Euthanasia and assisted suicide in western countries: a systematic review

In 2015 the issue of assisted death was widely publicized by the international media after the first legal euthanasia case was held in Colombia. Also in this same year, assisted suicide was legalized in Canada and in the state of California in the United States. Currently, assisted death is allowed in four Western European countries: Netherlands, Belgium, Luxembourg and Switzerland; two North American countries: Canada and the US, in the states of Oregon, Washington, Montana, Vermont and California; and Colombia, the sole representative in South America. From a systematic literature review, this work aims to establish the prevalence and the criteria adopted for the practice of euthanasia and assisted suicide in western countries and to discuss the position of similar countries where this practice is not recognized. A better understanding of the subject appears to be critical to the formation of opinions and the encouragement of further discussions.

Euthanasia and assisted suicide in western countries: a systematic review http://dx.doi.org/10.1590/1983-80422016242136 Historically, the word euthanasia means "good death", in other words, death without pain, without suffering.In the twentieth century, during the Third Reich, the word gained a negative connotation when it was improperly used in Nazi policies aimed at eliminating lives that were considered not worthy to exist 1 .Subsequently, after the word was demystified, discussions on the topic resurfaced, and, currently, the practice of euthanasia, in its classic sense, is allowed in some countries.In a more contemporary definition, euthanasia can be understood as employment or abstention of procedures that allow accelerating or inducing the death of incurably ill patients, in order to free them from the extreme suffering that torments them 1 .
As for the patient's consent, euthanasia can be classified into non-voluntary and voluntary -the first takes place without knowing the will of the patient, and the second in response to the expressed wishes of the patient 1 .The latter differs from assisted suicide as it is performed by a physician, while in assisted suicide the patient is the one who performs the final action.
Both from the medical and from the legal point of views, there is a big difference between "killing" and "letting die" 2 .Therefore, regarding the act, euthanasia is divided into active and passive, the first of which denotes the deliberate act of inducing death without the patient suffering (using, for example, lethal injection), and the second refers to death by deliberate omission to start medical action that would guarantee the prolongation of survival.It is worth noting the vagueness of the distinction between passive euthanasia and orthothanasia, which refers to "death at the right time", since there is no real boundaries between" not intervening and simply letting die" and "letting die in the seemingly correct time" 1 .
The term "assisted death" or "assisted dying" encompasses both the concept of euthanasia and assisted suicide 2 , both subjects of ongoing debates in today's society.Four European, one South American and two North Americans countries have legalized euthanasia and/or assisted suicide, but the law of these countries differ considerably regarding the practices 3 .
In July 2015, the topic was widely reported by the media after the first legal case of euthanasia was performed in Colombia 4 .In the same year, assisted suicide was legalized in Canada and in the state of California, in the United States (US) 4 .Given the divergent views and the general interest of the community on the subject, having knowledge of the experience and the views of various countries regarding the issue is essential to form opinions 3 .This is still a very controversial debate and -regardless of political, religious or moral aspects-it is fundamentally a human issue 2 .Thus, the objective of this work is to establish the prevalence and the criteria adopted for the practice of euthanasia and assisted suicide in Western countries and to discuss the position of other countries where the practice is not recognized.

Method
This work consists of a systematic review of the literature.The words "euthanasia," "assisted suicide", "Netherlands", "Belgium", "Luxembourg", "Switzerland", "United Kingdom", "Brazil", "Colombia" "Canada" and "United States" were used, in English and Portuguese, as keywords for the research.To identify the publications that composed this study, an online search was done in the following databases: Scientific Electronic Library Online (SciELO), National Center for Biotechnology Information (PubMed) and Google Scholar.The MeSH tool was used to help the search and categorization of articles.
The research was based on 19 publications relevant to the topic investigated.A list with these publications is presented at the end in Appendix 1.The following previously established inclusion criteria were considered: original works or reviews, available in full, published between 2005 and 2015.The articles that did not fit the inclusion criteria were removed from the sample.Regarding the exclusion criteria, we considered duplicated articles, publications prior to 2005 and those that, despite having the selected descriptors, did not directly address the proposed topic.In addition, recent news articles, websites and official reports from the countries mentioned were consulted to update data.Moreover, some articles were suggested by experts.

