by Katy Willis

The Complete Guide to Euthanasia in 2021: When is it Legal?

The Complete Guide to Euthanasia in 2021: When is it Legal?

Deciding to end your life compassionately and humanely isn’t an easy one. It’s also deeply personal, and rational data and medical science should inform that decision.

While euthanasia and assisted suicide are both still criminalized throughout the world, times are changing. More and more countries and jurisdictions across the world are updating their laws to allow individuals with serious, and typically fatal, health conditions to take control of this very difficult and personal decision.

Patients who are facing the unthinkable — a life-threatening illness — often turn to medically assisted suicide as a way to control the final days of their lives, increase their quality of life, reduce emotional and physical strain on their family, and release themselves from the inevitable suffering that awaits them.

In this article, we’ll present you with well-documented resources that provide information about:

  • The differences between euthanasia and assisted suicide
  • Where which practices are legal
  • A brief history of the laws in each jurisdiction
  • Which countries allow noncitizens to travel there for the procedure
  • The costs associated with the medications and medical treatment
  • The specific legal process you must undergo in each location

We hope these resources are both timely and helpful as you research this critically important issue.

Euthanasia vs. Assisted Suicide: What’s the Difference?

The terms euthanasia and assisted suicide are often used interchangeably, but there are some differences between the two.

Euthanasia is the process of terminating someone’s life. It’s performed by a doctor or another individual, and it may be active (committing an act that leads to death, such as administering a lethal dose of painkillers) or passive (not committing an act that could prolong life, such as providing life support).

Assisted suicide has only one key difference, and that is that the terminally ill person elects to end their own life, typically by taking an oral dose of medication. Physician-assisted suicide, when it’s specified as such, means that a doctor must either inject the dose, be present during the procedure, or be hands-on with the process in a key way. That definition varies from country to country.

The outcome and the objective are the same: An individual with a long-term and fatal illness has expressed a decision to end their life before the pain of the illness and the trauma it will impose on their loved ones become insufferable.

Medications and Process

The medications used vary from country to country, but the process is essentially identical. A combination of anesthesia and a powerful barbiturate or sedative (typically phenobarbital) ensures that the patient falls into a deep sleep prior to succumbing to cardiac arrest from the barbiturate.

In the vast majority of countries, patients may elect to die at home or in a healthcare facility.

Why is Euthanasia Controversial?

Euthanasia and compassionate end-of-life choices have been a very controversial topic in deeply religious countries and regions for decades. In heavily Catholic countries in South America,  Southwest Europe, and the United States, it still remains a challenging and difficult topic. However, as the practice becomes more commonplace throughout the world, and the rationale behind the practice far more widely understood, public opinion is quickly changing.

What is the Right to Die?

As controversy continues to abate on the issues surrounding supervised or legal suicide, the central issue is simple. Does a patient with a consistent, unmanageable, life-ending illness have the right to end their life in a dignified and painless way? Some diseases like ALS, cancer, and multiple sclerosis can make the very act of living both painful for the patient and cause economic and other hardships for that person’s families and caretakers.

For example, in the case of ALS, the moment a patient is diagnosed, they know two things are certain. One, they will lose control over their muscles, rendering them physically helpless, eventually forcing them to remain bedridden and potentially connected to respiratory and other life-sustaining equipment. Two, they will not survive the illness. At that point, that patient may wish to consider at which point, and how, they’re able to end both their and their family’s suffering when their quality of life has not just diminished, but vanished.


Where is Euthanasia/Assisted Suicide Legal?

These are the jurisdictions where either euthanasia or assisted suicide is legal. We’ll dig into the particulars of each farther down in the article.

Copy of Euthanasia Article

Why isn’t the U.K. on this list?

Euthanasia is illegal in the U.K. and remains punishable by law.

Copy of Euthanasia Article

Why isn’t the U.S. on this list?

The laws governing euthanasia and assisted suicide vary on a state-by-state basis. We’ll dig into which states permit the procedures and what they permit later.

Copy of Euthanasia Article

Why isn’t France on the list?

