Euthanasia and assisted suicide in western countries: a systematic review

Mariana Parreiras Reis de Castro Guilherme Cafure Antunes Lívia Maria Pacelli Marcon Lucas Silva Andrade Sarah Rückl Vera Lúcia Ângelo Andrade About the authors

Resumo

Em 2015 a temática da morte assistida foi amplamente divulgada pela mídia após o primeiro caso legal de eutanásia ter sido realizado na Colômbia. Além disso, no mesmo ano, o suicídio assistido foi legalizado no Canadá e no estado da Califór.nia, nos Estados Unidos. Atualmente, a morte assistida é permitida em quatro países da Europa Ocidental: Holanda, Bélgica, Luxemburgo e Suíça; em dois países norte-americanos: Canadá e Estados Unidos, nos estados de Oregon, Washington, Montana, Vermont e Califórnia; e na Colômbia, único representante da América do Sul. A partir de revisão sistemática da literatura, objetivou-se estabelecer a prevalência e os critérios adotados para a prática da eutanásia e do suicídio assistido em países ocidentais e discutir a posição de países onde essa prática não é reconhecida. Uma melhor compreensão do assunto mostra-se fundamental para a formação de opiniões e fomento de futuros debates.

Morte assistida; Eutanásia; Suicídio assistido; Cuidado paliativo

Abstract

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.

Assisted death; Euthanasia; Assisted suicide; Palliative care

Resumen

En 2015, el tema de la muerte asistida fue ampliamente difundida por los medios del mundo después de que el primer caso de la eutanasia legal haya sido realizado en Colombia. También, ese año el suicidio asistido fue legalizado en Canadá y en el estado de California en Estados Unidos. Actualmente, el suicidio asistido está permitido en cuatro países de Europa occidental: Países Bajos, Bélgica, Luxemburgo y Suiza; dos países de América del Norte: Canadá y Estados Unidos, en el estado de Oregon, Washington, Montana, Vermont y California; y Colombia, único representante de América del Sur. A partir de una revisión sistemática de la literatura, se planteo como objetivo determinar la prevalencia y los criterios adoptados para la práctica de la eutanasia y el suicidio asistido en los países occidentales y discutir la posición de países similares donde no se reconoce esta práctica. Una mejor comprensión de la materia parece ser crítica para la formación de opiniones y el fomento de las futuras discusiones.

Muerte asistida; Eutanasia; Suicidio asistido; Cuidado paliativo

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 11. Siqueira-Batista R, Schramm F. Conversações sobre a “boa morte”: o debate bioético acerca da eutanásia. Cad Saúde Pública. 2005;21(1):111-9.. 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 11. Siqueira-Batista R, Schramm F. Conversações sobre a “boa morte”: o debate bioético acerca da eutanásia. Cad Saúde Pública. 2005;21(1):111-9..

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 11. Siqueira-Batista R, Schramm F. Conversações sobre a “boa morte”: o debate bioético acerca da eutanásia. Cad Saúde Pública. 2005;21(1):111-9.. 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” 22. Menon S. Euthanasia a matter of life and death. Singapore Med J. 2013;54(3):116-28.. 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” 11. Siqueira-Batista R, Schramm F. Conversações sobre a “boa morte”: o debate bioético acerca da eutanásia. Cad Saúde Pública. 2005;21(1):111-9..

The term “assisted death” or “assisted dying” encompasses both the concept of euthanasia and assisted suicide 22. Menon S. Euthanasia a matter of life and death. Singapore Med J. 2013;54(3):116-28., 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 33. Steck N, Egger M, Maessen M, Reisch T, Zwahlen M. Euthanasia and assisted suicide in selected european countries and US States. Med Care. 2013;51(10):938-44..

In July 2015, the topic was widely reported by the media after the first legal case of euthanasia was performed in Colombia 44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481.. In the same year, assisted suicide was legalized in Canada and in the state of California, in the United States (US) 44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481.. 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 33. Steck N, Egger M, Maessen M, Reisch T, Zwahlen M. Euthanasia and assisted suicide in selected european countries and US States. Med Care. 2013;51(10):938-44.. This is still a very controversial debate and - regardless of political, religious or moral aspects– it is fundamentally a human issue 22. Menon S. Euthanasia a matter of life and death. Singapore Med J. 2013;54(3):116-28.. 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, 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.

