Assessment of capacity to give informed consent for medical assistance in dying: a qualitative study of clinicians' experience

BACKGROUND

Under the Canadian Criminal Code, medical assistance in dying (MAiD) requires that patients give informed consent and that their ability to consent is assessed by 2 clinicians. In this study, we intended to understand how Canadian clinicians assessed capacity in people requesting MAiD.

METHODS

This qualitative study used interviews conducted between August 2019 and February 2020, by phone, video and email, to explore how clinicians assessed capacity in people requesting MAiD, what challenges they had encountered and what tools they used. The participants were recruited from provider mailing listserves of the Canadian Association of MAiD Assessors and Providers and Aide médicale à mourir. Interviews were audio-recorded and transcribed verbatim. The research team met to review transcripts and explore themes as they emerged in an iterative manner. We used abductive reasoning for thematic analysis and coding, and continued to discuss until we reached consensus.

RESULTS

The 20 participants worked in 5 of 10 provinces across Canada, represented different specialties and had experience assessing a total of 2410 patients requesting MAiD. The main theme was that, for most assessments, the participants used the conversation about how the patient had come to choose MAiD to get the information they needed. When the participants used formal capacity assessment tools, this was mostly for meticulous documentation, and they rarely asked for psychiatric consults. The participants described how they approached assessing cases of nonverbal patients and other challenging cases, using techniques such as ensuring a quiet environment and adequate hearing aids, and using questions requiring only "yes" or "no" as an answer.

INTERPRETATION

The participants were comfortable doing MAiD assessments and used their clinical judgment and experience to assess capacity in ways similar to other clinical practices. The findings of this study suggest that experienced MAiD assessors do not routinely require formal capacity assessments or tools to assess capacity in patients requesting MAiD.

[Euthanasia in patients with dementia]

BACKGROUND

Euthanasia in patients with dementia is legally permitted, but many physicians experience it as (too) complex. They are frightened of the legal consequences and do not know how to assess the nature of the suffering. They also find it difficult to assess the patient's ability to provide consent.

CASE DESCRIPTION

Here we describe two cases of patients who were registered at Euthanasia Expertise Centre by a family member: a 72-year-old woman who had been diagnosed with Alzheimer disease 18 months previously and a 67-year-old man with Lewy body dementia. During the various consultations we had with them we were given a distinct picture of the nature of their suffering, and it became clear to us why they found this suffering unbearable.

CONCLUSION

By paying extra attention to the assessment of the ability to give consent and by exploring the degree of suffering experienced it is possible to meet the request for euthanasia by a patient with dementia within the framework of the law.

Euthanasia and physician-assisted suicide for patients with depression: thought-provoking remarks

Euthanasia and medical assistance in dying entail daunting ethical and moral challenges, in addition to a host of medical and clinical issues, which are further complicated in cases of patients whose decision-making skills have been negatively affected or even impaired by psychiatric disorders. The authors closely focus on clinical depression and relevant European laws that have over the years set firm standards in such a complex field. Pertaining to the mental health realm specifically, patients are required to undergo a mental competence assessment in order to request aid in dying. The way psychiatrists deal and interact with decisionally capable patients who have decided to end their own lives, on account of sufferings which they find to be unbearable, may be influenced by subjective elements such as ethical and cultural biases on the part of the doctors involved. Moreover, critics of medical aid in dying claim that acceptance of such practices might gradually lead to the acceptance or practice of involuntary euthanasia for those deemed to be nothing more than a burden to society, a concept currently unacceptable to the vast majority of observers. Ultimately, the authors conclude, the key role of clinicians should be to provide alternatives to those who feel so hopeless as to request assistance in dying, through palliative care and effective social and health care policies for the weakest among patients: lonely, depressed or ill-advised people.

First prosecution of a Dutch doctor since the Euthanasia Act of 2002: what does the verdict mean?

On 11 September 2019, the verdict was read in the first prosecution of a doctor for euthanasia since the Termination of Life on Request and Assisted Suicide (Review Procedures) Act of 2002 was installed in the Netherlands. The case concerned euthanasia on the basis of an advance euthanasia directive (AED) for a patient with severe dementia. In this paper we describe the review process for euthanasia cases in the Netherlands. Then we describe the case in detail, the judgement of the Regional Review Committees for Termination of Life on Request and Euthanasia (RTE) and the judgement of the medical disciplinary court. Both the review committees and the disciplinary court came to the conclusion there were concerns with this case, which mainly hinged on the wording of the AED. They also addressed the lack of communication with the patient, the absence of oral confirmation of the wish to die and the fact that the euthanasia was performed without the patient being aware of this. However, the doctor was acquitted by the criminal court as the court found she had in fact met all due care criteria laid down in the act. We then describe what this judgement means for euthanasia in the Netherlands. It clarifies the power and reach of AEDs, it allows taking conversations with physicians and the testimony of the family into account when interpreting the AED. However, as a practical consequence the prosecution of this physician has led to fear among doctors about prosecution after euthanasia.