Method and results
The selection of items for systematic review was done according to the flow chart (Figure 1).Based on these publications,

Discussion
Assisted death is allowed in four Western European countries: the Netherlands, Belgium, Luxembourg and Switzerland; two North American countries: Canada and the United States, in the states of Oregon, Washington, Montana and Vermont; and in South America: in Colombia 4 .The laws and criteria adopted for the purposes of this practice differ in each country.Explaining how assisted death occurs in these locations and compare their legislation to that of other similar countries in socio-economic and cultural aspects allows a better understanding of the subject, and works as a basis for future discussions 2 .The situation in Brazil and the UK has been addressed at the end of this paper in order to compare the position of other countries and enrich the discussion.The timeline with key milestones regarding assisted death in the world is presented in Appendix 2 to facilitate understanding.

Colombia
Colombia is the only country in Latin America where euthanasia is permitted.Although it was decriminalized in 1997 by the Constitutional Court, only in April 2015 the Ministério da Saúde (Ministry of Health) defined how it might occur.Until that date, it was classified as "murder by compassion" according to Article 326 of the Criminal Code, and the lack of well-established criteria for its realization, coupled with the controversial legislation, generated ambiguity, conflicting interpretations and uncertainties regarding the matter 4,5 .
Currently, the practice is regulated by Resolution 12116/2015 from the Ministério da Saúde e Proteção Social (Ministry of Health and Social Protection), which establishes criteria and procedures to ensure the right to death with dignity 6,7 .Intravenous drugs can be administered by physicians, in hospitals, to adult patients with terminal diseases that cause intense pain and suffering that cannot be relieved.The patient must consciously request assisted death, which must be authorized and supervised by a specialist doctor, a lawyer, and a psychiatrist or psychologist.Moreover, the current legislation does not prohibit this procedure for foreign patients 4 .
Only one case of euthanasia has been reported so far in the country, on the 3 rd July 2015.

Research articles
Euthanasia and assisted suicide in western countries: a systematic review http://dx.doi.org/10.1590/1983-80422016242136 It was Ovídio Gonzáles (79) who was stricken by a rare facial cancer that, although not metastasized, caused intense chronic pain 4 .Therefore, in view of the recent legalization, it is necessary to invest in the training of physicians and health professionals to deal with end of life ethical dilemmas 5,8 .

United States
Assisted suicide is legal in five of the fifty US states: Oregon, Washington, Montana, Vermont and California 4,9 .In 2014, New Mexico passed legislation consistent with the practice, but the decision was reversed on appeal in August 2015 4 .On the other hand, euthanasia is banned in all states 2 .
The first state to legalize assisted suicide was Oregon, on the 27 th October 1997, with the approval of the "Death with Dignity Act" 10 , which allows competent (able to consciously express their will) adults (from the age of 18), residents in Oregon, with terminal illnesses and life expectancy of less than six months, to receive medications in lethal doses, through voluntary self-administration, expressly prescribed by a doctor for this purpose.According to the Act, the self-administration of these lethal drugs is not considered suicide, but death with dignity 3,11 .It is worth noting that many Catholic hospitals have opted out from this practice 4 .
Since the law was passed in 1997 until the end of 2014, 1,327 people received the prescription of lethal medication, and of those, 859 died after self-administration.Six people woke up after the procedure, and most died within days.Some patients for whom the medication was prescribed died before administration, others waited to receive it, and some cases were not properly notified 12 .
Of the 859 people who received lethal medication, 52.7% were men, predominantly in the age group between 65 and 74, with higher education or post-graduation degree (45.9%).In 78% of the cases, the disease was cancer, followed by amyotrophic lateral sclerosis (ALS) at 8.3%.Most patients died at home (94.6%) and received palliative care.The most common concerns of these patients were loss of autonomy, mentioned by 91.5% of them, loss of ability to participate in activities that make life enjoyable (88.7%) and loss of dignity (79.3%) 12 .
In March 2009, the State of Washington approved its "Death with Dignity Act", almost identical to the one from Oregon, by which competent adults living in the area, with a life expectancy of six months or less, may require self-administration of a lethal medication prescribed by a doctor 3,4,13 .From 2009 to 2014, 724 people received prescriptions for lethal medication, of these, 712 died after self-administration.The situation of patients who received the prescriptions but did not use them is unknown 13 .As in Oregon, the statistics show, among the deaths, a higher incidence of men between 65 and 74 of age, with high education.The predominant underlying disease was also cancer, followed by neurodegenerative diseases 13 .
In the state of Montana, the Supreme Court ruled on the 31 st December 2009, that assisted suicide was not illegal, after the case of the patient Robert Baxter, a 76 year-old retired truck driver, carrying a terminal form of lymphocytic leukemia 14 .Unlike other states, Montana law is not as well-regulated on the subject.According to the Supreme Court, patients should be adults, mentally competent and suffer from terminal illnesses to request lethal medication.The act is secured by rights of privacy and dignity established by the constitution, and the doctors who assist are also protected by law 3,14,15 .

