**11. Geographic limitations on physician assistance**

See **Table 1**.

#### **11.1 Countries in which euthanasia and physician-assisted suicide are legal**

#### *11.1.1 Netherlands*

Euthanasia and physician-assisted suicide were legalized in the Netherlands in 2002 for Dutch citizens over 12 years old, in an act that made physicians exempt from criminal responsibility if they practiced under a set of conditions established by the law. Newborns have been eligible to be euthanized since 2004 under the Groningen Protocol if they are believed to have unbearable suffering and parents, the child's physician, and an independent physician agree to the procedure. In 2020 the Dutch announced plans to extend euthanasia to terminally ill children between the ages of one and 12. Euthanasia tourism is not possible: citizenship is not the issue. The treating physician who will vouch for the patient must be in the Netherlands. A patient cannot be treated outside the Netherlands and receive euthanasia in the Netherlands. Euthanasia rates have risen from just under 2% of all deaths in 2002 to just over 4% in 2019 [22].

#### *11.1.2 Belgium*

Belgium legalized PAS and euthanasia in 2002 for "competent" adults and emancipated minors suffering from "constant and unbearable physical or mental suffering that cannot be alleviated." Patients do NOT need to be suffering from terminal illness. The law was extended to minors in 2014. The Analysis of the 2020 Commission Report [23] asserted that 954 reported assisted deaths in 2010 had increased to 2656 by 2019, an increase of 267% in 9 years. The main conditions generating requests were cancer or polypathology unlikely to improve; no unemancipated minor euthanasia was recorded.

#### *11.1.3 Luxembourg*

Luxembourg became the third country in Europe to legalize euthanasia and physician-assisted suicide with a law that went into effect in 2009. Doctors have legal immunity from prosecution and lawsuits if they perform euthanasia or PAS for a patient with a grave and incurable condition who has asked repeatedly for the procedure. Luxembourg also requires palliative care and paid leave for relatives of terminally ill family members. In all cases, before euthanasia or assisted suicide can be performed, the doctor must fulfill certain formal and procedural conditions (e.g., conduct several interviews with the patient, etc.) [24].

Patients who live elsewhere but have a physician in Luxembourg may record endof-life wishes and plans in their medical file. Luxembourg attaches no stipulations of residency or nationality to placing this information in one's medical file. However, the physician must have been caring for the patient for a long, uninterrupted period. Minors, persons of legal age under guardianship or protection, and legally incapable persons may not legally request euthanasia or assisted suicide, nor may their parents, guardians or trustees make such a request on their behalf.


#### **Table 1.**

*Countries allowing assisted suicide or euthanasia, 2022 [21].*

The sixth biennial report by the National Commission for Control and Evaluation [25], published in March 2021, records 16 cases of euthanasia in 2019 (twice the 8 cases in 2018) and 25 cases in 2020. Total cases from 2009 to 2020 were 112. Lethal

injection was the mode for all but occasional rare cases of oral ingestion of a barbiturate. In 2020 the Commission approved the first euthanasia of a 96-year-old man claiming "fatigue of life," citing the Belgian practice.

#### *11.1.4 Canada*

Canada decriminalized suicide in 1972 but retained a provision prohibiting assisted suicide until it was struck down in 2015 by the Supreme Court of Canada, which gave the Canadian Parliament 1 year to pass a law legalizing and regulating physician-assisted suicide and perhaps euthanasia. Bill C-14 [26] passed the Senate in 2016, making assisted suicide and possibly euthanasia legal. The Court was unclear about the distinction between PAS and euthanasia, but Bill C-14 states that "medical assistance in dying (MAID) means (a) the administering by a medical practitioner or nurse practitioner of a substance to a person, at their request, that causes death; or (b) the prescribing or providing by a medical practitioner or nurse practitioner of a substance to a person, at their request, so that they may self-administer the substance and in doing so, cause their own death." These provisions apply to citizens or permanent residents of Canada, at least 18 years old, who have a "grievous and irremediable medical condition." To be eligible for MAID [27] in Canada, a person must be at least 18 years of age and be eligible for publicly funded health care services in Canada. By November 2020, more than 13,000 Individuals [28] nearing the end of life had been voluntarily euthanized as a result of this bill. In 2020, 2.5% of deaths in Canada were due to MAID. In March 2023, Canada is set to become one of the few nations allowing medical aid in dying (MAID) for people with afflictions that are solely mental, such as depression, schizophrenia, bipolar disorder, personality disorder, PTSD, or other mental affliction. In March 2021, Bill C-7 [29] made changes to the eligibility criteria, removing the "reasonably foreseeable death" criterion. As of March 17, 2023, MAID will be available to capable adults whose sole underlying condition is a mental illness.

Canada's MAID law says that intolerable suffering is wholly subjective and personal. Unlike the Netherlands, a doctor does not have to agree. Suffering is what the person says it is. Under those criteria, the Council of Canadian Academies suggests that Canada could become the most permissive jurisdiction in the world with respect to MAID and mental illness [30].

#### *11.1.5 Spain*

The fifth country to legalize both PAS and euthanasia, Spain wrote a "death with dignity" bill in 2011 that allowed passive euthanasia, the removal of treatment or lifesustaining machinery. Ten years later, Spain's parliament legalized both active euthanasia and PAS for Spanish citizens and legal residents who suffer from a "serious or incurable illness" or a "chronic or incapacitating condition" that causes "intolerable suffering" [31]. The person seeking death must make two requests, 15 days apart, in writing, and must be found "fully aware and conscious."