Psychiatric patients requesting euthanasia: Guidelines for sound clinical and ethical decision making

BACKGROUND

Since Belgium legalised euthanasia, the number of performed euthanasia cases for psychological suffering in psychiatric patients has significantly increased, as well as the number of media reports on controversial cases. This has prompted several healthcare organisations and committees to develop policies on the management of these requests.

METHOD

Five recent initiatives that offer guidance on euthanasia requests by psychiatric patients in Flanders were analysed: the protocol of Ghent University Hospital and advisory texts of the Flemish Federation of Psychiatry, the Brothers of Charity, the Belgian Advisory Committee on Bioethics, and Zorgnet-Icuro. These were examined via critical point-by-point reflection, focusing on all legal due care criteria in order to identify: 1) proposed measures to operationalise the evaluation of the legal criteria; 2) suggestions of additional safeguards going beyond these criteria; and 3) remaining fields of tension.

RESULTS

The initiatives are well in keeping with the legal requirements but are often more stringent. Additional safeguards that are formulated include the need for at least two positive advices from at least two psychiatrists; an a priori evaluation system; and a two-track approach, focusing simultaneously on the assessment of the patient's euthanasia request and on that person's continuing treatment. Although the initiatives are similar in intent, some differences in approach were found, reflecting different ethical stances towards euthanasia and an emphasis on practical clinical assessment versus broad ethical reflection.

CONCLUSIONS

All initiatives offer useful guidance for the management of euthanasia requests by psychiatric patients. By providing information on, and proper operationalisations of, the legal due care criteria, these initiatives are important instruments to prevent potential abuses. Apart from the additional safeguards suggested, the importance of a decision-making policy that includes many actors (e.g. the patient's relatives and other care providers) and of good aftercare for the bereaved are rightly stressed. Shortcomings of the initiatives relate to the aftercare of patients whose euthanasia request is rejected, and to uncertainty regarding the way in which attending physicians should manage negative or conflicting advices, or patients' suicide threats in case of refusal. Given the scarcity of data on how thoroughly and uniformly requests are handled in practice, it is unclear to what extent the recommendations made in these guidelines are currently being implemented.

Of dilemmas and tensions: a qualitative study of palliative care physicians' positions regarding voluntary active euthanasia in Quebec, Canada

OBJECTIVES

In 2015, the Province of Quebec, Canada passed a law that allowed voluntary active euthanasia (VAE). Palliative care stakeholders in Canada have been largely opposed to euthanasia, yet there is little research about their views. The research question guiding this study was the following: How do palliative care physicians in Quebec position themselves regarding the practice of VAE in the context of the new provincial legislation?

METHODS

We used interpretive description, an inductive methodology to answer research questions about clinical practice. A total of 18 palliative care physicians participated in semistructured interviews at two university-affiliated hospitals in Quebec.

RESULTS

Participants positioned themselves in opposition to euthanasia. Their justifications were framed within their professional commitment to not hasten death, which sat in tension with the value of patients' autonomy to choose how to die. Participants described VAE as unacceptable if it impeded opportunities to evaluate and alleviate suffering. Further, they contested government rhetoric that positioned VAE as a way to improve end-of-life care. Participants felt that VAE would diminish the potential of palliative care to relieve suffering. Dilemmas were apparent in their narratives, about reconciling respect for patient autonomy with broader palliative care values, and the value of accompanying and not abandoning patients who make requests for VAE while being committed to neither prolonging nor hastening death.

CONCLUSIONS

This study provides insight into nuanced positions of experienced palliative care physicians in Quebec and confirms expected tensions between an important stakeholder and the practice of VAE as guided by the new legislation.