Canada
In February 2015, after six years of debate in the Supreme Court, with the cases of patients Kay Carter and Gloria Taylor, Canada suspended the ban on euthanasia and assisted suicide 4,[20][21][22] .A grace period of one year was established, during which the federal and provincial government of Canada, as well as health professionals, were to prepare themselves to implement the new law.In January 2016, the deadline was extended for four months, extending the official legalization of assisted death and the deadline for provincial governments to establish their guidelines to the 6 th June.If this does not happen, the activity is going to be legal in the country, but not regulated in certain provinces, which will give physicians freedom to modify their own behaviour.Moreover, by that date, in un-regulated territories, aid to assisted death can be obtained through legal concessions [22][23][24] .
Quebec was the first province to regulate assisted death through the "Act Respecting End-of-Life Care", which entered into force in December 2015.Approved in the previous year, and based on Oregon's legislation, the Act covers capable adults who were diagnosed with serious and incurable diseases, advanced and irreversible decline of their capabilities, and intense physical and psychological suffering.However, it does not require a maximum life expectancy of six months 4,24,25 .According to the Act, "medical aid in dying" is the administration by a physician, of a lethal substance, following the patient's request 25 .This practice characterizes active voluntary euthanasia, although the term is not used explicitly in the document.The Canadian media announced in January 2016 that the first case of assisted death was confirmed by health authorities in Quebec, which did not provide information about the procedure and the patient's profile 26,27 .
The other Canadian territories have also mobilized themselves for the regulation of assisted death.In November 2015, a group created by the provincial government issued an advisory report to the provinces, aiming to draw up their own guidelines 28 .
In January 2016, the College of Physicians and Surgeons of Ontario published the "Interim Guidance on Physician-Assisted Death", regulating euthanasia and assisted suicide, with criteria similar to those adopted by Quebec 22 .In the same month, in a press article 29 , a lawyer from the Canadian Justice Department expressed his concerns regarding the new changes.According to him, the country will face a major challenge in the management of issues related to assisted death, as the country's health policies are regulated by provincial laws, while criminal laws are under national jurisdiction.To avoid problems, authorities suggested unified national guidelines, despite the short time to regulate 29 .

