Right to Life v Right to Die

INTRODUCTION

Overview

While euthanasia and assisted suicide are used interchangeably in some contexts, the two differ in that euthanasia is an all-encompassing concept that describes the active steps taken to end someone’s life. On the other hand, assisted suicide is like euthanasia where the only difference is that these steps are taken by the patient or the individual themselves with assistance from a third party that provides the means or offers information on the available means. As it can be inferred from the name, it is a form of suicide where an individual helped by another to take their own life. It is also important to point out that when the person who is to end their life requests for the procedure, it is classified as voluntary euthanasia.[1] As such, while assisted suicide involves helping someone take their own life at their request, while the person offering the help is a medic, it is referred to as physician-assisted suicide.

In most jurisdictions around the world, most forms of euthanasia and assisted suicide are outlawed with a few countries only allowing the practice as a relief from intolerable suffering and pain experienced for the terminally ill. Nevertheless, both euthanasia and assisted suicide are emotive and controversial topics with proponents supporting the practice as a relief from severe pain or suffering because of a terminal illness whereby death is foreseeable. On the other hand, opponents assert that with the development of medicine, palliative care should have the capacity to offer effective and efficient end-of-life care. [2] In any case, even when a patient wants to hasten their death, they can refuse treatment and other life prolonging mechanisms. A key example is when a patient signs a “Do not resuscitate” request. However, despite the ongoing controversy, assisted suicide is more available in several jurisdictions compared to euthanasia. In others, both assisted suicide and euthanasia are outlawed, and they can earn one a sentence on account of murder.

Focusing on the permissibility of physician-assisted suicide, ethically, the focus is mainly on the justifiability of euthanasia with most proponents relying on the utilitarian principle whereas opponents will usually rely on deontology.[3] Morally, the argument is mainly grounded upon the notion of the sanctity of life, and the moral permissibility of killing.[4] Legally, it is informed by the prevalent legislative and regulatory policies and the underlying assumptions. Mainly, the legality of euthanasia is tied to human rights arguments resulting in a split between the right to life and the implication of a right to die.[5] Proponents posit that euthanasia enhances the quality of life as it allows a patient to seek permanent relief from the pain and suffering experienced. Opponents hold that euthanasia is against the right to life and it may result in excesses since it is difficult to oversee the practice, which can result in doctors failing to offer the best end-of-life care. In line with this, the United Nations Declaration of Human Rights (UDHR) upholds that the right to life is universal and inalienable, therefore it cannot be taken away nor can one give it up. Conversely, proponents hold that euthanasia is permissible as it is an exercise of one’s autonomy over the course of their life.

All these proponent and opponent perspectives for euthanasia have a solid foundation that also offers a way to evaluate the dilemma presented by euthanasia to advance the debate on the permissibility of the practice and the prevalent considerations. Hence, using both England and Canada as case studies is key since they embody differing perspectives on the permissibility of euthanasia. This paper aims to advance this debate with a focus on the ethical, moral, and legal foundations for both faction and specifically, how these foundations inform the right to life versus the right to die debate.

Background

Adopted and ratified by the United Nations General Assembly in 1948, the UDHR became the first document to stipulate the fundamental human rights that ought to be universally safeguarded. As such, it serves as a foundation for human rights law for which it set out the basic human rights. Among these basic rights, the right to life is considered to be among the most important right, as it makes possible to enjoy the other rights.[6] As such, under international human rights, governments are mandated to put in place the necessary measures including legislative measures to safeguard this right through passing laws that protect individuals and also putting in place the necessary steps to protect one’s life if it is at risk.

At the same time, it is key to note that with the development of basic human rights; the right to life does not only entail being alive but also focuses on enhancing the quality of life especially in the advent of the democratic rule of law. This has resulted in the rise of key rights namely, the right to personal liberty and the right to self-determination. The right to personal liberty entails having the capacity to live freely without external interference and to some extent, the right to self-determination sets out how this should be attained that is, freely determining one's political, social, economic, and economic pursuits and development. In practice, the right to self-determination is the right to determine one’s destiny. [7]

However, since the ratification of the UDHR, new circumstances have emerged resulting in the rise of novel rights such as the right to health care, education, a clean environment among others, which are focused on enhancing the quality of life. In the same way, the development in medicine has resulted in advances on how to prolong and preserve life. However, to some extent, this translates to one enjoying a longer life but this does not necessarily translate to a better quality of life, especially during the end of one’s life as it is largely characterised by dependence, disgrace, debility, and more so for those with terminal illnesses.[8] When this is considered within the confines of the right to human dignity, which determines that personal honour, reputation, respect, and name should be protected, the quality of life during one’s end of life can be outlined to contravene this right especially for the terminally ill. In the same way, states are obligated to respect and safeguard the right to human dignity. When this is evaluated within the confines of assisted suicide, it can be conceptualized that it confers a right to die as a way to preserve one’s dignity by ensuring one dies on their terms.

