lord Hope, took a similar view in the case of Diane Pretty, noting that the way a person “chooses to pass the closing moments of her life is part of the act of living”.