The Netherlands
In April 2002, both euthanasia and the assisted suicide were regulated and became no longer punishable in the Netherlands, after more than thirty years of debate.Before legalization, these practices were tolerated for a few decades, having been reported by Dutch doctors since 1991 3,4,30 .
The process of assisted death should fit into several criteria very similar to those applied in Belgium and Luxembourg.In all three countries, the patient must be competent, carry out the request voluntarily, and have chronic conditions that cause intense physical or psychological suffering.The physician should inform the patient about his or her health status and life expectancy and, together, reach the conclusion that there is no reasonable alternative.Also, another doctor should be consulted about the case, and all procedures should be reported to the authorities 3,4,30 .
People with dementia are also eligible, as well as children, aged between 12 and 17, with proven mental capacity.Parents or guardians must also agree to act in the case of patients between 12 and 15 years old, and join the discussions for patients between 16 and 17 years old.In some specific circumstances, assisted death may also apply to newborns, according to the regulations of the "Groningen Protocol", from 2005 4,31 .
Between September 2002 and December 2007, 10,319 cases were reported.Of these, 54% were male, 53% were between 60 and 79 years old and 87% were diagnosed with cancer 30 .In 2013, 4,829 cases were reported, and 78.5% of these occurred at home.In recent years, five doctors (0.1% of cases) were judged for not fulfilling the criteria set out in the legislation 4,30 .

Belgium
Since September 2002, voluntary euthanasia has been allowed in Belgium for mentally competent people, suffering from incurable conditions, including mental illness, which cause unbearable physical or psychological suffering.The assisted suicide is not explicitly regulated by law, but cases reported to the Comissão Federal de Controle e Avaliação de Eutanásia (Federal Evaluation and Control Commission for Euthanasia) are treated the same as euthanasia 3,4 .
Euthanasia and assisted suicide in western countries: a systematic review http://dx.doi.org/10.1590/1983-80422016242136 The Belgian legislation is similar to the Dutch one, however, if the patient is not terminal, the doctor should consult an independent third party specialist, and at least one month should pass between the patient's request and the euthanasia procedure 3,30 .
On the 13 th February 2014, Belgium removed the age restriction for euthanasia, despite strong opposition from religious people and from some members of the medical profession.Before this change, the legislation of euthanasia already applied to adolescents over 15 years old, legally emancipated by legal decree.In any case, in the last twelve years, the Federal Commission reported only four cases involving patients younger than 20, and none of them was a child 32 .
With the new legislation, children of any age may require euthanasia, provided they are able to understand the consequences of their decisions, as certified by a child psychologist or psychiatrist.The child must be in terminal condition, with constant and unbearable physical suffering, which cannot be relieved.The child's decision should be supported by their parents or legal guardians, who have veto rights 31 .Although the age restriction is not imposed by law, the child must show discernment capacity and be conscious at the time of making the request.These prerequisites limit the range of children who might qualify, and the forecast is that the changes, although very important, will not have such a significant impact 31 .
According to the Federal Commission between 2010 and 2014, reported cases almost doubled, increasing from 953 to 1,807.The prevalence remains men, aged between 60 and 79, with cancer; however, a recent study showed increased requests from patients older than 80 and with other diseases.Furthermore, it is estimated that 44% of assisted deaths occur in hospitals, 43% at home and 11% in nursing homes 4,30,32 .

Luxembourg
On the 16 th March 2009, euthanasia and assisted suicide were legalized in Luxembourg, and are currently regulated by the Comissão Nacional de Controle e Avaliação (National Commission for Control and Assessment).The law covers competent adults, people with incurable and terminal diseases that cause physical or psychological constant and unbearable suffering, with no possibility of relief 4,34 .
The patient must request the procedure through his or her "end-of-life provisions", which is a written document that is obligatorily registered and analysed by the Comissão Nacional de Controle e Avaliação (National Commission for Control and Assessment).The document also allows the patient to record the circumstances in which he or she would like to be submit to assisted death, which is performed by a physician who the applicant trusts.The request may be revoked by the patient at any time, and in this case will be removed from the medical record 34 .Before the procedure, the physician should consult another independent expert, the patient's health team, and a "trusted person" appointed by the patient; after its completion, the death must be reported to the Commission within eight days 4,34 .
According to the Commission's last report, between 2009 and 2014, 34 cases of assisted death had been registered.Of these, 21 were female, predominantly aged between 60 and 79; 27 had cancer and 22 underwent the procedure in a hospital 35 .