Figure 1
Selection of studies

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 44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481.. 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 22. Menon S. Euthanasia a matter of life and death. Singapore Med J. 2013;54(3):116-28.. 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 44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481.,55. Guerra YM. Ley, Jurisprudencia y Eutanasia: introdución al estudio de la normatividade comparada a la luz del caso comlombiano. Rev Latinoam Bioét. 2013;13(2):70-85..

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 66. Torres JHR. The right to die with dignity and conscientious objection. Colomb. Med. 2015;46(2):52-3.,77. Colombia. Ministerio de Salud y Protección Social. Resolución nº 1216, del 2015. Por medio de la cual se da cumplimiento a la orden cuaria de la sentencia T-970 de 2014 de la Honorable Corte Constitucional en relación con las directrices para la organización y funcionamiento de los Comités para hacer efectivo el derecho a morir con dignidade. Bogotá; 2015 [acesso 20 out 2015]. Disponível: http://bit.ly/1Uwfy7D
http://bit.ly/1Uwfy7D...
. 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 44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481..

Only one case of euthanasia has been reported so far in the country, on the 3rd July 2015. It was Ovídio Gonzáles (79) who was stricken by a rare facial cancer that, although not metastasized, caused intense chronic pain 44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481.. 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 55. Guerra YM. Ley, Jurisprudencia y Eutanasia: introdución al estudio de la normatividade comparada a la luz del caso comlombiano. Rev Latinoam Bioét. 2013;13(2):70-85.,88. Sarmiento-Medina M I, Vargas-Cruz S L, Velasquez-Jimenez, Claudia M, Sierra de Jaramillo M. Problemas y decisiones al final de la vida en pacientes con enfermedad en etapa terminal. Rev Salud Pública. 2012;14(1):116-28..

United States

Assisted suicide is legal in five of the fifty US states: Oregon, Washington, Montana, Vermont and California 44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481.,99. McGreevy P. After struggling, Jerry Brown makes assisted suicide legal in California. Los Angeles Time. [Internet]. 5 out 2015 [acesso 28 out 2015]. Disponível: http://lat.ms/1PfpV0Y
http://lat.ms/1PfpV0Y...
. In 2014, New Mexico passed legislation consistent with the practice, but the decision was reversed on appeal in August 2015 44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481.. On the other hand, euthanasia is banned in all states 22. Menon S. Euthanasia a matter of life and death. Singapore Med J. 2013;54(3):116-28..

The first state to legalize assisted suicide was Oregon, on the 27th October 1997, with the approval of the “Death with Dignity Act” 1010. Loggers ET, Starks H, Shannon-Dudley M, Back AL, Appelbaum FR, Stewart FM. Implementing a death with dignity program at a comprehensive cancer center. New Engl J Med. 2013;368:1417- -24., 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 33. Steck N, Egger M, Maessen M, Reisch T, Zwahlen M. Euthanasia and assisted suicide in selected european countries and US States. Med Care. 2013;51(10):938-44.,1111. Oregon Public Health Division. Death with Dignity Act Requirements. 1997 [acesso 30 out 2015]. Disponível: http://1.usa.gov/1XT4sAO
http://1.usa.gov/1XT4sAO...
. It is worth noting that many Catholic hospitals have opted out from this practice 44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481..

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 1212. Oregon Public Health Division. Death with Dignity Act. [Internet]. [acesso 2 nov 2015]. Disponível: http://1.usa.gov/1p9mUPV
http://1.usa.gov/1p9mUPV...
.

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%) 1212. Oregon Public Health Division. Death with Dignity Act. [Internet]. [acesso 2 nov 2015]. Disponível: http://1.usa.gov/1p9mUPV
http://1.usa.gov/1p9mUPV...
.