Assisted suicide in Canada

In 2016, Canada legalised the voluntary form of euthanasia as a reprieve from the suffering experienced by terminally ill persons after which it was referred to as medical assistance in dying. Under Bill C-14, the parliament of Canada amended the Canadian Criminal Code to legalise physician-assisted suicide and physician-administered euthanasia as well as how both procedures can be accessed in Canada.[9] This amendment was pursuant to the Carter V. Canada case filed in the Supreme Court of Canada in 2015. The Supreme Court then ruled that it was important to change parts of the Criminal Code to ensure alignment with the Canadian Charter of Rights and Freedoms.[10] This change involved repealing the parts that prohibited and criminalized medical assistance in dying. The Supreme Court granted the government until June 6, 2016, to come up with new legislation on the matter.[11]

The trial judge evaluated whether the prevalent criminal prohibition to seek and to offer physician assisted suicide violates their rights to life, security and liberty as well as being against the right to equal treatment by and under the law as enshrined in the Canadian Charter of Freedoms. By extension, the trial judge declared that the prohibition deprives a competent adult of such assistance where they clearly consent to end their life and when one suffers from an irremediable and grievous condition that causes intolerable suffering. For such individuals, the trial judge ruled that the prohibition against physician assisted dying for such cases is unconstitutional since it deprives an individual of their right to life, liberty and security.

From a right to life perspective, the court held that it may cause individuals to prematurely take their own life in fear they would not have the chance to do so when the suffering becomes intolerable. From a right to liberty and security perspective, by denying a person the right to determine their bodily integrity, the law then impinges on their liberty. What is more, by forcing one to endure intolerable suffering it goes against the security of an individual. Hence, autonomy, quality of life and dignity are invoked. Finally, the trial judge also argued that the risk of abuse and error does not justify this criminalization, instead, she held that a properly run regulatory regime had the capacity to safeguard the vulnerable from the foreseeable abuses and errors of the practice.

Assisted suicide in England

In England, Northern Ireland, and Wales, assisted suicide is a crime. Whereas the courts have recognized the medical intricacies involved with medical treatment at the end of life, they hold that it is important for criminal law to safeguard the right to life whereby those in the medical profession should focus on treating a dying patient.[12] Hence, regardless of the motive, the law in these countries does not permit the taking of a life. An individual found culpable of aiding another to commit suicide count face a sentence of up to 14 years in prison. Under the 1961 Suicide Act, assisting or encouraging suicide or an attempt is an offence.[13] As a result, most of the individuals needing the procedure have had to travel to other countries to end their lives. 

Research aims and objectives

This research aims to advance the human rights debate on the permissibility of physician-assisted suicide by focusing on the moral, ethical, and legal foundations that underlie the decision to either allow or prohibit it. To attain this, this research inquiry will be guided by the following objectives.

• To determine the fluidity of ethical, legal, and moral principles as they relate to physician-assisted suicide.

• Determine the foundations upon which proponents and opponents ground their sentiments on physician-assisted suicide.

• Outline the influence of assisted suicide on the understanding and safeguarding of human rights.

Research questions

To evaluate the moral, legal, and ethical perspectives, and the relationship to how the right to life and right to die dichotomy is phrased with a focus on physician-assisted suicide, this research inquiry will be guided by the following research questions:

• What is the role of patient autonomy and competence in guiding the administration of the procedure?

• What is the relationship between assisted suicide and quality of life, and how does this inform the right to die?

• Is there a point where the right to die takes pre-eminence over the right to life?

Conclusion

To evaluate the right to life versus the right to die debate as informed by the ethical, moral and legal foundations of both factions, this dissertation will be split into five key sections. The literature review will provide the theoretical foundation that has been utilized by both factions to identify information gaps and trends that inform the development of the debate. The methodology section will then detail the rationale for the employed research methods and techniques utilized by the study. The findings and discussion section will then present the results from the research as well as overall inferences that can be drawn from these results when contextualized with the conclusions arrived at in the review of literature section. Finally, the conclusion will bring together the learning drawn from the research study with regards to how the divergent ethical, moral and legal foundations are influencing the right to life versus right to die debate as it relates to assisted suicide.