While the process of assisted suicide or euthanasia is still far from legal in France, passive euthanasia is allowed. Passive euthanasia is often undefined by law, but it’s a common practice in the U.S. Essentially, loved ones and doctors make a decision to remove a patient from life-supporting machines and processes. The process can also involve a patient refusing to continue medical treatment, especially common amongst those with late-stage, terminal cancer diagnoses.

Doctors in France are now allowed to terminate heavily invasive treatment and life-sustaining protocols for patients who would otherwise die on their own. This may not seem like a large or critically important position shift to someone who lives, say, in the U.S. where doctors of neurologically unresponsive patients often agree or even argue for those patients to be removed from life support (breathing and feeding tubes).

Doctors in the U.S. have also been similarly open to allowing next of kin or decision-makers of patients who are kept alive with extremely invasive methods (and who are otherwise non-responsive) to halt those invasive actions. While that process has been commonplace (and relatively non-controversial) around the world, a 2005 French law allowed the loved ones of patients kept alive by so-called rigorous treatment to be removed from life support systems.

Passive euthanasia is increasingly common. Germany has codified the language into law.

Regions and Countries Where Assisted Suicide and Euthanasia Are Legal: The Deep Dive

Our researchers spent weeks looking into the various jurisdictions and issues surrounding both euthanasia and assisted suicide in every country where it’s legal. We will also discuss where it is and isn’t possible to travel to or where you must be a resident.

Anyone looking to make this decision should consult with a physician and potentially a legal authority in their region.

Victoria, Australia

In 1996, Australia’s Northern Territory was among the first spots in the world to legally establish a pathway to assisted suicide. However, after some controversy surrounding its passage, a 1997 federal law overruled the territory law and compassionate suicide was once again illegal.

Nearly 20 years later, as public perception shifted, so did this region’s attitude toward the practice. In 2019, the Voluntary Assisted Dying Act came into effect in the region again, and with it, a very large area of Australia legalized physician-assisted suicide.

In December 2019, Western Australia passed new legislation, and as of 2021, the bill will be official law.

Drug Administration Methods

  • Patient takes medication orally
  • Physician administers medication through an injection

Legal Requirements

  • Australian citizen or permanent resident
  • Lived in Victoria for at least one year
  • Patient must initiate the discussion with a physician and be of sound mind during those discussions
  • Two doctors must confirm a diagnosis of an advanced, incurable illness where the patient is likely to die within six months
  • Independent review board oversight
  • 10-day waiting period before permission is granted

Process

  • Self-administered (oral)
  • If the patient is unable to administer the dose, the coordinating medical team may then apply for a permit authorizing them to administer the medication intravenously
  • Designated contact person can store, carry, and transport the medication
  • Medical professional isn’t required to be present if medication is self-administered

Cost

  • Cost of the actual medication is not publicly available. The surrounding services provided by medical professionals are covered by Australia’s public health program.

Copy of Euthanasia Article

Belgium

With almost no exception, Belgium has the most permissive laws when it comes to legal suicide. In 2002, an initial law allowing euthanasia for adults and emancipated minors went into effect. In 2014, the country also then allowed euthanasia by legal injection for minors. It’s one of the few countries that currently allows a physician to administer lethal drugs to a patient suffering from mental illness.

Drug Administration Methods

  • Self-administered (oral)
  • Infusion or injection (physician)

Legal Requirements

  • No required diagnosis in adults
  • Minors require a terminal diagnosis from a physician with agreement from a guardian or legal representative
  • If the physician is responding to a patient’s medical directive (e.g., a living will), the patient must be permanently unconscious and suffering from an incurable condition

Process

  • Doctors are required to consult with the patient for a period of time to establish that the patient is aware of the decision and the process
  • In some cases, if death isn’t imminent, a pathologist or psychiatrist may be asked to assess the patient’s condition

Cost

  • Free

Canada

In 2016, the Canadian government formally passed federal legislation legalizing euthanasia and assisted suicide. Similar to most countries, patients must have a terminal illness and are required to work closely with medical professionals throughout the process. Patients must also work with two doctors and be of stable mind to make the request independently for themselves.

