Dying With Dignity Canada was pleased to host the 2022 World Federation of Right to Die Societies (WFRTDS) International Conference in Toronto November 2 – 5, 2022. In recognition of the event, we will share a series of blog posts about assisted dying around the world, about the WFRTDS, and summaries of a handful of sessions hosted at the conference.

Alida Doelle (she/her) is a second year student at Dalhousie University, Schulich School of Law. She conducted research on access to MAID during an internship with DWDC in the summer of 2022.

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A small number of countries around the world have been expanding access to various forms of medical assistance in dying (MAID), a movement that started in Switzerland in 1942. The eligibility criteria, safeguards, method of provision and scope of access vary from one jurisdiction to another. There are also different ways countries have legalized the service. Some countries have done so through legislation, while others legalized MAID through a court decision.  

In the past three years alone, courts in Germany, Italy and Austria have released rulings removing bans on assisted dying. In countries where MAID is legalized through a court decision, but no legislation has been passed to regulate the service, the eligibility criteria and safeguards are often much harder to define.  

The world has also seen a growing number of jurisdictions introducing legislation to increase access and remove barriers to MAID. Since 2019, six Australian states have passed legislation to legalize MAID. In the United States there are now ten states with legislation in place allowing assisted dying, and many more states have proposed bills which are at various steps of the legislative process. Just this year there has been proposed legislation in Utah, Delaware, Connecticut, Massachusetts and New York. Through both legislation and litigation, access to MAID has been steadily increasing across the globe.  

Despite growing support and access, MAID continues to attract opposition and debates regarding the extent to which it should be available. Every jurisdiction that has legalized MAID, has different levels of accessibility. Even within the same country, as seen in Australia and the United States, legislation differs across states providing varying eligibility criteria and safeguards.  

Here in Canada, the eligibility criterion is one of the most permissive in the world, particularly since the reasonable foreseeability criteria was removed with Bill C-7’s passage in 2021¹. In March of 2024, those with a mental illness as the sole underlying condition will no longer be excluded from accessing MAID and Canada will be among a handful of European countries including the Netherlands, Belgium, Luxembourg and Switzerland who already allow MAID for those with mental illness as a sole underlying condition.  

Unlike some countries, Canada permits two forms of MAID. One approach, often referred to as euthanasia, is where a MAID practitioner administers a substance causing death. The other approach, often referred to as assisted suicide, is where a medication is prescribed to an individual who then self-administers the medication that causes their death. Switzerland, as well as all US states that have passed legislation, only allow assisted suicide. [See Language matters: Why we use the term ‘medical assistance in dying’]  

Canada is currently studying the possibility of expanding access to mature minors, something countries such as the Netherlands, Belgium and Colombia already allow. The other area where Canada still limits access is in relation to advance requests. Many countries, including the Netherlands, Belgium, Luxembourg, Spain and Colombia, allow advanced requests for MAID to be made, Canada currently does not.  

The table below provides an overview of MAID around the world. Many countries, such as Germany, Italy and Peru, that have legalized MAID through the courts do not have clear information available regarding eligibility criteria and safeguards, particularly information available in English. Such countries are left out of the table.   

Comparison of some international jurisdictions that allow MAID (July 2022) 

Jurisdiction	Terminal Illness Requirement	Minors	Mental Illness	Advance Requests	Methods of Provision
Netherlands	No	Yes*	Yes	Yes, 12+	Both
Belgium	No (yes for minors)	Yes*	Yes	Yes*	Euthanasia*
Luxembourg	No	No	Yes	Yes*	Both
Switzerland	No	No*	Yes	No	Assisted suicide
Spain	No	No	Yes*	Yes	Both
Canada	No	No	Yes, in March 2024	No	Both
Colombia	No*	Yes*	Yes*	Yes	Both
United States2	Yes*	No	No	No	Assisted suicide
New Zealand	Yes	No	No	No	Both
Australia3	Yes	No	No	No	Varies across states

The countries discussed so far have allowed some form of MAID to be legal, and in many cases have expanded access over the years. There are also countries who do not currently allow MAID, but have made many attempts to legalize the service. For example, in Portugal, the president has twice refused to sign a bill allowing MAID. In June 2022, Parliament passed yet another bill to legalize MAID. This is the third attempt to legalize the service, however, the president would need to give approval in order for the bill to become law⁴.  

Currently, most jurisdictions that allow MAID have a residency requirement to access the service, therefore preventing MAID tourism to their country or state. Switzerland is the only exception to this with no residency requirement, making it a common destination for those who would like to access the service but who live in a jurisdiction where it is not accessible. MAID tourism is likely to decrease as access to MAID increases.  

As countries continue to debate the legal, ethical and health care issues surrounding MAID, the landscape of medically assisted dying is likely to continue to change around the world. If the current trend of expanding access continues, MAID will become available to more and more individuals around the world.  

Footnotes

¹ Most permissive of the jurisdictions studied in Article: Comparative and Critical Analysis of Key Eligibility Criteria for Voluntary Assisted Dying Under Five Legal Frameworks (page 1696).  

² There are ten states which have passed legislation legalizing assisted suicide. All information provided in this chart is the same for all ten states, see the detailed chart for additional information and differences among states. The ten states are: Oregon, Washington State, Vermont, California, Colorado, DC, Hawaii, New Jersey, Maine and New Mexico.  

³ Six Australian states have passed legislation regarding MAID. See the more detailed chart for additional information for each state and differences among states. The six states are: Victoria, Western Australia, Tasmania, South Australia, Queensland and New South Wales.  

⁴ https://wfrtds.org/portugals-lawmakers-approve-3rd-attempt-to-allow-euthanasia/