This approach is effective since from the introductory chapter, it can be outlined that while humanity is fundamentally influenced by the right to life as a basis for the enjoyment of all the other rights, changes and developments in society have gradually focused on enhancing the quality of life as opposed to ensuring the preservation of life. It is this gradual development that has led to questioning the degree to which death or the process of dying can be construed as being part of life. By extension, this influences the degree to which individuals, societies and governments alike determine the role one should have in their death if any, and to what extent the right to life implies a right to die.

LITERATURE REVIEW

Overview

Decisions surrounding death are very critical to humanity, especially the role of an individual or another party in inducing it. As such, assisted suicide and its forms have attracted attention from different perspectives, as it is both a controversial and highly emotive debate. Historically, the role of medicine has been for long entwined with the preservation of life. In practice, this role is defined by the predominant legal, ethical, personal, religious and sociocultural environment. Nevertheless, while a lot of progressivity is being evidenced in the world, the issue of assisted suicide invokes a similar change in trajectory in the medical field, which is significantly supported under a right to die perspective. That is, while no such right exists officially, assisted suicide is posited as an avenue to introduce this right with a significant moral and ethical justification. Similarly, the right to life is informed by moral and ethical underpinnings but this is an existed fundamental right as aforementioned. Hence, this section will present and evaluate literature on how the assisted suicide debate has matured into a human rights issue. Consequently, this will result in the development of theoretical framework that underpins each faction as well as generating insights on the trends on the permissibility of assisted suicide across jurisdictions.

Ethical considerations

At the core, ethics is focused on the objective understanding of right and wrong through the evaluation of one’s character against specific rules, actions or behaviours. Hence, an ethical evaluation of the issue will be grounded on evaluating the source of boundaries that support both opponent and proponent factions. This evaluation will uncover the reasons they both oppose and support assisted suicide respectively. In line with this, it is key to note that present-day professional ethos that is at the heart of the medical profession is the Hippocratic Oath. Among the ideals medical practitioners swear to in the Oath includes offering treatment to the best of their abilities and safeguarding life of their patients. As such, it ensures doctors do not pursue their self-interests and by extension, it breeds trust between a patient and a physician while also making sure a medical practitioner is committed to protect the life of their patient.[14]

However, it is key to note that present-day medicine has resulted in some realities that call for a contemporary approach, although there is no clear direction on how this should be structured in regard to permitting assisted suicide. That is, while advances in medicine have succeeded in coming up with mechanisms to prolong life, this does not necessarily result in an improved quality of life especially for those with terminal or degenerative diseases. [15] Hence, advances in medicine have resulted in the perception that society has attained a certain degree over death especially in regard to the advances made in palliative care.

The opponent perspective

Members of this faction are led by the understanding that during the routine care of individuals with both terminal and non-terminal illnesses, there exists both extreme and terrible circumstances. In such instances, it is posited that physicians should rely on the dictum outlined by Edward Livingstone Trudeau that is “to cure sometimes, to relieve often, and to console always.”[16] When this is evaluated within the context of assisted suicide, a physician should not prescribe or carry out the practice because a patient asks for it. By doing so, physicians sidestep from their role as professional and trusted healers and they become sheer providers of services on demand. As a result, when faced with extreme and terrible circumstances that terminal and debilitating illnesses can bring about, instead of resorting to offering or agreeing to assisted suicide, physicians should seek to preserve the measure of health that is possible while helping such patients bear the pain and the progressive loss of autonomy and bodily functioning. This is because, patients with such illnesses will often experience distress, unmet healthcare needs and duress which results in the clouding of their judgement by pain and fatigue.[17]

As aforementioned, ethics is entwined with an individual’s character. When this understanding is considered within the context of assisted suicide, it is posited that in the same way human activity influences one’s character and judgement, choosing to protect life or having the option to putting it to an end will fundamentally transform a physician. This is because being a physician is an autonomous decision on how to identify oneself with what entails medical practice. Specifically, the physician-patient relationship should be mediated by principles that safeguard the patient’s overall good.[18] Hence, it is asserted that a physician should have an innate respect for life, which should transcend a patient’s autonomy as a way to protect a patient from the power of medicine. In this regard, assisted suicide can be posited as a power of medicine that patients should be protected, that is, the power of medicine to end one’s life at will.

It is important to note that condoning assisted suicide is often phrased as a compassion argument for which the respect of life should transcend this. That is, by committing themselves to respect and safeguard life before allowing the influence of beneficence and compassion on their practice, a patient is protected from the influence of a physician’s ideologies as well as human weaknesses and frailties.[19] This is because, from the perspective of a patient, the decision to end their life on account that their life is no longer worth living is a value judgement and not a medical one. On the other hand, a medical professional agreeing to be complacent to the practice is inherently an exercise of personal value judgement.