When slippery slope arguments miss the mark: a lesson from one against physician-assisted death

In 1989, Susan Wolf convincingly warned of a troublesome consequence that should discourage any movement in American society towards physician-assisted death-a legal backlash against the gains made for limiting life-sustaining treatment. The authors demonstrate that this dire consequence did not come to pass. As physician-assisted suicide gains a foothold in USA and elsewhere, many other slippery slope arguments are being put forward. Although many of these speculations should be taken seriously, they do not justify halting the new practice. Instead, our courts, regulatory agencies, journalists, professional organisations and researchers should carefully monitor and study it as it unfolds, allowing continuous improvement just as our society has done in implementing the practice of limiting life-sustaining treatment.

Two kinds of physician-assisted death

I argue that the concept 'physician-assisted suicide' covers two procedures that should be distinguished: giving someone access to humane means to end his own life, and taking co-responsibility for the safe and effective execution of that plan. In the first section I explain the distinction, in the following sections I show why it is important. To begin with I argue that we should expect the laws that permit these two kinds of 'assistance' to be different in their justificatory structure. Laws that permit giving access only presuppose that the right to self-determination implies a right to suicide, but laws that permit doctors to take co-responsibility may have to appeal to a principle of mercy or beneficence. Actually this difference in justificatory structure can to some extent be found in existing regulatory systems, though far from consistently. Finally I argue that if one recognizes a right to suicide, as Oregon and other American states implicitly do, and as the European Court of Human Rights has recently done explicitly, one is committed to permit the first kind of 'assistance' under some conditions.

Euthanasia requests in a Canadian psychiatric emergency room: A case series: Part 1 of the McGill University euthanasia in psychiatry case series

Euthanasia was decriminalized in Quebec in December 2015, and Canada-wide in June 2016. Both the Provincial and Federal legislation have limited the right to medical assistance in dying (MAID) to end-of-life cases; which makes MAID inaccessible to most patients solely suffering from psychiatric illness. While some end-stage anorexia nervosa or elderly patients may meet the end-of-life criterion because of their medical comorbidities or their age (Kelly et al., 2003), repeated suicide attempts or psychotic disorganization would not qualify since they would not be seen as elements of an illness leading to a foreseeable "natural death" (Canada, 2016). This is in contradiction to other jurisdictions, such as Belgium and the Netherlands as well as the eligibility criteria stated in the Supreme Court of Canada's decision in Carter v. Canada (Supreme Court of Canada, 2015). Here we analyze three cases of patients who presented to a psychiatric emergency department and requested MAID for psychiatric reasons. While none of the patients were eligible for MAID under Canadian law, we find that their demographics match closely that of patients granted MAID for psychiatric reasons in jurisdictions where that practice is allowed. Based on these cases, we comment on potentially negative consequences that may come from decriminalizing MAID for psychiatric reasons (such as an increased assessment burden on ED staff) and potentially positive consequences (such as encouraging suffering patients who had not consulted to seek care). While it is by no means our intention to take a political or moral stand on this important issue, or to conclusively weigh the negatives and positives of allowing MAID for psychiatric reasons, we do stress the importance of an active voice for psychiatry in this ongoing public debate.

Voluntary Assisted Dying Legislation in Victoria: What Can We Learn from the Netherlands Experience?

The Voluntary Assisted Dying Bill 2017 Vic (VAD Bill) was passed by the Legislative Assembly of the Victorian Parliament on 20 October 2017. The Bill is partly based on the Majority Report provided by the Legal and Social Issues Committee of the Victorian Legislative Council following its Inquiry into End of Life Choices (June 2016). The Majority Report recommended introduction of euthanasia and assisted suicide legislation. The Bill is modelled on the Ministerial Advisory Panel on Voluntary Assisted Dying Final Report, which drafted 66 recommendations on legalising administration and supply of substances for the purpose of causing the person's death. The Victorian government accepted the 66 recommendations, which the Chair of the Ministerial Advisory Panel, Professor Brian Owler, described as detailing safe and compassionate framework for voluntary assisted dying in Victoria. This analysis will focus on matters of major concern relating to the VAD Bill, namely criteria for accessing voluntary assisted dying and in particular, the age threshold and decision-making capacity. The proposed legislation resembles the Dutch Termination of Life on Request and Assisted Suicide (Review Procedures) Act of April 2002 (the Netherlands); consequently, the discussion will draw on the Dutch experience over the past 15 years.