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 33. Steck N, Egger M, Maessen M, Reisch T, Zwahlen M. Euthanasia and assisted suicide in selected european countries and US States. Med Care. 2013;51(10):938-44.,44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481.,1313. Washington State Department of Health. Washington State Department of Health 2014 Death with Dignity Act Report. [Internet]. 2014 [acesso 2 nov 2015]. Disponível: http://1.usa.gov/1DaWEB1
http://1.usa.gov/1DaWEB1...
. 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 1313. Washington State Department of Health. Washington State Department of Health 2014 Death with Dignity Act Report. [Internet]. 2014 [acesso 2 nov 2015]. Disponível: http://1.usa.gov/1DaWEB1
http://1.usa.gov/1DaWEB1...
. 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 1313. Washington State Department of Health. Washington State Department of Health 2014 Death with Dignity Act Report. [Internet]. 2014 [acesso 2 nov 2015]. Disponível: http://1.usa.gov/1DaWEB1
http://1.usa.gov/1DaWEB1...
.

In the state of Montana, the Supreme Court ruled on the 31st 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 1414. Knaplund KS. Montana becomes third u.s. state to allow physician aid in dying. Soc Sci Res. [Internet]. 2010 [acesso 2 nov 2015]:1-10. Disponível: http://bit.ly/1Omdenc
http://bit.ly/1Omdenc...
. 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 33. Steck N, Egger M, Maessen M, Reisch T, Zwahlen M. Euthanasia and assisted suicide in selected european countries and US States. Med Care. 2013;51(10):938-44.,1414. Knaplund KS. Montana becomes third u.s. state to allow physician aid in dying. Soc Sci Res. [Internet]. 2010 [acesso 2 nov 2015]:1-10. Disponível: http://bit.ly/1Omdenc
http://bit.ly/1Omdenc...
,1515. Breitbart W. Physician-Assisted suicide ruling in Montana: struggling with care of the dying, responsibility, and freedom in big sky country. Palliat Support Sare. 2010;8(1):1-6..

In Vermont, assisted suicide was legalized on the 20th May 2013 by Act 39 – regarding “patient choice and control at end of life”. The Departamento de Saúde estadual (state Department of Health) suggested that by 2016, physicians and patients were gradually adhering to the proposal of the Act, since many hospitals opted out, stating they were not ready to implement it. In any case, the right to assisted death is reserved for adult patients, residents of Vermont, with life expectancy shorter than six months, who are able to voluntarily request and self-administer the medication dose 44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481.,1616. Vermont. Department of Health. Patient choice and control at end of life. [Internet]. 2013 [acesso 2 nov 2015]. Disponível: http://1.usa.gov/1OGe9bd
http://1.usa.gov/1OGe9bd...
.

On the 5th October 2015, Jerry Brown, governor of California, signed the Assembly Bill No. 15, also referred to as the “End of Life Option Act”, allowing assisted suicide for competent adults, residents in the state, with terminal illnesses and life expectancy of less than six months 1717. Botelho G. California governor signs ‘right to die’ bill. [Internet]. CNN. 6 out 2015 [acesso 2 nov 2015]. Disponível: http://cnn.it/1U4Insd
http://cnn.it/1U4Insd...
. The law, which came into force in 2016, was based on the Act from Oregon, from 1997. Its approval resumed old discussions about assisted death 1818. California. California Legislative Information. Assembly Bill nº 15. [Internet]. out 2015 [acesso 2 nov 2015]. Disponível: http://bit.ly/1T3ejBe
http://bit.ly/1T3ejBe...
,1919. Siders D, Koseff A. Jerry Brown signs doctor-assisted death bill. The Sacramento Bee. [Internet]. 5 out 2015 [acesso 15 nov 2015]. Disponível: http://bit.ly/1j9JyeR
http://bit.ly/1j9JyeR...
. At the time the law was passed, the governor stated that, in the end, he was led to reflect on how he would act in the face of his own death. The governor declared that he would not know what to do if he was dying with prolonged and excruciating pain. Also, he pointed out that it was comforting to be able to consider the options offered by the Oregon Act and would not deny that right to others

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 44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481., 2020. Canada. Supreme Court of Canada. Supreme Court Judgments 2015 SCC 5 (2015). [Internet]. [acesso 15 nov 2015]. Disponível: http://bit.ly/1j9JyeR
http://bit.ly/1j9JyeR...