What is more, when assisted suicide is permitted, it will stifle medical research. That is, traditionally, medicine has been grounded on the tenets of health restoration and suffering relief. This has not only influenced medical practice, but it has also driven medical research which is the reason different medical frontiers have been achieved. Hence, resigning to killing patients to relieve their suffering may result in the abandonment of the search for more effective forms of relief for patients with debilitating and terminal illnesses.[20] Collectively, this will reduce the quality of life for patients with these conditions who may be forced to consent to assisted suicide because medicine does not offer effective relief for the suffering they undergo. In line with this, the life prolonging advances made in the medical field will stagnate if not completely halted. Therefore, as with the case with suicide and suicide prevention, medical research has come to the determination that a desire to die is inherently a cry for help with regards to the meaning of life and a patient being in a perpetual state of hopelessness.[21] With this understanding, physicians should come to terms with a patient’s condition and understand that the desire to end their life is a maladaptive coping mechanism in search for peace of mind. However, the remedy is not giving into this, but striving to revisit and understand the changing healthcare needs of such a patient, whereby, the remedy should be focused on educating, supporting and engaging with a patient and not agreeing to end their life.[22],[23],[24]

Another key aspect is related to the position medical professionals take regarding capital punishment where they hold that it is unethical as it can result in an innocent person being executed. This is founded on the irreversibility of death. When this is related to assisted suicide, it is key to note that while an individual can be considered to be legally competent to consent to assisted suicide, this does not consider the undue influence of fear, worry, pain and fatigue on a patient’s decision making.[25],[26] What is more, it is reported in the Seattle Cancer Alliance report that from the 114 surveyed persons who had requested information on physician assisted suicide/dying, none of them wanted to move forward with the process even with a history or a diagnosis of clinical depression. Hence, this is to show that patients can and do change their minds. However, when the practice is legalised, it does not give room for this change of mind later on.[27] As with the case of capital punishment, the procedure being legal may result in a patient being killed because of a brief period of being influenced by psychological distress.

However, it is key to note that opponents do not disagree with the notion of one wanting to end their life, only how this is attained. This is because, it is considered ethical to withhold or withdraw life-prolonging treatment with the option of a patient taking pain-relieving medication for the pain that may be experienced. Also, medications that can inadvertently shorten one’s lifespan are considered ethical. Hence, for patients who are intent on ending their lives, they already have provisions how that can be attained. The only difference is that the death should not be intentionally carried out by the patient with the help of a physician.[28]

The proponent perspective

For proponent factions, under the inherent right to human dignity, one does by extension have a right to a dignified death. In the same way, it is outlined that we all have a mandate to mutually respect one another. When this is related to the debate on assisted suicide, it is outlined that respecting a patient should encompass the following dimensions, respect for their wishes, respecting the core values that drive their life, respecting their interests and having a concern for their wellbeing.[29] Therefore, if it is determined that a patient suffers from an incurable disease, death becomes inevitable. Consequently, when assisted suicide is sought, this does not negate the fact that the patient died because of the illness. Case in point, it is argued that when a poor person dies of hunger, it is outlined that they died of hunger and not poverty.[30]

Invoking the right to self-determination, it is outlined that an individual has an inherent right to take responsibility for their life. As such, since death is part of life, it should also fall under the purview of this right especially when death is foreseeable. [31] This is significantly founded upon the autonomy of will as the core of the nature of both human dignity and the mind. Therefore, it is argued that both the interests and the will of a patient should transcend the wishes of the doctors and legislators. In that, the best interest of the patient should not and cannot be limited by the perception of the physician since there are occurrences where a patient may want to shorten their life regardless of their existing healing possibilities. Where this is not respected, it translates to a restriction of their will.[32] Interestingly, a patient’s autonomy of will is evidenced by a patient electing to continue with treatment procedures even when a doctor informs them that death is inevitable. Hence, in the same way that the medical perception does not limit the decision to seek treatment, it should not limit the decision to end one’s life. By invoking the concept of autonomy of will and the right to self-determination, autonomy of will becomes a dominant factor that should be relied upon on whether a patient wants to accelerate their death or seek treatment despite suffering from a debilitation or terminal illness.