Switzerland
Assisted suicide is permitted in Switzerland and, in accordance with Article 115 of the Código Penal (Penal Code) of 1918, the practice is only punishable when performed for "non-altruistic" reasons 3,4 .Unlike other countries, such as the Netherlands, and some US states, assisted suicide is not clearly regulated, and there are no specific laws that determine under what conditions a person can request assistance 36 .
Although Article 115 was not originally developed for the regulation of this practice, from the 1980s onwards many institutions who support assisted death used it as a basis to justify their actions.Currently, six active institutions are responsible for most cases of assisted suicide in the country, with different criteria for selecting candidates 3,36 .
Only three institutions restrict the procedure for terminally ill patients, and in four of them foreigners can also undertake the procedure.It is estimated that between 2008 and 2012, 611 foreigners, including a Brazilian, 268 from Germany and 126 from the UK, received lethal medication.During this period, foreigners accounted for almost two-thirds of all cases 4,36 .The service has attracted a considerable number of patients, called "suicide tourists", to the country.In the UK, for example, the term "going to Switzerland" has become a euphemism for assisted suicide 36 .
The procedure is also allowed for people with mental illness, but the Supreme Court requires a psychiatric report stating that the patient's suicide

Research articles
Euthanasia and assisted suicide in western countries: a systematic review http://dx.doi.org/10.1590/1983-80422016242136desire was self-determined and well considered, and is not part of their mental disorder 3 .Doctors who prescribe the drug are responsible for the process and should always inform patients about their condition and possible alternatives.However, a well-established doctor-patient relationship is not prerequisite for practice, and usually these doctors are not present at the time of death 3 .
All countries, except Switzerland and the state of Montana (US) require notification of cases of assisted suicide and regular release of public reports 3 .However, recent studies show that the user's profile differs from other countries: assistance is predominant amongst women, and the percentage of cancer patients is lower 3,35 .Euthanasia is prohibited in Switzerland in accordance with Article 114 of the Código Penal (Penal Code) 3 .

Brazil
Although not yet regulated in Brazil, the topic has been widely discussed among physicians, philosophers, religious people and legal professionals who seek the best way to insert the issue in our legal system 37 .Euthanasia is considered a crime of murder, according to the Article 121 of the Código Penal (Criminal Code), and, depending on the circumstances, the conduct of the agent can also be configured as a crime of inducement, instigation or assistance to suicide, as stated in Article 122 38 .Furthermore, in accordance with Article 41 of the sixth Código de Ética Médica (Code of Medical Ethics), it is forbidden for physicians to shorten the patient's life, even if upon their request or that of their legal representative.The Code also points out that, in cases of incurable and terminal illness, the physician should offer all palliative care available without undertaking useless or obstinate diagnostic or therapeutic actions 39,40 .
It is noteworthy that, as claimed by Felix, Costa, Alves Andrade, Duarte and Brito, orthothanasia (sometimes used as a synonym for "passive euthanasia") is well secured by the Constitution, as it aims to ensure a dignified death for the terminal patient, who has the autonomy to refuse inhuman and degrading treatment 37 .
The Conselho Federal de Medicina (Federal Council of Medicine) also made its position clear on the subject.Resolution 1805/2006 allows the physician to limit or suspend procedures and treatments that prolong the life of terminally ill patients, respecting the will of the person or their legal representative.It also ensures that the patient continues to receive all the care necessary to relieve suffering, assuring them comfort, comprehensive care and right to be discharged 40,41 .Resolution 1995/2012, valuing the principle of patient autonomy, provides for an advance directive (or living will), ensuring its prevalence over any other non-medical opinion, including the wishes of the family.The directives are defined by the resolution as a set of desires, previously and expressly manifested by the patient, regarding the care and treatment they want, or do not want, to receive when they are unable to freely and autonomously express their will 40,42 .