21. Attaran A. Unanimity on death with dignity — legalizing physician-assisted dying in Canada. N Engl J Med. 2015;372(22):2080-2.
-2222. The College of Physicians and Surgeons of Ontario. CPSO Interim Guidance on Physician-Assisted Death. [Internet]. 2016 [acesso 26 fev 2016]. Disponível: http://bit.ly/1nKql5N
http://bit.ly/1nKql5N...
. 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 6th 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 2222. The College of Physicians and Surgeons of Ontario. CPSO Interim Guidance on Physician-Assisted Death. [Internet]. 2016 [acesso 26 fev 2016]. Disponível: http://bit.ly/1nKql5N
http://bit.ly/1nKql5N...

23. CBC News. Supreme Court gives federal government 4-month extension to pass assisted dying law. [Internet]. 15 jan 2016 [acesso 26 fev 2016]. Disponível: http://bit.ly/1UxNCAg
http://bit.ly/1UxNCAg...
-2424. Canada. Judgments of the Supreme Court of Canada. Supreme Court of Canada. [Internet]. 15 jan 2016 [acesso 26 fev 2016]. Diponível: http://bit.ly/1swaJ8p
http://bit.ly/1swaJ8p...
.

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 44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481.,2424. Canada. Judgments of the Supreme Court of Canada. Supreme Court of Canada. [Internet]. 15 jan 2016 [acesso 26 fev 2016]. Diponível: http://bit.ly/1swaJ8p
http://bit.ly/1swaJ8p...
,2525. Assemblee Nationale Québec. Bill nº 52: an act respecting end-of-life care. [acesso 26 fev 2016]. Diponível: http://bit.ly/Kn9aTa
http://bit.ly/Kn9aTa...
. According to the Act, “medical aid in dying” is the administration by a physician, of a lethal substance, following the patient’s request 2525. Assemblee Nationale Québec. Bill nº 52: an act respecting end-of-life care. [acesso 26 fev 2016]. Diponível: http://bit.ly/Kn9aTa
http://bit.ly/Kn9aTa...
. 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 2626. Rukavina S. Quebec patient receives doctor-assisted death in Canadian legal first. CBC News. [Internet]. 15 jan 2016 [acesso 26 fev 2016]. Disponível: http://bit.ly/1PwAokX
http://bit.ly/1PwAokX...
,2727. Hamilton G. First Quebec euthanasia case confirmed, two others reported. Nacional Post. [Internet]. 15 jan 2016 [acesso 26 fev 2016]. Disponível: http://bit.ly/1OomqE4
http://bit.ly/1OomqE4...
.

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 2828. Canadá. End-of-Life Law and Policy in Canada. Health Law Institute. [Internet]. [acesso 26 fev 2016]. Diponível: http://eol.law.dal.ca/
http://eol.law.dal.ca/...
.

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 2222. The College of Physicians and Surgeons of Ontario. CPSO Interim Guidance on Physician-Assisted Death. [Internet]. 2016 [acesso 26 fev 2016]. Disponível: http://bit.ly/1nKql5N
http://bit.ly/1nKql5N...
. In the same month, in a press article 2929. Kirkup K. Assisted-death committee warned about Canada’s jurisdictional patchwork. CBC News. 18 jan 2016 [acesso 26 fev 2016]. Diponível: http://bit.ly/1sERYzm
http://bit.ly/1sERYzm...
, 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 2929. Kirkup K. Assisted-death committee warned about Canada’s jurisdictional patchwork. CBC News. 18 jan 2016 [acesso 26 fev 2016]. Diponível: http://bit.ly/1sERYzm
http://bit.ly/1sERYzm...
.

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 33. Steck N, Egger M, Maessen M, Reisch T, Zwahlen M. Euthanasia and assisted suicide in selected european countries and US States. Med Care. 2013;51(10):938-44.,44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481.,3030. Rurup ML, Smets T, Cohen J, Bilsen J, Onwuteaka-Philipsen BD, Deliens L. The first five years of euthanasia legislation in Belgium and the Netherlands: Description and comparison of cases. Palliat Med. 2012;26(1):43-9..

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 33. Steck N, Egger M, Maessen M, Reisch T, Zwahlen M. Euthanasia and assisted suicide in selected european countries and US States. Med Care. 2013;51(10):938-44.,44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481.,3030. Rurup ML, Smets T, Cohen J, Bilsen J, Onwuteaka-Philipsen BD, Deliens L. The first five years of euthanasia legislation in Belgium and the Netherlands: Description and comparison of cases. Palliat Med. 2012;26(1):43-9..