In line with this, it is posited that it is tyrannical for the death of an individual to be directed by the perception of others on what is justifiable. When this is considered within the assisted suicide debate, it can be asserted that one does not have the right to decide for another person whether their life is worth living or not.[33] This is because, pain and suffering can be bearable for one individual based on their values of life they adhere to but it can be unbearable to another person to a point that life ceases to have any value especially considering that it is outlined that 97 percent of all pain experienced by patients can be controlled, but 3 percent of the experienced pains remain and cannot be controlled.[34] By extension, these pains can be unbearable. Hence, it is difficult to determine with certainty whether the pain experienced by a patient due to the condition or illness is controllable and by extension, medical determination on the quality of life cannot be presumed true and thus it should not transcend the wishes of a patient.

When assisted suicide is conceptualized with regards to biomedical ethics, it can be supported especially under the beneficence principle, at least to some extent. That is, while beneficence alludes to healing and the prevention of sickness and injury, it is posited that assisted suicide can be of benefit to a patient since it is an act of mercy fuelled by compassion.[35] This argument especially has a foundation on the fact that physicians are supposed to have the capacity for empathetic imagination whilst maintaining their distance and respect for a patient to ensure they do not become pitiful. As such, when empathy lacks in a physician, the capacity to identify and tolerate a patient’s suffering is reduced and often leads to denial of patients in distress or their avoidance. Consequently, for proponent groups, assisted suicide becomes an act of compassion that seeks to respect a patient’s autonomy while also meeting the inherent mandate of non-abandonment.[36]

The morality of assisted suicide

Unlike ethics, which is objective, morality is subjective. That is, ethical considerations will evaluate one’s character against an external criterion whatever that may be to determine the permissibility of one’s conduct. On the other hand, moral considerations will focus on the subjective understanding on what constitutes right and wrong behaviour. As such, morality is often value driven. Nevertheless, it is key to note that morals influence and are the foundation for ethics but morals are not founded on ethical principles.

The principle of autonomy is also fundamental in evaluating the morality of assisted suicide. That is, while it has been outlined that the evaluation that one’s life is a value judgement and not a medical judgement, proponents of assisted suicide detail that it is also not possible to accurately ascertain that the medical judgement should take pre-eminence over a patient’s value judgement. Hence, in addition to being tyrannical to pigeonhole everyone’s death to take the course that others find acceptable, no one has the moral right to decide for another whether their life is worth living.[37] This is because, we all lead our lives in line with the values we find acceptable, which differ, from one individual to another. Therefore, while pain and suffering can be bearable to one individual, it may not be to another person as it may be incomparable with their values of life. From this argument presented by proponents, it can be further alluded to that, a decision that a patient arrives at must be morally acceptable to them.[38] Hence, there is no reason to deny a patient access to assisted suicide on account of the decision being immoral as that would be imposing another’s/societal values on such a patient.

Hence, proponents argue that at the end of life, the right to autonomy supersedes the claim that life must be preserved, this is especially so when the condition is terminal and death is imminent. As a result, the sacredness of life is also significantly impaired. In this sense, assisted suicide becomes moral as it allows such an individual to decide on the timing and manner of their death for the following ends, the deteriorating quality of life, avoidance of suffering and pain, safeguarding personal dignity, having a sense of control, and ensuring others remember a patient in the manner the patient wants to be remembered.[39]

Sanctity of life is also another key factor influencing the moral standing on assisted suicide. Specifically, owing to the degree of similarity between assisted suicide and murder or at least aiding the deletion of a life which is inherently immoral and wrong, this raises the concern over the role one or another party has over their life or that of another person. This is because, human life is conceptualized as an expression of divine will, as such, death should only follow the course of nature and it should not be intentionally caused by oneself or another individual. Therefore, doing otherwise is an exercise of human will on the law of nature, which is termed to be inherently immoral. [40] By extension, this means that individual autonomy cannot supersede the sanctity of life and according to opponent factions; life should not be shortened or terminated on account of a patient’s convenience or out of sympathy and compassion for a patient’s suffering.

While this argument can be countered by the notion that not all persons believe in God, it would be a fallacy to discount the role religion has had in shaping societal and individual moral values. This is not just in Christianity but different religions around the world which most if not all societies adhere to. In all these religions, human life is held to be sacred and not within the purview of human decision making in that, one cannot intentionally take their or another person’s life. Physician assisted suicide falls within this category, as a physician will oversee the intentional taking of a life. However, withholding or withdrawing life prolonging procedures does not invoke a similar moral dilemma since a life is not taken but it is nature that is left to take its course with an option to offer pain relief for the dying patient.