United Kingdom
The UK does not officially allow assisted death, although in recent years discussions on the subject have been very frequent 43 .Recent research shows that the majority of the population, including much of the medical profession, is in favour of assisted suicide 43 .However, in the last decade, the British Parliament rejected several proposals for its regulation 2 .The last of them, the "Assisted Dying Bill", prepared by Lord Falconer, was rejected by the lower house in September 2015 44 .The document, based on the Oregon legislation, proposed the legalisation of assisted suicide (but not of euthanasia) for competent patients, over 18 years old, with a life expectancy of less than six months 43,45 .
Active euthanasia is considered a crime of murder, and according to section 2 of the Suicide Act 1961, assisting it is punishable by up to 14 years in prison 2,46 .However, in February 2010, the Crown Prosecution Service introduced new guidelines on assisted suicide, after the case of Debbie Purdy.She was diagnosed with multiple sclerosis in 1994, and wanted to know if her husband would be charged if he accompanied her to Switzerland to receive lethal medication.The new guidelines state that assisting a suicide may, in some cases, be decriminalized, for example, if the assistance is out of compassion, and the decision of death is voluntary, conscious, well thought out and communicated to the authorities 2,47 .Even after this resolution, legal conflicts continue to occur.In 2013, for example, the wife and the son of a man were arrested for trying to take him to a clinic of assisted death in Switzerland 42 .

Final considerations
With the increase in population life expectancy, the cases of chronic and disabling diseases also

Research articles
Euthanasia and assisted suicide in western countries: a systematic review http://dx.doi.org/10.1590/1983-80422016242136increase.Added to this, a stronger focus on humanized medicine and palliative care prompted debates on quality of death in many countries.In this scenario, assisted death is a current, and still very controversial, topic.
In the Western World, euthanasia and/or assisted suicide are legal in some countries.Although the criteria adopted for these practices are different in each location, the profile of patients who seek assistance is almost invariably the same.
In Brazil, assisted death is not legalized, but the debate is timely, among other reasons, due to the anticipated growth of the elderly population in the coming years, which will also increase the number of chronic and disabling diseases.It is estimated that in 2020 the country will be the sixth largest in the number of elderly 48 .This data is worrying, since the quality of death in Brazil is considered poor and undeveloped 48,49 .Therefore, we consider that improvements in terminal patient care are imperative, regardless of the debate in question.
The UK also criminalizes assisted death.However, in recent years, discussions on the subject have become increasingly frequent.The British refused various legalization proposals, although surveys indicate that the majority of the population is in favour of change.Still, unlike Brazil, the UK leads the ranking of the most developed countries in the care of patients at the end of life and is considered a world reference in palliative care 48,49 .
During the writing of this paper, the first case of euthanasia in Colombia took place, assisted suicide was recognized in Canada and in the state of California in the United States, and the state of New Mexico repealed the decision of legalization.That said, we suggest updated research be done at regular intervals.
The issue of assisted death is broad and multifaceted; therefore, the analysis of the data from the countries presented should consider the context in which they are, valuing historical, religious, socioeconomic and cultural aspects.Moreover, the discussion raises awareness regarding human finitude, making room for the timely and favourable development of palliative care services, and stimulating consideration of important bioethical issues such as the right to death and the patient's autonomy; the sacredness of life; the doctor-patient relationship; the principles of beneficence and non-maleficence; and issues related to the regulation of the practice itself.
Finally, we hope that this review represents an updated source of assisted death scenario in the Western World, allowing for more comprehensive and critical view on the subject.

Figure 1 .
Figure 1.Selection of studies

Table
1 briefly describes information regarding the journal, author, year of publication, article title, type of study, objective and limitations presented by the publications studied.

and assisted suicide in western countries: a systematic review
The authors are grateful to the Conselho Nacional de Desenvolvimento Científico e Tecnológico -CNPQ (National Council for Scientific and Technological Development) for the financial support given and for the PhD grant provided to the co-author Sarah Rückl.

Table 1 .
Characteristics of selected articles [continuation]

Table 1 .
Characteristics of selected articles