What’s the difference between euthanasia, assisted dying and assisted suicide?

“The main difference between euthanasia and assisted suicide is who performs the final, fatal act,” said Richard Huxtable, professor of medical ethics and law at the University of Bristol.

Euthanasia refers to active steps taken to end someone’s life to stop their suffering and the “final deed” is undertaken by someone other than the individual, for example a doctor. If the person concerned has requested this, it falls under the term “voluntary euthanasia”.

Assisted suicide is about helping someone to take their own life at their request – in other words the final deed is undertaken by the person themselves. Assisted dying can be used to mean both euthanasia, generally voluntary, and assisted suicide; however, some campaign groups use it to refer only to assisted suicide of terminally ill people.

“One of the dilemmas we have in these ongoing debates is how people use the various phrases,” says Huxtable. Most, but not all, jurisdictions that allow some form of euthanasia or assisted suicide require the involvement of medical professionals.

Palliative sedation, in which people can request to be kept under deep sedation until they die, is allowed in many countries, including the Netherlands and France – is not euthanasia.

Which countries permit any of these variants?

The Netherlands and Switzerland are the most well known, and Belgium considered perhaps the most liberal, but several other jurisdictions allow some form of euthanasia or assisted suicide. That said, permitted circumstances differ considerably.

In the Netherlands both euthanasia and assisted suicide are legal if the patient is enduring unbearable suffering and there is no prospect of improvement. Anyone from the age of 12 can request this, but parental consent is required if a child is under 16. There are a number of checks and balances, including that doctors must consult with at least one other, independent doctor on whether patient meets the necessary criteria.

Belgium, Luxembourg, Canada and Colombia also allow both euthanasia and assisted suicide, although there are differences – for example only terminal patients can request it in Colombia, while Belgium has no age restriction for children (although they must have a terminal illness).

Assisted suicide is more widely available than euthanasia. Among the places where people can choose to end their life this way are Switzerland and a number of US states including California, Colorado, Hawaii, New Jersey, Oregon, Washington state, Vermont and the District of Columbia. Laws permitting assisted suicide came into force in the Australian state of Victoria last month.

Again, the exact circumstances in which assisted suicide is allowed vary, with some jurisdictions – Oregon and Vermont – only allowing it in the case of terminal illness. For some places it is permitted not because laws have been passed, but because laws do not prohibit it. For example in Switzerland it is an offence to assist a suicide if it is done with selfish motives. “The result of that is there is this growth of not-for-profit organisations,” says Prof Penney Lewis, an expert on the law around end-of-life care at King’s College London.

Other countries, including New Zealand, are considering legalising some form of euthanasia.

What’s the situation in the UK?

Euthanasia and assisted suicide are illegal. Euthanasia can lead to a murder charge and assisted suicide could result in a sentence of up to 14 years in prison.

That said, anonymous surveys suggest euthanasia does occur in the UK – but it is very rare. A study published in 2009 using responses from more than 3,700 medical professionals suggested 0.2% of deaths involve voluntary euthanasia and 0.3% involved euthanasia without explicit patient request – no assisted suicide was recorded.

It is not normally illegal for a patient to be given treatment to relieve distress that could indirectly shorten life – but this is not euthanasia. It is already legal in the UK for patients to refuse treatment, even if that could shorten their life, and for medical care to be withdrawn by doctors in certain cases, for example where a patient is in a vegetative state and will not recover (sometimes controversially called passive euthanasia).

How many people undergo euthanasia or assisted suicide?

Total figures from around the world are hard to collate. Figures from Switzerland show that the numbers of those living in the country who underwent assisted suicide rose from 187 in 2003 to 965 in 2015.

According to the 2017 Regional Euthanasia Review Committees (RTE), in the Netherlands there were 6,585 cases of voluntary euthanasia or assisted suicide – 4.4% of the total number of deaths. About 96% of cases involved euthanasia, with less than 4% assisted suicide, and the largest proportion of cases involved people with cancer.

Agnes van der Heide, professor of decision-making and care at the end of life at the Erasmus University Medical Center in Rotterdam, says the reason euthanasia is more common than assisted suicide in the Netherlands is multifaceted. Doctors may feel that by performing the deed themselves they can have more control over dosages and the time the procedure takes.

“Patients are often in a very advanced stage of their disease where it is practically difficult if not impossible to drink the lethal drink they have to take when they chose for assistance in suicide,” she adds. “It is a very bitter-tasting drink and it is quite an effort to drink it until the end,” she added. There might also be an element of viewing the act as a medical procedure and hence preferring a physician to do the job.

Lewis says the vast majority of people do not end their lives by euthanasia even if they can. “There is far more withdrawal of life-sustaining treatment, even in jurisdictions that permit euthanasia,” she says.

What happened in the case of the Dutch teenager Noa Pothoven?

Noa Pothoven, who was 17, died last month – she had anorexia and severe depression. At first media reports suggested she had been “legally euthanised”, but later reports said it was unclear how she died, with her friends releasing a comment saying that she died after she stopped eating and drinking.