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 44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481.,3131. Vizcarrondo FE. Neonatal euthanasia: the Groningen Protocol. Linacre Q. 2014;81(4):388-92..

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 3030. Rurup ML, Smets T, Cohen J, Bilsen J, Onwuteaka-Philipsen BD, Deliens L. The first five years of euthanasia legislation in Belgium and the Netherlands: Description and comparison of cases. Palliat Med. 2012;26(1):43-9.. 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 44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481.,3030. Rurup ML, Smets T, Cohen J, Bilsen J, Onwuteaka-Philipsen BD, Deliens L. The first five years of euthanasia legislation in Belgium and the Netherlands: Description and comparison of cases. Palliat Med. 2012;26(1):43-9..

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 33. Steck N, Egger M, Maessen M, Reisch T, Zwahlen M. Euthanasia and assisted suicide in selected european countries and US States. Med Care. 2013;51(10):938-44.,44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481..

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 33. Steck N, Egger M, Maessen M, Reisch T, Zwahlen M. Euthanasia and assisted suicide in selected european countries and US States. Med Care. 2013;51(10):938-44.,3030. Rurup ML, Smets T, Cohen J, Bilsen J, Onwuteaka-Philipsen BD, Deliens L. The first five years of euthanasia legislation in Belgium and the Netherlands: Description and comparison of cases. Palliat Med. 2012;26(1):43-9..

On the 13th 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 3232. Dierickx S, Deliens L, Cohen J, Chambaere K. Comparison of the expression and granting of requests for euthanasia in Belgium in 2007 vs 2013. Jama Intern Med. 2015;175(10):1703-6..

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 3131. Vizcarrondo FE. Neonatal euthanasia: the Groningen Protocol. Linacre Q. 2014;81(4):388-92.. 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 3131. Vizcarrondo FE. Neonatal euthanasia: the Groningen Protocol. Linacre Q. 2014;81(4):388-92..

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 44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481.,3030. Rurup ML, Smets T, Cohen J, Bilsen J, Onwuteaka-Philipsen BD, Deliens L. The first five years of euthanasia legislation in Belgium and the Netherlands: Description and comparison of cases. Palliat Med. 2012;26(1):43-9.,3232. Dierickx S, Deliens L, Cohen J, Chambaere K. Comparison of the expression and granting of requests for euthanasia in Belgium in 2007 vs 2013. Jama Intern Med. 2015;175(10):1703-6..

Luxembourg

On the 16th 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 44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481., 3434. Portail Santé. Fin de vie. [Internet]. 2015 [acesso 15 nov 2015]. Disponível: http://bit.ly/1tuCKxv
http://bit.ly/1tuCKxv...
.

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 3434. Portail Santé. Fin de vie. [Internet]. 2015 [acesso 15 nov 2015]. Disponível: http://bit.ly/1tuCKxv
http://bit.ly/1tuCKxv...
. 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 44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481.,3434. Portail Santé. Fin de vie. [Internet]. 2015 [acesso 15 nov 2015]. Disponível: http://bit.ly/1tuCKxv
http://bit.ly/1tuCKxv...
.

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 3535. Portail Santé. Troisième rapport de la loi du 16 mars 2009 sur l’euthanasie et l’assistance au suicide (années 2013 et 2014). [acesso 15 nov 2015]. Disponível: http://bit.ly/292Me89
http://bit.ly/292Me89...
.

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 33. Steck N, Egger M, Maessen M, Reisch T, Zwahlen M. Euthanasia and assisted suicide in selected european countries and US States. Med Care. 2013;51(10):938-44.,44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481.. 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 3636. Gauthier S, Mausbach J, Reisch T, Bartsch C. Suicide tourism: a pilot study on the Swiss phenomenon. J Med Ethics. 2014;0:1-7..

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 33. Steck N, Egger M, Maessen M, Reisch T, Zwahlen M. Euthanasia and assisted suicide in selected european countries and US States. Med Care. 2013;51(10):938-44., 3636. Gauthier S, Mausbach J, Reisch T, Bartsch C. Suicide tourism: a pilot study on the Swiss phenomenon. J Med Ethics. 2014;0:1-7..