One of the differences of Canada’s law, versus many other requirements in the handful of U.S. states where the process is legal, is that the patient’s death doesn’t have to be within a defined time frame. In the Canadian legal framework, patients with painful, long-term illnesses where death may not come for some time are still entitled to enter voluntarily into this arrangement if they decide it’s best for their circumstances.

Because advanced directives for euthanasia are illegal, anyone with a degenerative illness that compromises their mental function, like dementia or Alzheimer’s disease, can’t request the procedure in advance.

Drug Administration Methods

  • Self-administered (oral)
  • Infusion or injection (physician or nurse)
  • In the province of Quebec, medication must be administered by a physician (and not a nurse)

Legal Requirements

  • Only available to Canadian citizens who have active Canadian healthcare coverage
  • Minimum of 18 years old
  • Mentally competent
  • Patient must initiate the request
  • Diagnosis of a grievous and irremediable medical condition:
    • Irreversible state of decline
    • Serious illness, disease, or disability
    • Unbearable physical or mental pain
    • Terminal (although death doesn’t need to be immediate)

Process

  • Patient submits a written request with signatures from two witnesses
  • Physician evaluation
  • Two separate medical opinions required
  • Mandatory 10-day waiting period
  • Advance directives for euthanasia are prohibited

Cost

  • Free through Canada’s national healthcare system

Colombia

“Despite public arguments that physician-assisted suicide (PAS) is needed to avoid excruciating pain and other symptoms, the reasons attributed to patients who seek PAS are not uncontrolled symptoms but lost autonomy, independence, and control.”

Dr. Daniel Sulmasy
Acting Director, Kennedy Institute of Ethics
Professor of biomedical ethics at Georgetown University
August 2019

In 2015, the Colombian government legalized euthanasia. Even after federal courts decriminalized medically assisted suicide in 1997, doctors could potentially face criminal prosecution from laws that remained on the books penalizing so-called “mercy killings.” Since 2018, it has also been legal for parents to seek assisted suicide and euthanasia for their children starting at 6 years old.

Drug Administration Methods

  • Self-administered (oral)
  • Infusion or injection by a physician
  • Palliative care (sedation in a deep coma to bring about a natural and peaceful death)

Legal Requirements

  • Diagnosis of a terminal illness with intolerable suffering and no potential for improvement
  • Be older than 6 with the consent and supervision of their parents
  • Be older than 12 with the consent of at least one parent
  • Be older than 14
  • Be of sound mind to agree to the process
  • Legal Colombian citizen

Process

  • A request must be submitted to a licensed physician, which is then reviewed by a medical committee
    • Committees must include a doctor with a specialty in that illness, a mental health professional (clinical psychologist or a psychiatrist), and a lawyer
    • The committee is designated and selected by an individual hospital
  • In the case of a dispute, a third party reviews the application
  • 10-day waiting period
  • All medical professionals must comply with the patient’s request for the procedure

Cost

  • The law stipulates that cost cannot be an impediment to the procedure

Netherlands

Copy of Euthanasia Article

In 2002, the Netherlands successfully passed the Termination of Life on Request and Assisted Suicide Act legalizing euthanasia nationally. It has always been a frontrunner on this issue, and the progressive nation has allowed some form of euthanasia since the 1970s. The requirements to receive the medical treatment are quite strict. It allows children as young as 12 to apply, and every patient (unlike Belgium) must have a medical diagnosis of a terminal illness or an “enduring psychiatric illness” (medically-diagnosed mental health condition) to be considered.

Drug Administration Methods

  • Self-administered (oral) with a physician present
  • Infusion or injection by a physician

Legal Requirements

  • Legal resident of the country only
  • Diagnosis of a terminal illness or an enduring mental health condition
  • Unbearable and hopeless suffering with no prospect of improvement
  • Patient must make the decision alone and demonstrate a stable mental condition
  • 12 years of age or older
  • Patients between the ages of 12 and 16 must have a parent’s legal consent
  • To prevent so-called “suicide tourism,” doctor and patient must prove an established relationship
  • Advanced directives are permitted, provided the declaration is prepared by a doctor

Process

  • Overseeing physician ensures legal procedures are followed
  • Second independent doctor reviews and then authorizes the request
  • Doctor must be present when the patient takes the medicine orally
  • Post-mortem review conducted by a doctor, medical ethics expert, and legal professional to confirm the medical staff carried out the process correctly

Cost

  • All costs related to the investigation and medications are reimbursed by Dutch medical insurance

Copy of Euthanasia Article

Switzerland

Copy of Euthanasia Article

Like Belgium, Switzerland has a very permissive environment for assisted suicide. All forms of euthanasia are illegal, but it’s legal for an individual to administer a lethal dose of medication. Because a physician’s role in the country is poorly defined, non-hospitals have intervened as the organizations where individuals may request and receive the assistance they need.