Van der Heide said that while she could not comment on Pothoven’s case, it is possible for minors over the age of 12 to seek euthanasia or assisted suicide in the Netherlands, under certain conditions.

Has there been suicide tourism?

In some places, yes. According to van der Heide, while suicide tourism is not formally forbidden in the Netherlands, physicians must work with the patient to establish that they meet certain criteria. “I think if a physician would provide euthanasia to a patient he doesn’t know then it is very likely that the regional committee would have a problem with that,” she says.

However, people do travel to Switzerland for assisted suicide. According to statistics from Dignitas, 221 people travelled to the country for this purpose in 2018, 87 of whom were from Germany, 31 from France and 24 from the UK.

What does the public think about euthanasia and assisted suicide?

It depends a bit on the question you ask. A recent poll conducted by the National Centre for Social Research for MDMD found that 93% of people in the UK approved of, or wouldn’t rule out, doctor-assisted suicide if the person is terminally ill.

The British Social Attitudes survey, published in 2017, sheds light on views about voluntary euthanasia, showing that people generally support the idea of doctors ending the life of a terminally ill person who requests it (78%), but that there is less support for a close relative doing the job (39%). It also shows that fervent support for voluntary euthanasia was lower if the person in question has a non-terminal illness or is dependent on relatives for all their needs but not terminal or in pain.

What do doctors think?

Euthanasia and assisted suicide have proved contentious among doctors. Some argue that support for such ideas goes against the commitment to “do no harm”. Others say some people might choose not to end their life if they are made aware that they could be made comfortable with good end of life care.

“Some health professionals are familiar with the care of dying patients and with what palliative care can do – so they may have a feeling that assisted dying isn’t always necessary ,” says Dominic Wilkinson, professor of medical ethics at the University of Oxford.

But some doctors are supportive – at least for particular circumstances such as terminal illness – saying it can be a humane act, and that individuals should be allowed autonomy in when to die. After many years of opposing assisted dying, this year the Royal College of Physicians shifted its stance to become neutral on the subject following a poll of 7,000 UK hospital doctors in which 43.4% opposed allowing assisted dying and 31.6% supported it. The Royal College of GPs has recently announced it is going to start a consultation with members for their views.

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In the Netherlands, a survey of almost 1,500 physicians published in 2015 found more than 90% of GPs and 87% of elderly care physicians supported the liberal Dutch approach to euthanasia and assisted suicide. That might be because the development of the laws was carried out with input from the medical profession.

“All the criteria and also the practice of euthanasia is mainly shaped by how physicians feel it should be,” says van der Heide. “I think for the typical patient with end-stage cancer and severe unbearable suffering, there is hardly any physician in the Netherlands who thinks that the issue of harming patients is at stake there.”

Have the laws been a success?

That depends how you look at it. Support for the Dutch laws clearly remains high, but some say there are signs of a “slippery slope”, with the practice being applied too widely.

As van der Heide points out, the Dutch laws were designed with cases like terminal cancer in mind – but while cancer patients still make up the majority of requests, the proportion of requests related to other conditions is growing. “Gradually of course [it] became more known to both physicians and patients what the requirements were and that they could also apply to other categories,” she says.

That has led to controversy. The 2017 RTE report recorded concerns by Dutch psychiatrists and doctors about the use of euthanasia for people with psychiatric disorders and patients in a very advanced stage of dementia. The 2015 survey found of the almost 1,500 responses that 31% of GPs and 25% of elderly care physicians would grant assisted dying for patients with advanced dementia, with the figures at 37% and 43% respectively for those with psychiatric problems.

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However as Huxtable points out, other jurisdictions including Oregon show that broadening of use is not inevitable. “The fact there has been some slide in the Netherlands should give everyone reason to pause,” he says. “We should think right form the outset what do we think in principle is defensible and are we going to – and we should – police the boundaries.”

There have also been allegations of malpractice. In 2018 both the Netherlands and Belgium reported their first cases in which doctors were investigated for possibly breaching the laws, with three more investigations under way in the Netherlands involving the euthanasia of psychiatric patients.

“Nowadays there are more controversial cases, so the likelihood that there now will be cases that do not fulfil the criteria to the extent that the public prosecutor thinks it is necessary to install a criminal procedure is more likely than it used to be,” says van der Heide.

Are there other concerns?

There have been concerns by disabilities groups that as euthanasia and assisted suicide become more common, it could put a pressure on those living with non-terminal conditions to end their lives. But van der Heide says doctors in the Netherlands take great care when dealing with requests to make sure patients meet strict requirements, and turn down those who do not.

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She adds that the development of laws to allow euthanasia or assisted dying must be handled carefully. “I indeed acknowledge that having a system in which euthanasia is an option should be really carefully monitored and researched because it in principle involves the risk of life of vulnerable people being regarded as less worthy or more prone to doctors’ assistance in dying,” she says.