Organ donation after medical assistance in dying or cessation of life-sustaining treatment requested by conscious patients: the Canadian context

In June 2016, following the decision of the Supreme Court of Canada to decriminalise assistance in dying, the Canadian government enacted Bill C-14, legalising medical assistance in dying (MAID). In 2014, the province of Quebec had passed end-of-life care legislation making MAID available as of December 2015. The availability of MAID has many implications, including the possibility of combining this practice with organ donation through the controlled donation after cardiac death (cDCD) protocol. cDCD most often occurs in cases where the patient has a severe neurological injury but does not meet all the criteria for brain death. The donation is subsequent to the decision to withdraw life-sustaining treatment (LST). Cases where patients are conscious prior to the withdrawal of LST are unusual, and have raised doubts as to the acceptability of removing organs from individuals who are not neurologically impaired and who have voluntarily chosen to die. These cases can be compared with likely scenarios in which patients will request both MAID and organ donation. In both instances, patients will be conscious and competent. Organ donation in such contexts raises ethical issues regarding respect for autonomy, societal pressure, conscientious objections and the dead-donor rule. In this article, we look at relevant policies in other countries and examine the ethical issues associated with cDCD in conscious patients who choose to die.

The provision of medical assistance in dying: protocol for a scoping review

INTRODUCTION

Medical assistance in dying (MAID), a term encompassing both euthanasia and assisted suicide, was decriminalised in Canada in 2015. Although Bill C-14 legislated eligibility criteria under which patients could receive MAID, it did not provide guidance regarding the technical aspects of providing an assisted death. Therefore, we propose a scoping review to map the characteristics of the existing medical literature describing the medications, settings, participants and outcomes of MAID, in order to identify knowledge gaps and areas for future research.

METHODS AND ANALYSIS

We will search electronic databases (MEDLINE, EMBASE, CINAHL, CENTRAL, PsycINFO), clinical trial registries, conference abstracts, and professional guidelines and recommendations from jurisdictions where MAID is legal, up to June 2017. Eligible report types will include technical summaries, institutional policies, practice surveys, practice guidelines and clinical studies. We will include all descriptions of MAID provision (either euthanasia or assisted suicide) in adults who have provided informed consent for MAID, for any reason, including reports where patients have provided consent to MAID in advance of the development of incapacity (eg, dementia). We will exclude reports in which patients receive involuntary euthanasia (eg, capital punishment). Two independent investigators will screen and select retrieved reports using pilot-tested screening and eligibility forms, and collect data using standardised data collection forms. We will summarise extracted data in tabular format with accompanying descriptive statistics and use narrative format to describe their clinical relevance, identify knowledge gaps and suggest topics for future research.

ETHICS AND DISSEMINATION

This scoping review will map the range and scope of the existing literature on the provision of MAID in jurisdictions where the practice has been decriminalised. The review will be disseminated through conference presentations and publication in a peer-reviewed journal. These results will be useful to clinicians, policy makers and researchers involved with MAID.

Death AND DIGNITY. WHY VOLUNTARY EUTHANASIA IS A QUESTION OF CHOICE

The prospect of voluntary euthanasia has created strong debate for decades and provoked passionate opinions from both sides of the fence. While not legal in Australia, a recent revived push for national voluntary euthanasia legislation has once again opened up the conversation and nurses have been encouraged to join the debate. Robert Fedele investigates the latest thinking and why more people are supporting voluntary euthanasia and the right to die with dignity.

Medical murder in Belgium and the Netherlands

This article is a response to Raphael Cohen-Almagor's paper entitled 'First do no harm: intentionally shortening lives of patients without their explicit request in Belgium'. His paper deals with very important matters of life and death, however its concept usage is in part misleading. For instance, the fact that medical murder takes place both in Belgium and the Netherlands is missed. Cohen-Almagor calls such acts 'worrying' and considers them to be 'abuse'. However, it remains an open question whether or not there can be such a thing as legitimate murder in a medical context. From the combined perspectives of justice and the duty to end unbearable suffering, there might be. Thus, key arguments for euthanasia are also prominent in an argument for medical murder.

Canada on course to introduce permissive assisted dying regime

Canada's Supreme Court decided in February 2015 that the criminalisation of assisted dying in the country violates the country's citizens and residents constitutional rights. This paper reviews policy recommendations produced by a special expert advisory panel appointed by Canada's provinces and territories, where the responsibility for the provision of health care lies. It also reviews a similar document produced by a special federal parliamentary committee. Based on the review of these two milestone documents it is argued that a Canadian consensus seems to emerge that foreshadows a permissive regulatory regime in that country.

