Tag: South Africa

Over the past five years, the practice of allowing a physician to help severely ill patients end their lives with medication has been legalized in nine countries on three continents. Courts or legislatures, or both, are considering legalization in a half-dozen more, including South Korea and South Africa, as well as eight of the 31 American states where it remains prohibited.

It is a last frontier in the expansion of individual autonomy. More people are seeking to define the terms of their deaths in the same way they have other aspects of their lives, such as marriage and childbearing. This is true even in Latin America, where conservative institutions such as the Roman Catholic church are still powerful.

“We believe in the priority of our control over our bodies, and as a heterogeneous culture, we believe in choices: If your choice does not affect me, go ahead,” said Dr. Julieta Moreno Molina, a bioethicist who has advised Colombia’s Ministry of Health on its assisted dying regulations.

Yet, as assisted death gains more acceptance, there are major unresolved questions about who should be eligible. While most countries begin with assisted death for terminal illness, which has the most public support, this is often followed quickly by a push for wider access. With that push comes often bitter public debate.

Should someone with intractable depression be allowed an assisted death?

European countries and Colombia all permit people with irremediable suffering from conditions such as depression or schizophrenia to seek an assisted death. But in Canada, the issue has become contentious. Assisted death for people who do not have a reasonably foreseeable natural death was legalized in 2021, but the government has repeatedly excluded people with mental illness. Two of them are challenging the exclusion in court on the grounds that it violates their constitutional rights.

In public debate, supporters of the right to assisted death for these patients say that people who have lived with severe depression for years, and have tried a variety of therapies and medications, should be allowed to decide when they are no longer willing to keep pursuing treatments. Opponents, concerned that mental illness can involve a pathological wish to die, say it can be difficult to predict the potential effectiveness of treatments. And, they argue, people who struggle to get help from an overburdened public health service may simply give up and choose to die, though their conditions might have been improved.

Should a child with an incurable condition be able to choose assisted death?

The ability to consent is a core consideration in requesting assisted death. Only a handful of countries are willing to extend that right to minors. Even in the places that do, there are just a few assisted deaths for children each year, almost always children with cancer.

In Colombia and the Netherlands, children over 12 can request assisted death on their own. Parents can provide consent for children 11 and younger.

The issue is under renewed scrutiny in the Netherlands, where, over the past decade, a growing number of adolescents have applied for assisted death for relief from irremediable psychiatric suffering from conditions such as eating disorders and anxiety.

Most such applications by teens are either withdrawn by the patient, or rejected by assessors, but public concern over a few high-profile cases of teens who received assisted deaths prompted the country’s regulator to consider a moratorium on approvals for children applying on the basis of psychiatric suffering.

Should someone with dementia be allowed assisted death?

Many people dread the idea of losing their cognitive abilities and their autonomy, and hope to have an assisted death when they reach that point. But this is a more complex situation to regulate than for a person who can still make a clear request.

How can a person who is losing their mental capacity consent to dying? Most governments, and doctors, are too uncomfortable to permit it, even though the idea tends to be popular in countries with aging populations.

In Colombia, Spain, Ecuador and the Canadian province of Quebec, people who have been diagnosed with Alzheimer’s disease or other kinds of cognitive decline can request assessment for an assisted death before they lose mental capacity, sign an advance request — and then have a physician end their life after they have lost the ability to consent themselves.

But that raises a separate, challenging, question: After people lose the capacity to request an assisted death, who should decide it’s time?

Their spouses? Their children? Their doctors? The government? Colombia entrusts families with this role. The Netherlands leaves it up to doctors — but many refuse to do it, unwilling to administer lethal drugs to a patient who can’t clearly articulate a rational wish to die.

All of these questions are becoming part of the discussion as the right to control and plan one’s own death is pushed in front of reluctant legislatures and uneasy medical professionals.

Dr. Madeline Li, a Toronto psychiatrist, was given the task of developing the assisted-dying practice in one of Canada’s largest hospitals when the procedure was first decriminalized in 2015. She began with assessing patients for eligibility and then moved to providing medical assistance in dying, or MAID, as it is called in Canada. For some patients with terminal cancer, it felt like the best form of care she could offer, she said.

But then Canada’s eligibility criteria expanded, and Dr. Li found herself confronting a different kind of patient.

“To provide assisted dying to somebody dying of a condition who is not happy with how they’re going to die, I’m willing to assist them, and hasten that death,” she said. “I struggle more with people who aren’t dying and want MAID — I think then you’re assisting suicide. If you’re not dying — if I didn’t give you MAID, you wouldn’t otherwise die — then you’re a person who’s not unhappy with how you’re going to die. You’re unhappy with how you’re living.”

Who has broken the taboo?

For decades, Switzerland was the only country to permit assisted death; assisted suicide was legalized there in 1942. It took a further half century for a few more countries to loosen their laws. Now decriminalization of some form of assisted death has occurred across Europe.