The only stipulation of the law states that the medications may not be administered for “selfish”, or profitable, reasons. Nonprofit organizations (including Dignitas, Eternal Spirit, and Pegasos Association) allow nonnationals to voluntarily check-in and die on the premises.

Drug Administration Methods

  • Self-administered (oral or intravenous)
  • There’s a lot of gray area in the law here, but a third party may help administer medication to the patient if needed within a facility

Legal Requirements

  • Available for anyone in the world, making Switzerland a popular destination for the terminally ill and elderly seeking a painless and compassionate death

Process

  • Each organization has a slightly different process
    • For example, Dignitas (one of the most well-known facilities in Europe) requires membership

Cost

  • Varies by organization (the law prohibits organizations from making a profit)
  • Dignitas reduces the cost significantly for Swiss residents who are also members
  • Non-Swiss citizens who travel to the country should expect to pay thousands of euros
  • Because of this variance, patients need to investigate and contact each organization separately to discuss individual options, cost, requirements, and processes

Copy of Euthanasia Article

Luxembourg

In 2009, Luxembourg became the third country in Europe to legalize euthanasia after Belgium and the Netherlands.

Drug Administration Methods

  • Self-administered (oral)
  • Infusion or injection by a physician

Legal Requirements

  • Patient must start the process while they’re mentally aware
  • 18 and over; patients 16 years of age may seek permission to die with parental consent
  • Diagnosed with a terminal condition without the possibility of improvement
  • Physical suffering must be evident
  • Must prove an existing relationship with the doctor

Process

  • Patient must apply for the process in writing
  • Patient may nominate an individual to complete the application process in a doctor’s presence if that patient can no longer write
  • Advanced directives are legal when prepared in advance
  • Thorough vetting and interview process with a physician
  • Second physician must review the application
  • Following the two-step physician review process, the first doctor requests approval from the National Control and Assessment Commission
  • Patient can withdraw the request at any time

Cost

  • Unknown — Luxembourg, like most European countries, has socialized medicine, so presumably many of these medical costs are covered for citizens

New Zealand

In October 2020, New Zealand became the seventh country in the world to legalize euthanasia. As the law is currently written, a doctor may object to administering the medication or participating in the process, but they must refer the patient to another physician who agrees. Advanced directives are not allowed.

Drug Administration Methods

  • Self-administered (oral or intravenous)
  • Infusion or injection by a physician or nurse practitioner

Legal Requirements

  • 18 years or older
  • Citizen or permanent resident of New Zealand
  • Diagnosed with a terminal illness that’s likely to end a patient’s life within six months
  • Showing “significant and ongoing decline in physical capability”
  • Experiencing “unbearable suffering that cannot be eased”
  • Have the mental capacity to make an informed decision about their own end-of-life choices
  • Patients suffering from mental illness are not eligible

Process

  • Person must initiate the process with their physician
  • Physician, along with another independent physician, ensures the patient meets the criteria
  • If either doctor is unsure of the patient’s mental capacity, the case is referred to a psychiatric professional
  • Patient selects date, method, and time of their death
  • Physician, nurse practitioner, or patient administers the medication
  • Patient can change their mind at any time
  • Patient must consent to the process if administered by a third party; the consent doesn’t have to be verbal (gestures and so forth are allowed)

Cost

  • There is no public clarification, but as New Zealand has socialized medicine and only citizens and residents are eligible, the cost is presumably covered

Spain

In 2021, the largely progressive members of Spain’s parliament legalized euthanasia and assisted suicide. Before the law passed with 202 votes in favor and 141 against, medical professionals and loved ones faced up to 10 years in prison for helping someone end their life. The law only allows people with serious and incurable illnesses to be eligible, and the public healthcare system will cover it.