The Extension of Belgium's Euthanasia Law to Include Competent Minors

Following considerable debate, the practice of euthanasia was legalized in Belgium in 2002, thereby making Belgium one of the few places in the world where this practice is legal. In 2014 the law was amended for the first time. The 2014 amendment makes euthanasia legally possible for all minors who repeatedly and voluntarily request euthanasia and who are judged to possess "capacity of discernment" (regardless of their biological age), as well as fulfil a number of other criteria of due care. This extension of the 2002 euthanasia law generated a lot of national and international debate and has been applauded by many and heavily criticized by others. This evolution is clearly of interest to end-of-life debates in the entire world. This paper will therefore describe how this amendment came to get passed using official documents from Belgium's Senate and Chamber of Representatives where this amendment was discussed and subsequently passed. Next, some of the most commonly given arguments in favour of the law are identified, as well as the arguments most often voiced against the amendment. All these arguments will be expanded upon and it will be examined whether they hold up to ethical scrutiny. Analysing the official documents and identifying the most commonly voiced arguments gives valuable insight into how Belgium came to amend its euthanasia law and why it did so in 2014. It also becomes clear that although the current amendment is often seen as far-reaching, more radical ideas were proposed during the drafting of the law. Also, in analysing those arguments in favour of the amendment and those against, it is clear that the validity of some of these is questionable.

Legal Standards for Brain Death and Undue Influence in Euthanasia Laws

A major appellate court decision from the United States seriously questions the legal sufficiency of prevailing medical criteria for the determination of death by neurological criteria. There may be a mismatch between legal and medical standards for brain death, requiring the amendment of either or both. In South Australia, a Bill seeks to establish a legal right for a defined category of persons suffering unbearably to request voluntary euthanasia. However, an essential criterion of a voluntary decision is that it is not tainted by undue influence, and this Bill falls short of providing adequate guidance to assess for undue influence.

The Assisted Dying Bill and the role of the physician

This article explores the role of the physician in the Assisted Dying Bill, which is currently progressing through the House of Lords. The Supreme Court decision in Nicklinson and Others has alerted Parliament to the possibility that the current prohibition against assisted suicide may breach Article 8 of the European Convention in relation to the right to choose how to end one's life. In this article, the role of healthcare professionals in the proposed legalisation of physician-assisted suicide is examined, together with consideration of key ethical concerns over who might be permitted to access assisted dying. Whether the proposed law presents an ethically sound alternative to the current prohibition against assisting in suicide is not clear, but Parliament must now respond in order to address human rights issues and the call to legalise medically assisted suicide.

First do no harm: intentionally shortening lives of patients without their explicit request in Belgium

The aim of this article is to provide a critical review of one of the most worrying aspects of the euthanasia policy and practice in Belgium--the deliberate shortening of lives of some patients without their explicit voluntary request. Some suggestions designed to improve the situation and prevent abuse are offered.

Physician-assisted death with limited access to palliative care

Even among advocates of legalising physician-assisted death, many argue that this should be done only once palliative care has become widely available. Meanwhile, according to them, physician-assisted death should be banned. Four arguments are often presented to support this claim, which we call the argument of lack of autonomy, the argument of existing alternatives, the argument of unfair inequalities and the argument of the antagonism between physician-assisted death and palliative care. We argue that although these arguments provide strong reasons to take appropriate measures to guarantee access to good quality palliative care to everyone who needs it, they do not justify a ban on physician-assisted death until we have achieved this goal.

Expanding the Use of Continuous Sedation Until Death: Moving Beyond the Last Resort for the Terminally Ill

As currently practiced, the use of continuous sedation until death (CSD) is controlled by clinicians in a way that may deny patients a key choice in controlling their dying process. Ethical guidelines from the American Medical Association and the American Academy of Pain Medicine describe CSD as a "last resort," and a position statement from the American Academy of Hospice and Palliative Medicine describe it as "an intervention reserved for extreme situations." Accordingly, patients must progress to unremitting pain and suffering and reach a last-resort stage before the option to pursue CSD is considered. Alternatively, we present and defend a new guideline in which decisionally capable, terminally ill patients who have a life expectancy of less than six months may request CSD before being subjected to the refractory suffering of a treatment of "last resort."

Non-physician-assisted suicide in The Netherlands: a cross-sectional survey among the general public

CONTEXT

In The Netherlands, approximately 45% of patients' requests for euthanasia are granted by a physician. After a rejected request, some patients approach non-physicians and ask them for assistance in suicide. Recently, a non-physician who assisted his mother's suicide was declared guilty without punishment.

AIM

The aim of the current study was to investigate the opinion of the Dutch general public on non-physician-assisted suicide.