Role of the legislative and regulatory environment

Advances in medical ethics have made significant gains that allow medics to be accountable to their patients or kin on accounts of negligence, recklessness of culpable omission.[41] Also, criminal law regards the potential offense of homicide as a wrongful act resulting in the loss of life. By extension, where life is taken deliberately it is legally interpreted as murder. By extension, euthanasia meets all the conditions of a murder charge where the availability of consent or intentions of a medical practitioner are inconsequential to the charge.[42] What is more, when euthanasia is allowed, it presents a key legal concern over its abuse and the resultant slippery slope. Hence, even when it is allowed, there should exist laws that safeguard its misuse by medical practitioners. Therefore, it is key to note that the legislative and regulatory environment does not only influence the legality of assisted suicide but also how the practice is administered to ensure it is not misused or abused, especially for jurisdictions where it is permitted. On the other hand, for those jurisdictions where it is outlawed the legislative and regulatory environment point to the influence of ethical and moral principles in policymaking which are important in understanding how the assisted suicide debate is phrased in such jurisdictions.

Arguably, assisted suicide can be evaluated as an attempt at introducing another right, the right to die as an expression of personal liberty. By extension, this offers a foundation for the right to die making the criminalization of euthanasia a limit on one right to self-determination. However, by actively taking one’s life or getting medical assistance to do so, euthanasia goes against the legal principle of safeguarding one’s life which is a legal obligation extended to the state.

Conclusion

From the discussion, it is evident that both proponents and opponents have significant ethical, moral and legal foundations. Specifically, opponent factions focus on the right to life, whereby, assisted suicide is posited as a risk for the preservation of life. On the other hand, proponents focus on the right to autonomy and self-determination as a foundation for the proposed right to die. On the one hand, it is evident that regarding the permissibility of assisted suicide there is no clear direction on whether it should or it should not be permitted. On the other hand, assisted suicide has resulted in a healthy debate regarding the confines of the right to life if any and whether the right to die has any moral or ethical foundations. This is because, the debate has forced humanity to re-evaluate the role of legal, moral and ethical dimensions in healthcare and how this influences the conceptualization of quality of life both perceived and as experienced by patients especially the role of societal norms, as well as the capability and competence of a patient as they relate to assisted suicide. 

METHODOLOGY

Research design

Considering the complexity of the research question, the research study will utilize comparative law as it is focused on the examination of legal systems as well as how they influence and relate to social sciences. This examination of the legal systems is focused on identifying both the points of convergence and divergence in the different jurisdictions. This is because, there is a need to evaluate the ethical, moral and legal foundations underlying the decision to allow and prohibit physician-assisted suicide in Canada and England respectively. As such, the result is an objective and holistic understanding of a phenomenon under study since it will contribute to an understanding of how ethical, legal and moral principles influence the right to life versus right to die arguments.

Data collection and analysis

The research will adopt a variation-finding comparison approach across the three meaning making factors, ethics, morality and legal systems. Therefore, both England and Canada will be compared on ethical, moral and legal principles on active euthanasia, with a specific focus on physician-assisted suicide. With regard to data collection, ethical and moral principles will be inferred from public sentiment as recorded in secondary data such as news sources, government publications among others. Legal disparities will then be evaluated from case law from both England and Canada that relate to physician-assisted suicide. Finally, statistical sources will be consulted for trend analysis evaluations on issues that relate to physician-assisted suicide in both countries.

On the other hand, data analysis will follow a comparative approach. Based on the stipulated research questions, the countries will be evaluate based on how they relate on the themes being explored by the research questions. This will then be used to inform the position of both countries on the right to life and right to die dichotomy. By extension, it offers a conceptual framework on how the ethical, moral and legal environment influences the position a society takes on physician-assisted suicide.

Ethical considerations

The conduct of a researcher and the believability of findings significantly influence the validity and reliability of research. This is what grounds the importance of ethical standards for research studies. Therefore, as outlined by World Health Organization, research ethics determine the standards researchers should adhere to which outlines the need for an ethics committee to ensure adherence to these standards.[43] As a result, this research inquiry will adhere to the ethical guidelines stipulated by the university. In addition, since this research is significantly founded on secondary data, it will be founded on the tenets of academic attribution whereby, all ideas that influence the inference formation process will be accurately referenced. This is in the interest of upholding academic integrity while also capitalizing on previous works to create a key foundation to approach the phenomenon under study.

Conclusion

The legislative environment is significantly grounded on human rights with nations charged with the mandate of safeguarding these rights and people are expected to adhere to the rule of law in their exercise of the rights. As aforementioned, the rule of law can be influenced by the prevalent moral and ethical sentiments, but it can also be independent from being influenced by ethical and moral sentiments. From the background, it can be outlined that the legal stance in the UK is significantly influenced by the prevalent moral sentiments especially regarding the conceptualization of the sanctity of life and the right to life. On the other hand, Canada can be perceived as being legally progressive. Therefore, it is envisioned that using comparative law will be instrument in highlighting how the laws differ between Canada and UK regarding the permissibility of assisted suicide. Regarding the identification of the points of convergence and divergence from a moral, legal and ethical stance, the variation finding comparison approach is deemed effective and viable. This serves to ensure both the validity and reliability of the research study, which also outlines the importance of ethical consideration in how the research study was conducted.