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 44. Dyer O, White C, Garcia Rada A. Assisted dying: law and practice around the world. BMJ. 2015;351:h4481.,3636. Gauthier S, Mausbach J, Reisch T, Bartsch C. Suicide tourism: a pilot study on the Swiss phenomenon. J Med Ethics. 2014;0:1-7.. 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 3636. Gauthier S, Mausbach J, Reisch T, Bartsch C. Suicide tourism: a pilot study on the Swiss phenomenon. J Med Ethics. 2014;0:1-7..

The procedure is also allowed for people with mental illness, but the Supreme Court requires a psychiatric report stating that the patient’s suicide desire was self-determined and well considered, and is not part of their mental disorder 33. Steck N, Egger M, Maessen M, Reisch T, Zwahlen M. Euthanasia and assisted suicide in selected european countries and US States. Med Care. 2013;51(10):938-44..

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 33. Steck N, Egger M, Maessen M, Reisch T, Zwahlen M. Euthanasia and assisted suicide in selected european countries and US States. Med Care. 2013;51(10):938-44..

All countries, except Switzerland and the state of Montana (US) require notification of cases of assisted suicide and regular release of public reports 33. Steck N, Egger M, Maessen M, Reisch T, Zwahlen M. Euthanasia and assisted suicide in selected european countries and US States. Med Care. 2013;51(10):938-44.. 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 33. Steck N, Egger M, Maessen M, Reisch T, Zwahlen M. Euthanasia and assisted suicide in selected european countries and US States. Med Care. 2013;51(10):938-44., 3535. Portail Santé. Troisième rapport de la loi du 16 mars 2009 sur l’euthanasie et l’assistance au suicide (années 2013 et 2014). [acesso 15 nov 2015]. Disponível: http://bit.ly/292Me89
http://bit.ly/292Me89...
. Euthanasia is prohibited in Switzerland in accordance with Article 114 of the Código Penal (Penal Code) 33. Steck N, Egger M, Maessen M, Reisch T, Zwahlen M. Euthanasia and assisted suicide in selected european countries and US States. Med Care. 2013;51(10):938-44..

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 3737. Felix ZC, Costa SFG, Alves AMPM, Andrade CG, Duarte MCS, Brito FM. Eutanásia, distanásia e ortotanásia: revisão integrativa da literatura. Ciênc. saúde coletiva. 2013;18(9):2733-46.. 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 3838. Brasil. Presidência da República. Decreto-Lei nº 2.848, de 7 de dezembro de 1940. Código Penal. 1940 [acesso 20 out 2015]. Disponível: http://bit.ly/18kAH0G
http://bit.ly/18kAH0G...
. 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 3939. Conselho Federal de Medicina. Código de Ética Médica. [acesso 20 out 2015]. Disponível: http://bit.ly/1RAU0ou
http://bit.ly/1RAU0ou...
, 4040. Santos DA, Almeida ERP, Silva FF, Andrade LHC, Azevêdo LA, Neves NMBC. Reflexões bioéticas sobre a eutanásia a partir de caso paradigmático. Rev. Bioét. (Impr.). 2014;22(2):367-72..

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 3737. Felix ZC, Costa SFG, Alves AMPM, Andrade CG, Duarte MCS, Brito FM. Eutanásia, distanásia e ortotanásia: revisão integrativa da literatura. Ciênc. saúde coletiva. 2013;18(9):2733-46..

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 4040. Santos DA, Almeida ERP, Silva FF, Andrade LHC, Azevêdo LA, Neves NMBC. Reflexões bioéticas sobre a eutanásia a partir de caso paradigmático. Rev. Bioét. (Impr.). 2014;22(2):367-72., 4141. Conselho Federal de Medicina. Resolução nº 1.805, de 28 de novembro de 2006. Na fase terminal de enfermidades graves e incuráveis é permitido ao médico limitar ou suspender procedimentos e tratamentos que prolonguem a vida do doente, garantindo-lhe os cuidados necessários para aliviar os sintomas que levam ao sofrimento, na perspectiva de uma assistência integral, respeitada a vontade do paciente ou de seu representante legal. Brasília: CFM; 2006 [acesso 4 jun 2016]. Disponível: http://bit.ly/1URTl3S
http://bit.ly/1URTl3S...
. 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 4040. Santos DA, Almeida ERP, Silva FF, Andrade LHC, Azevêdo LA, Neves NMBC. Reflexões bioéticas sobre a eutanásia a partir de caso paradigmático. Rev. Bioét. (Impr.). 2014;22(2):367-72.,4242. Brasil. Conselho Federal de Medicina. Resolução nº 1.995, de 31 agosto de 2012. Dispõe sobre as diretivas antecipadas de vontade dos pacientes. [Internet]. Brasília: CFM; 2012 [acesso 04 jun 2016]. Disponível: http://bit.ly/207VBbw
http://bit.ly/207VBbw...
.