Drug Administration Methods

  • Self-administered
  • Administered by a medical professional

Legal Requirements

  • 18 years or older
  • Citizen or permanent resident of Spain
  • Patient must be diagnosed with a “serious or incurable” illness or a condition that causes “intolerable suffering”

Process

  • Person must initiate the process with their physician
  • There must be two requests, in writing and 15 days apart
  • Patient must be “fully aware and conscious” when making the requests
  • Physician ensures the patient meets the criteria and approves the process
  • Second medical professional and an evaluation board must also approve

Cost

  • Free through Spain’s national healthcare system

United States

Copy of Euthanasia Article

The U.S. federal government has yet to legalize or decriminalize euthanasia or assisted suicide. However, several states have passed referendums either by popular vote or state legislature to legalize physician-assisted suicide:

  • Oregon (1998)
  • Washington (2009)
  • Vermont (2013)
  • California (2016)
  • Colorado (2016)
  • District of Columbia (2018)
  • Hawaii (2019)
  • Maine (2019)
  • New Jersey (2019)

While euthanasia is still not formally legalized in Montana, in 2009 the state Supreme Court ruled in favor of a terminally ill patient who was seeking a compassionate death. The state legislature has since then failed to pass legislation banning the procedure. A Death With Dignity Act failed in 2011, 2013, and 2015. However, because the state ruling stays intact, the procedure remains decriminalized.

Drug Administration Methods

  • Self-administered (oral)

Legal Requirements

  • Full-time resident of Oregon, Washington, Vermont, California, Colorado, District of Columbia, Hawaii, Maine, or New Jersey
  • 18 years old
  • Mentally competent and able to communicate about healthcare wishes
  • Diagnosed with a terminal illness that leads to death within six months
  • Physically able to self-administer the drug

Residency Requirements by State

  • California, Colorado, Hawaii, Oregon, and Washington
    • You must provide a combination of:
      • State issued ID or driver’s license
      • Documents showing you rent or own (residential) property in the state
      • Proof of state voter registration
      • Recent state tax return
  • Maine:
    • All of the above, plus:
      • Documents verifying you occupy the location of a dwelling, such as received mail, hunting/fishing license, or receipt of any public benefit conditioned upon residency
  • New Jersey:
    • Doesn’t permit proof of residency by way of a rental agreement (lease) or documentation proving that you own residential property
    • Any of the other aforementioned documentation in addition to “any other government record that the attending physician reasonably believes to demonstrate the individual’s current residency in this State”
  • Vermont:
    • While the law doesn’t specify how to prove residency, it’s recommended that you provide the documentation listed at the top
  • District of Columbia
    • No minimum length of residency requirement
    • No specific rules are established in the law to prove residency, but asks for two documents in your name, such as a utility bill, property tax bill, insurance policy, or medical bill, among others

Process

While there are some variances state by state, the process is largely similar in every state where physician-assisted suicide is legal.

  • Patient must make an oral request for the medication from a physician who’s licensed in the state where the patient is making the request
  • Request must take place in that state’s physical boundaries (e.g., no telehealth from out of state)
  • Attending physician must confirm that the patient satisfies the eligibility criteria
  • Attending physician must also inform the patient of alternatives, including palliative care, hospice, and pain management options
  • Physician must notify the patient’s designated next of kin of the prescription request
  • Second consulting physician must confirm the diagnosis, prognosis, and the patient’s mental competence
    • If either physician questions the patient’s mental capacity, the law requires them to refer the patient for a psychological or psychiatric evaluation
    • In Hawaii: Mental health evaluation is mandatory for all patients requesting medications under the law
  • 15-day waiting period
    • In Hawaii: Waiting period is 20 days
  • Patient must make a second oral request of the physician during that waiting period
  • At any time, the patient must submit a written request using the forms required by an individual state, with two witness signatures (physician may not be one of the witnesses)
    • It’s recommended that the patient complete the written request after the two-physician review is successfully completed
  • Second waiting period for the District of Columbia, Hawaii, Maine, New Jersey, Oregon, Vermont, and Washington
    • Physician must wait 48 hours from the time of receiving the written request to write the prescription
  • After satisfying all of the above, the patient may fill the prescription at a pharmacy
  • Patient isn’t legally required to consume the medication even after they’ve received the prescription

Cost

  • Depending on the medication and an individual insurance policy, the drug costs can vary wildly. For example, some medications cost upward of $25,000 per dose. However, it’s more typical that the cost averages between $400 and $600.