FINDINGS AND DISCUSSION

This section will focus on legal analysis of assisted suicide in the UK and Canada by looking into the statutes, legal policies and case law in both jurisdictions. As a result, this section will offer an accurate comparison of the law in both countries whilst also juxtaposing it against prevalent theoretical foundations. Guided by the following research objectives, this section will focus on outlining the degree to which UK champions the right to life whilst Canada offers a foundation for the right to die, and the role played by changing public sentiments on assisted suicide if any.

• To determine the fluidity of ethical, legal, and moral principles as they relate to physician-assisted suicide.

• Determine the foundations upon which proponents and opponents ground their sentiments on physician-assisted suicide.

• Outline the influence of assisted suicide on the understanding and safeguarding of human rights.

Right to life v right to die: The UK perspective

Suicide Act 1961

Section (1) of the Act abrogated the rule of law where it was traditionally a crime for one to commit suicide. As such, for individuals who are not successful in their attempt to take their own life, they are not sentenced. However, section 2 of the Act as amended by the Coroner and Justice Act (1988) still maintains that assisted suicide is a crime.

The European Convention on Human rights (ECHR) and the Human Rights Act 1998

In 1953, the ECHR entered into force across Europe’s member states, and it served as a key foundational document for the Human Rights Act enacted by the UK government in 1998. However, it is important to note that while the enshrined rights are grounded on the articles of the ECHR, the Act also allows judges to read and propose other laws that are compatible with those stipulated in the convention while also holding that it is unlawful for a public authority to act in a way that does not align with the convention. Hence, in addition to the act serving as a safeguard for human rights by empowering one to defend their rights in a court of law, it also compels public organizations including the government to treat everyone equally, fairly, as well as with dignity and respect.

Specifically, section 4 of the Act allows a higher court (the high court, the court of appeal or the supreme court) to consider if a legislative provision is incompatible with human rights as enshrined in the ECHR. In the event it is, a declaration of incompatibility is made. Nevertheless, such a ruling does not take pre-eminence for the case being argued due to the provisions set out in section 4(6). This is to mean that even when a declaration of incompatibility is made, the law does not change instantaneously. Instead, Parliament has the last say as it decides if it wishes to amend the law.

Case law

R (Purdy) v DPP [2009] UKHL 45

The applicant, Debbie Purdy, wanted to die following her diagnosis of primary progressive multiple sclerosis. While her condition was incurable, her decision was informed by an assessment that it would come a time when her existence would be unbearable. However, for the purposes of the case, she was seeking immunity from prosecution for her husband, as she wanted to travel to a country where the practice was legal but because of the phrasing of the section 2(1) of the Suicide Act 1961; her husband’s help would be considered aiding and abetting which is currently outlawed. However, section 2(4) of the Act also states, “no proceedings shall be instituted for an offence under this section except by or with the consent of the Director of Public Prosecutions.” Therefore, for the purposes of this case, the appellant sought the disclosure of the criteria the DPP would use in determining whether to prosecute. This is despite that the DPP had not pursued those who had committed a similar offence in the past. The applicant also argued that both sections 2(1) and 2(4) contravened article 8(2) of the EHCR.

To this, the House of Lords relied on the precedent set forth in R (Pretty) v Director of Public Prosecutions (Secretary of State for the Home Department Intervening) [2002] 1 AC 800 where it was held that art 8 was focused on safeguarding personal autonomy in the course of one’s life, but this did not confer a right to decide when or how to die and hence, section 2(1) was not an infringement on the right to privacy. What is more, with regard to the principle of legality based on art 8(2) the House of Lords held that the Code was not written in the context of s 2(1) of the Suicide Act and the DPP was ordered to come up with a set of guidelines for the Suicide Act (1961) to determine the risk of prosecution in the event the applicant’s husband helped her end her life. In line with this, the House of Lords ruled that the applicant had the right to determine how to end her life as it is part of living, and this should be respected.

Regarding the legality of section 2(1), the lack of a crime specific policy did not make the Act unlawful or not in accordance with the law. What is more, Lords Nueberger and Hope further stipulated that it was not their mandate to change the law to decriminalize assisted suicide which remains a matter for the consideration of the parliament. Hence, their role in the matter is to say what the law is and when need be, clarify it.