But there has recently been a wave of legalization in Latin America, where Colombia was long an outlier, having allowed legal assisted dying since 2015.

Ecuador has decriminalized assisted dying through constitutional court cases, and Peru’s Supreme Court has permitted individual exceptions to the law which prohibits the procedure, opening the door to expansion. Cuba’s national assembly legalized assisted dying in 2023, although no regulations on how the procedure will work are yet in place. In October, Uruguay’s parliament passed a long-debated law allowing assisted death for the terminally ill.

The first country in Asia to take steps toward legalization is South Korea, where a bill to decriminalize assisted death has been proposed at the National Assembly several times but has not come to a vote. At the same time, the Constitutional Court, which for years refused to hear cases on the subject, has agreed to adjudicate a petition from a disabled man with severe and chronic pain who seeks an assisted death.

Access in the United States remains limited: 11 jurisdictions (10 states plus the District of Columbia) allow assisted suicide or physician-assisted death, for patients who have a terminal diagnosis, and in some cases, only for patients who are already in hospice care. It will become legal in Delaware on Jan. 1, 2026.

In Slovenia, in 2024, 55 percent of the population who voted in a national referendum were in favor of legalizing assisted death, and parliament duly passed a law in July. But pushback from right-wing politicians then forced a new referendum, and in late November, 54 percent of those who voted rejected the legalization.

And in the United Kingdom, a bill to legalize assisted death for people with terminal illness has made its way slowly through parliament. It has faced fierce opposition from a coalition of more than 60 groups for people with disabilities, who argue they may face subtle coercion to end their lives rather than drain their families or the state of resources for their care.

Why now?

In many countries, decriminalization of assisted dying has followed the expansion of rights for personal choice in other areas, such as the removal of restrictions on same-sex marriage, abortion and sometimes drug use.

“I would expect it to be on the agenda in every liberal democracy,” said Wayne Sumner, a medical ethicist at the University of Toronto who studies the evolution of norms and regulations around assisted dying. “They’ll come to it at their own speed, but it follows with these other policies.”

The change is also being driven by a convergence of political, demographic and cultural trends.

As populations age, and access to health care improves, more people are living longer. Older populations mean more chronic disease, and more people living with compromised health. And they are thinking about death, and what they will — and won’t — be willing to tolerate in the last years of their lives.

At the same time, there is diminishing tolerance for suffering that is perceived as unnecessary.

“Until very recently, we were a society where few people lived past 60 — and now suddenly we live much longer,” said Lina Paola Lara Negrette, a psychologist who until October was the director of the Dying With Dignity Foundation in Colombia. “Now people here need to think about the system, and the services that are available, and what they will want.”

Changes in family structures and communities, particularly in rapidly urbanizing middle-income countries, mean that traditional networks of care are less strong, which shifts how people can imagine living in older age or with chronic illness, she added.

“When you had many siblings and a lot of generations under one roof, the question of care was a family thing,” she said. “That has changed. And it shapes how we think about living, and dying.”

How does assisted dying work?

Beyond the ethical dilemmas, actually carrying out legalized assisted deaths involves countless choices for countries. Spain requires a waiting period of at least 15 days between a patient’s assessments (but the average wait in practice is 75 days). In most other places, the prescribed wait is less than two weeks for patients with terminal conditions, but often longer in practice, said Katrine Del Villar, a professor of constitutional law at the Queensland University of Technology who tracks trends in assisted dying

Most countries allow patients to choose between administering the drugs themselves or having a health care provider do it. When both options are available, the overwhelming majority of people choose to have a health care provider end their life with an injection that stops their heart.

In many countries only a doctor can administer the drugs, but Canada and New Zealand permit nurse practitioners to provide medically assisted deaths too.

One Australian state prohibits medical professionals from raising the topic of assisted death. A patient must ask about it first.

Who determines eligibility is another issue. In the Netherlands, two physicians assess a patient; in Colombia, it’s a panel consisting of a medical specialist, a psychologist and a lawyer. The draft legislation in Britain would require both a panel and two independent physicians.

Switzerland and the states of Oregon and Vermont are the only jurisdictions in the world that explicitly allow people who are not residents access to assisted deaths.

Most countries permit medical professionals to conscientiously object to providing assisted deaths and allow faith-based medical institutions to refuse to participate. In Canada, individual professionals have the right to refuse, but a court challenge is underway seeking to end the ability of hospitals that are controlled by faith-based organizations and that operate with public funds to refuse to allow assisted deaths on their premises.

“Even when assisted dying has been legal and available somewhere for a long time, there can be a gap between what is legal and what is acceptable — what most physicians and patients and families feel comfortable with,” said Dr. Sisco van Veen, an ethicist and psychiatrist at Amsterdam Medical University. “And this isn’t static. It evolves over time.”

Jin Yu Young in Seoul, José Bautista in Madrid, José María León Cabrera in Quito, Veerle Schyns in Amsterdam and Koba Ryckewaert in Brussels contributed reporting.