Life Insurance

  • In states where it’s legal, life insurance benefits will not be affected. Note that if the patient dies out of state, it may be legally named a suicide and that patient may then forego any life insurance payments.

 

Copy of Euthanasia Article

Can You Travel to a Different Jurisdiction and Legally Seek Assisted Suicide or Euthanasia?

Generally, no. We have already listed the exceptions to the rule, including (and mainly) Switzerland. That doesn’t appear to be changing any time soon, as lawmakers rejected a referendum in 2011 to ban assisted suicide for foreigners.

While it’s not remotely legal to bring drugs outside of the country, in Mexico, you can purchase liquid pentobarbital at pet shops around the country. The intended use is for pet owners to end the lives of their pets humanely. Pentobarbital is also one of the most common drugs used for assisted suicide, and in Mexico, it’s an affordable drug that’s easy to purchase.

Euthanasia is Not a Leading Cause of Death in the Netherlands
Deaths From Euthanasia/Medically Assisted Suicide: 5,516 (2015)
Deaths Caused by Dementia: 12,000 (2014)
Deaths From Cancer: 42,000 (2013)

What Country May Soon Update Its Laws?

As in the U.S., more and more countries are relaxing their previous views on assisted suicide and euthanasia. Many countries may very soon reform their legal stance on compassionate death.

Ireland

While it’s not the law of the land in Ireland, experts, analysts, and journalists assume that similar to the legalization of abortion in the country, euthanasia may easily be next on the list of newly legal activities in the very Catholic country. There have been a number of high-profile cases of patients who fought for the right to die (including one woman who was suffering from terminal cervical cancer in 2005) and lost. It’s also currently illegal to travel to Dignitas in Switzerland to receive hospice care. Friends and family of the terminally ill could face criminal penalties in Ireland upon their return.

The public largely supports death with dignity laws, and those high-profile cases have resulted in the introduction of legislation that would legalize some form of assisted suicide.

Copy of Euthanasia Article

Some who argue against euthanasia and assisted suicide contend that these options can put undue pressure on the medically vulnerable, causing them to seek end-of-life treatment because they fear they’ll be a burden on loved ones. Others worry about medical professionals, family members, and others taking advantage of euthanasia laws for their own benefit, such as making a profit on the service or collecting on an inheritance. And then there are those who simply cannot reconcile voluntary death with their moral or religious beliefs.

While these are all important considerations, proponents of euthanasia maintain that the right to end one’s life is a matter of autonomy, dignity, and respect. It’s not a decision to take lightly, and as evidenced by the strict procedures you’ve read about above, it’s a responsibility that countries that allow euthanasia take very seriously.

If you live in a region that allows euthanasia or may soon permit it, or you have the ability to travel to a place like Switzerland that offers care to anyone, you should give thought to this option as you would any other that pertains to the end of your life or the end of a loved one’s. Discuss it with family as you would insurance benefits, burial requests, and inheritance allocation — whether you’re for it, against it, or wish to explore it at another time.

And if you live in an area that has yet to legalize euthanasia and assisted suicide, know that public sentiment around the world is changing. More and more people are holding the opinion that in order to be a fair and humane society, we must recognize all human rights, including the right to die.

About Author
Katy Willis
Katy Willis
Expert DNA & Health Test Researcher

Katy has been researching and writing for more than 15 years. She has a deep understanding of DNA and at-home health testing for humans and pets. She believes in providing genuine, honest information that helps people achieve their goals.

Katy has been researching and writing for more than 15 years. She has a deep understanding of DNA and at-home health testing for humans and pets. She believes in providing genuine, honest information that helps people achieve their goals.