THE GLOBAL LANDSCAPE OF
PHYSICIAN-ASSISTED DYING
OCTOBER 27, 2015
Kathryn Beck and Rosario G. Cartagena
What we aim to cover


Overview of the Global Landscape
Comparing Approaches:
 Is
PAD legislated?
 What form of PAD is available?
 Criteria for access
 Procedural safeguards

Sticky Issues
Goal of today’s presentation


To provide a comparative look at jurisdictions where
PAD is legal and regulated
Experiences in other jurisdictions can provide a
helpful ‘toolbox’ of potential regulatory options
available to us here in Canada
Overview of the Global Landscape
Global landscape
CANADA
2015*
NETHERLANDS
2002
(Euthanasia)
WASHINGTON
2009
MONTANA
2009*
OREGON
1997
CALIFORNIA
*2016
COLOMBIA
1997*
BELGIUM
2002
(Euthanasia)
QUEBEC
*2015
VERMONT
2013
LUXEMBOURG
2009
(Euthanasia)
SWITZERLAND
1942*
The changing landscape
PAD in the United States
States with PAD legislation
States where PAD is legal by court decision
States considering PAD legislation this session
States that considered but did not pass PAD legislation this session
States with no legislative activity on PAD
Accessed at: http://www.deathwithdignity.org/advocates/national
Comparing Approaches
Is PAD legislated?
Yes
California
No
√*
Montana
√
Oregon
√
Vermont
√
Washington
√
Belgium
√
Luxembourg
√
Netherlands
√
Switzerland
√
Colombia
√
* not yet in force
What form of PAD is available?
Lethal Prescription
(self-administered)
California
√
Oregon
√
Vermont
√
Washington
√
Quebec
Lethal Injection
(administered by
physician)
Lethal Injection (selfadministered)
√
Belgium
√
√
Luxembourg
√
√
Netherlands
√
√
Switzerland
√
√
Criteria for Access
Residency
Residency Required
California
√
Oregon
√
Vermont
√
Washington
√
Quebec
√
Non-Residents Eligible
Belgium
√*
Luxembourg
√*
Netherlands
√*
Switzerland
√
* but a sufficiently close and long-term physician-patient relationship is required
Voluntariness
Voluntariness Required
California
√
Oregon
√
Vermont
√
Washington
√
Quebec
√
Belgium
√*
Luxembourg
√
Netherlands
√*
Switzerland
√**
*
there is a separate line of case law governing very limited circumstances in which a defence of necessity
may be available in the case of euthanasia without request from the patient (e.g. in the case of
neonates), but this is beyond the scope of the legislation governing assisted dying
**
though the requirement is not explicitly legislated, it is assured through various safeguards
Condition and/or suffering
Terminal disease*
California
√
Oregon
√
Vermont
√
Washington
√
Unbearable suffering
Belgium
√
Luxembourg
√
Netherlands
√
Switzerland
√
Quebec
*
At the end of life; suffering from a serious and incurable illness; in an advanced state of
irreversible decline in capability; and experiencing constant and unbearable pain
a terminal disease is defined to mean that the patient is suffering from a terminal, incurable and
irreversible disease and death is likely within 6 months
Carter legal test
the prohibition on physician-assisted dying is void
insofar as it deprives a competent adult of such
assistance where (1) the person affected clearly
consents to the termination of life; and (2) the person
has a grievous and irremediable medical condition
(including illness, disease or disability) that causes
enduring suffering that is intolerable to the
individual in the circumstances of his or her condition
Minimum age
Adults ǂ
Minors
California
√
Oregon
√
Vermont
√
Washington
√
Quebec
√
Belgium
√
√ɸ
Luxembourg
√
ä
Netherlands
√
√₸
Switzerland
√
√
ǂ 18+
ɸ Legally competent emancipated minors and minors with capacity of discernment (with consultation of child
psychiatrist/psychologist and notification to parent/guardian; only for terminally ill patients)
§ Minors ages 16 to 17 (with consent of parent/guardian)
₸ Minors ages 12 to 15 (with consent of parent/guardian) and 16 to 17 (with consultation of parent/guardian)
Procedural Safeguards
When and how must request be made?
Oral Request
Written Request
Witnesses
California
√
2 at least 15 days apart
√
2 (at least 1 independent)
Oregon
√
2 at least 15 days apart
√
2 (at least 1 independent)
Vermont
√
2 at least 15 days apart
√
2 (both independent)
Washington
√
2 at least 15 days apart
√
2 (at least 1 independent)
Quebec
√
1
Belgium
√
Number of requests not specified
Luxembourg
√
Number of requests not specified
Netherlands
√
Number of requests not specified
√
Signed and dated in
presence of and
countersigned by health or
social services professional
Capacity
Capacity Requirement
California
Capacity to make medical decisions
Oregon
Ability to make and communicate health care decisions
Vermont
Ability to make and communicate health care decisions
Washington
Ability to make and communicate an informed decision
Quebec
Capable of giving consent to care
Belgium
Not addressed
Luxembourg
Capable and conscious
Netherlands
Not addressed
Switzerland
Dignitas: Sound judgment
Exit: Physician assesses decisional capacity
Advanced directives
Yes
No
California
√
Oregon
√
Vermont
√
Washington
√
Quebec
√
Patient can specify whether or not they consent to care that may
be required in the event they become incapable of giving consent.
Such directives may not be used to request medical aid in dying
Belgium
√
If patient unconscious and advanced directive drafted within 5 yrs
Luxembourg
√
If patient unconscious, suffering from incurable condition and has
registered the end of life provision