United Kingdom

The UK does not officially allow assisted death, although in recent years discussions on the subject have been very frequent 4343. Frost TDG, Sinha D, Gilbert BJ. Should assisted dying be legalized? Philos Ethics Humanit Med. 2014;9:3.. Recent research shows that the majority of the population, including much of the medical profession, is in favour of assisted suicide 4343. Frost TDG, Sinha D, Gilbert BJ. Should assisted dying be legalized? Philos Ethics Humanit Med. 2014;9:3.. However, in the last decade, the British Parliament rejected several proposals for its regulation 22. Menon S. Euthanasia a matter of life and death. Singapore Med J. 2013;54(3):116-28.. The last of them, the “Assisted Dying Bill”, prepared by Lord Falconer, was rejected by the lower house in September 2015 4444. Mason R. Assisted dying bill overwhelmingly rejected by MPs. The Guardian. [Internet]. 11 set 2015 [acesso 15 nov 2015]. Disponível: http://bit.ly/1ES50P5
http://bit.ly/1ES50P5...
. 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 4343. Frost TDG, Sinha D, Gilbert BJ. Should assisted dying be legalized? Philos Ethics Humanit Med. 2014;9:3.,4545. Londres. Care Not Killing. Lord Falconer’s Assisted Dying Bill. [Internet]. [acesso 16 nov 2015]. Disponível: http://bit.ly/1Lxb9C1
http://bit.ly/1Lxb9C1...
.

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 22. Menon S. Euthanasia a matter of life and death. Singapore Med J. 2013;54(3):116-28.,4646. Simillis C. Euthanasia: a summary of the law in England and Wales. Med Sci Law. 2008;48(3):191-8.. 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 22. Menon S. Euthanasia a matter of life and death. Singapore Med J. 2013;54(3):116-28.,4747. The Crown Prosecution Service. Policy for prosecutors in respect of cases of encouraging or assisting suicide. [Internet]. 2014 [acesso 20 nov 2015]. Disponível: http://bit.ly/1XnPSQZ
http://bit.ly/1XnPSQZ...
. 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 4242. Brasil. Conselho Federal de Medicina. Resolução nº 1.995, de 31 agosto de 2012. Dispõe sobre as diretivas antecipadas de vontade dos pacientes. [Internet]. Brasília: CFM; 2012 [acesso 04 jun 2016]. Disponível: http://bit.ly/207VBbw
http://bit.ly/207VBbw...
.

Final considerations

With the increase in population life expectancy, the cases of chronic and disabling diseases also increase. 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 4848. Kovács MJ. A caminho da morte com dignidade no século XXI. Rev. bioét. (Impr.). 2014;22(1):94- -104. This data is worrying, since the quality of death in Brazil is considered poor and undeveloped 4848. Kovács MJ. A caminho da morte com dignidade no século XXI. Rev. bioét. (Impr.). 2014;22(1):94- -104,4949. Economist Intelligence Unit. Quality of death Ranking end-of-life care across the world. Lien Foundation: 2010.. 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 Parliament 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 4848. Kovács MJ. A caminho da morte com dignidade no século XXI. Rev. bioét. (Impr.). 2014;22(1):94- -104,4949. Economist Intelligence Unit. Quality of death Ranking end-of-life care across the world. Lien Foundation: 2010..

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.

Appendix 1

Appendix 2

Acknowledgment

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.

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Publication Dates

  • Publication in this collection
    May-Aug 2016

History

  • Received
    14 Jan 2016
  • Reviewed
    31 May 2016
  • Accepted
    13 June 2016
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