METHODS

A cross-sectional survey among the Dutch general public was performed. A total of 1113 respondents were included (response rate 80%). The survey covered two case descriptions in which a patient asks a non-physician for assisted suicide after a non-granted request for physician-assisted dying. In both cases, a son, friend or professional facilitates the suicide by either the provision of information or the purchase of lethal medication. Respondents were invited to give their opinion on these cases and in addition on 10 propositions on non-physician-assisted suicide.

RESULTS

When a son provides information on how to acquire lethal medication in case of a patient with a terminal illness, this involvement is accepted by 62% of the respondents. The actual purchase of lethal medication receives less support (38%). If the patient suffers without a serious disease, both forms of assistance are less accepted (46% and 24%, respectively). In addition, only 21% support the legalisation of non-physician-assisted suicide. The Dutch public prefer involvement of a physician in assisted suicide (69%).

CONCLUSIONS

The Dutch general public consider non-physician-assisted suicide in some specific cases a tolerable alternative for patients with a rejected request for physician-assisted dying if the assistance is limited to the provision of information. However, the majority do not support the legalisation of non-physician-assisted suicide.

Voluntary palliated starvation: a lawful and ethical way to die?

Increasingly, individuals want control over their own destiny. This includes the way in which they die and the timing of their death. The desire for self-determination at the end of life is one of the drivers for the ever-increasing number of jurisdictions overseas that are legalising voluntary euthanasia and/or assisted suicide, and for the continuous attempts to reform State and Territory law in Australia. Despite public support for law reform in this field, legislative change in Australia is unlikely in the near future given the current political landscape. This article argues that there may be another solution which provides competent adults with control over their death and to have any pain and symptoms managed by doctors, but which is currently lawful and consistent with prevailing ethical principles. "Voluntary palliated starvation" refers to the process which occurs when a competent individual chooses to stop eating and drinking, and receives palliative care to address pain, suffering and symptoms that may be experienced by the individual as he or she approaches death. The article argues that, at least in some circumstances, such a death would be lawful for the individual and doctors involved, and consistent with principles of medical ethics.

Splitting the difference? Principled compromise and assisted dying

Compromise on moral matters attracts ambivalent reactions, since it seems at once laudable and deplorable. When a hotly-contested phenomenon like assisted dying is debated, all-or-nothing positions tend to be advanced, with little thought given to the desirability of, or prospects for, compromise. In response to recent articles by Søren Holm and Alex Mullock, in this article I argue that principled compromise can be encouraged even in relation to this phenomenon, provided that certain conditions are present (which I suggest they are). In order to qualify as appropriately principled, the ensuing negotiations require disputants to observe three constraints: they should be suitably reflective, reliable and respectful in their dealings with one another. The product that will result from such a process will also need to split the difference between the warring parties. In assisted dying, I argue that a reduced offence of 'compassionate killing' can achieve this. I acknowledge, however, that splitting the difference can induce splitting headaches, as there remain certain questions to be answered. Hopefully, however, sufficient work is done here to defend attempts to occupy the middle ground, whether these relate to assisted dying specifically or to other disputed moral matters.

Suicide, assisted suicide and euthanasia: International perspectives

Suicide, assisted suicide and euthanasia are elusive and controversial issues worldwide. To discuss such issues from only one perspective may be limiting. Therefore, this paper was written by authors from various regions, each of whom has been asked to reflect on the issues. The countries/cultures are: Australia, China, Cuba, Ireland, India, Japan, Russia, South Africa, The Netherlands, North America (Turtle Island) and United States. Historically and today, suicide is viewed differently. Assisted suicide and euthanasia are equally seen from multifarious perspectives. Highlighting development in the Netherlands, Australia's Northern Territory and Japan (ie. the famous Yamanouchi Case), the review shows growing re-examination of the right to die. There appear, however, to be no uniform legal and ethical positions. Further debate and discussion globally is needed to avoid myopic perspectives.

An absurd inconsistency in law: Nicklinson's case and deciding to die

R (Nicklinson) v Ministry of Justice [2012] EWHC 2381 was a tragic case that considered a perennial question: whether voluntary active euthanasia is murder. The traditional position was affirmed, that is, it is indeed murder. The law's treatment of decisions to refuse treatment resulting in death is a stark contrast to the position in respect of voluntary, active euthanasia. In cases of refusing treatment, principles of individual autonomy are paramount. This article presents an overview of the legal distinction between refusing medical treatment and voluntary, active euthanasia. It questions the purported differences between what are described as acts of "active" or "passive" euthanasia. It also highlights the inconsistency of the law's treatment of different ways that people decide to die.