Netherlands
√
If patient has lost ability to express her will, previously had a
discussion with her doctor and meets due care criteria
Informed consent and feasible alternatives
Yes
California
√
Oregon
√
Vermont
√
Washington
√
Quebec
√
Belgium
√
Luxembourg
√
Netherlands
√
No
Consultation with second physician
Consultation with Second Physician
(No Independence Requirement)
California
√
Oregon
√
Vermont
√
Washington
√
Consultation with Second Physician
(Must be Independent)
Quebec
√*
Belgium
√*
Luxembourg
√*
Netherlands
√
* Physician must also discuss patient’s request with members of the patient’s care team. In Luxembourg the patient
can object to this.
Consultation with mental health specialist
Yes
California
√
If any indication of mental disorder
Oregon
√
If appropriate
Vermont
√
Physician or mental health specialist must
verify capacity in every case
Washington
√
If any indication of psychiatric or
psychological disorder or depression
√
Quebec
Belgium
Not addressed in Legislation
√
Mental health specialist must be consulted
if the patient is not terminally ill
Luxembourg
√
Netherlands
√
Record documentation and reporting
Record Documentation
Requirements
Reporting to Oversight Body
√*
Physician must also complete the “End of Life
Option Act Checklist”
√
Oregon
√*
Physician must also complete the “Oregon Death
with Dignity Act Attending Physician Interview”
within 10 days of patient’s ingestion of lethal
medication or death from any other case
√
Within 7 days of writing prescription, physician must send
patient’s written request and a report to State Registrar, Center
for Health Statistics
Vermont
√*
√
Physician must promptly file a report with Department of Health
Washington
√*
√
Within 30 days of writing a prescription, attending physician must
file the patient’s written request, the Attending Physician
Compliance Form and the Consulting Physician Compliance Form
with the Department of Health
Within 30 days of dispensing medication, the dispensing
pharmacist must file a Pharmacy Dispensing Record Form
Within 30 days of patient’s death, attending physician must file
an Attending Physician After Death Reporting Form
Switzerland
n/a
√
A report must be filed with the police and a death certificate
must indicate the cause of death
California
*The Act outlines a specific list of documents to file in the patient’s medical record
Record documentation and reporting
Record Documentation
Requirements
Reporting to Oversight Body
Quebec
√
√
Belgium
√
Luxembourg
√
Netherlands
√
- Within 10 days following administration of medical aid in dying,
physician must inform council of physicians, dentists and pharmacists
(the “Council”), the head of medical services, or the Collège des
médecins du Québec (the “College”) of administration
- Within 10 days following administration of medical aid in dying,
physician must give notice to Commission on End-of-Life Care (the
“Commission”)*
√
Physician must complete and deliver to the Federal Control and
Evaluation Commission (FCEC) a prescribed registration form
√
Within 4 days of performing euthanasia, physician must submit a
registration document in the appropriate form to the National
Control and Assessment Commission (NCAC)
√
Physician must report on assisted death to the Medical Examiner
using a prescribed form and report the cause of death to the
municipal coroner
*A Commission on End-of-Life Care is established under the Act in Quebec to examine matters relating to end-of-life care
Review and annual report
California
Oregon
Vermont
Washington
Quebec
Review by Oversight Body
Annual Report Available to Public
√
√
State of Public Health Officer annually reviews a
sample of medical records
√
√
The Oregon Health Authority annually reviews a
sample of medical records
n/a
n/a
√
√
Department of Health annually reviews all medical
records
√
√*
- The Council, the College, or its competent committee
must assess the quality of care provided
- On receiving notice from a physician the Commission
must assess compliance
- The College must prepare an annual report on
end-of-life care provided by physicians practicing
in private health facilities
*The Commission must submit a report to the Minister every 5 years on the status of end-of-life care in Quebec
Review and biennial report
Belgium
Luxembourg
Netherlands
Switzerland
Review by Oversight Body
Biennial Report
√
√
FCEC determines whether conditions of the Act have been
met
√
√
NCAC determines whether conditions of the Act have been
met
√
n/a
Medical examiner must conduct an examination of the
deceased patient and ascertain the completeness and
accuracy of the physician’s report. Medical examiner then
notifies relevant Regional Review Committee (RRC). RRC
determines whether conditions of the Act have been met
n/a
n/a
Sticky Issues
Sticky Issues
1.
2.
3.
4.
5.
6.
7.
8.
The voice of the disability community
The law as it applies to those suffering from mental
health disease
The implementation of appropriate, available, welldeveloped palliative care services
The conversation surrounding organ donation
The role of advanced directives
The assurance of ‘enough’ training for assessing
capacity
How will the physician – patient relationship be
construed?
How to address criminal offence charges or other
related offences
Kathryn Beck
+1 416 868 3349
Rosario Cartagena
+1 416 943 8904