R (Nicklinson) v Ministry of Justice [2014] UKSC 38

The applicant, Tony Nicklinson, had suffered severe stroke back in 2005 and following his paralysis from the neck down, he sought to end his life but it was impossible to do so without suicide. However, this was also not possible as taking part in the suicide of another person is currently a criminal offence under section 2 of the Suicide Act. In concept the case was similar to Purdy, but the reprieve sought was different as Nicklinson applied for a declaration that would make it legal for medical practitioners to assist in his suicide or have the prevalent legal regime deemed incompatible with Art 8 of the ECHR.

However, drawing on the parliamentary supremacy as held in UK’s constitutional law a majority of five justice held that while the court does have a constitutional authority to make a declaration of incompatibility on the general prohibition of assisted suicide, they ruled that parliament was better aligned to assess the issue compared to the courts. With regard to this, it was unanimously held that the concern of assisted suicide does not fall under UK’s margin of appreciation, and it also does not engage Art 8 of the ECHR.

With regards to the failure to engage art 8, the court relied on the Pretty v UK Case to outline that there was no violation of the article owing to the ban on assisted suicide since the interference is justified as necessary in a democratic society for the protection of the rights of others. For the case of invoking the margin of appreciation, it is important to note that it is a provision to balance individual rights with national interests whilst resolving potential conflicts. Similarly, even upon appeal the European Court will usually refer to the decision by the state which is also captured in the appeal decision by the European Court of Human Rights. That is, while the court found that the question on assisted suicide did fall under the state’s margin of appreciation, it was held that requiring domestic courts to provide a judgement on the merits of such a complaint would invariably force an institutional role not foreseen by the constitutional order. Hence, the ruling by the Supreme Court that parliament was the best place to decide on assisted suicide based on its ethical, social, and philosophical nature was upheld as an effective way to deal with the compatibility of primary legislation and the Convention.

R (Conway) v Secretary of State for Justice [2017] EWHC 2447

For this case, the applicant, Mr. Douglas Conway suffered Motor Neuron Disease characterised by the progressive degeneration of nerve cells responsible for voluntary muscle movement making him require increasing levels of assistance with eating, control of bodily functions and daily life. Therefore, like the previous cases where the applicants sought a declaration of incompatibility for section 2(1) of the Suicide Act. Mr Conway’s argument was grounded on section 4 of the Human Rights Act 1998. Hence, he invokes article 8 of the EHCR to prove that the blanket ban is an interference on his right for private life grounded on the Hass v Switzerland (2011) 53 EHRR 33 case where it was argued that the right to decide how and when to die is an aspect of private life within article 8 of the Convention.

However, by relying on Nicklinson v United Kingdom (2015) 61 EHRR SE7, the court ruled that while there was an interference on his private life as enshrined in Article 8(1) of the ECHR, the interference is justified under Article 8(2) of the Convention which was also confirmed by the European Court of Human Rights when the court sustained the ruling on Nicklinson by the domestic court. Specifically, the prohibition was deemed necessary to protect the weak and vulnerable, to safeguard the sanctity of life, and to grant assurance to patients on the ethical standards that mediate the patient-physician relationship, which is critical in the provision of appropriate care.[44]

Trends in public sentiment

Public opinion in the UK on assisted suicide is significantly controversial. This is because of the influence of context on the position one takes on assisted suicide. Overall, doctors and the public support assisted suicide. That is, doctors should be allowed to attend to the wishes of a patient with terminal illness and experiencing insufferable pain to end their lives. In the same way, assisted suicide services should be available for patients who may need them. However, support significantly drops, from 80 percent to 45 percent, for patients who suffer from incurable and painful conditions but not terminal.[45]

In addition to the nature of the condition, the degree of information at the disposal of an individual also reduces support for assisted suicide. Case in point, empirical arguments against the practice resulted in a drop in support from 73 percent to 42 percent.[46] This shows quite an erratic support for the practice whereby, even though there is some degree of acceptance, the public also prefers to err on the side of life as opposed to legalizing the practice in the prevalent legally, morally, and ethically ambiguous and diverse environment on assisted suicide. Therefore, while public sentiment in the UK is not explicitly against assisted suicide, in that, there is an innate support for assisted suicide for terminally ill and mentally competent adults.[47] However, there is a need for strict safeguards to be put in place before assisted suicide can be considered for legalisation. This goes to the UK population is more inclined towards the preservation of the quality of life that is possible to be preserved in addition to not holding a right to life as equally conferring a right to die.

Right to life v right to die: The Canadian perspective

The Constitution Act 1982

The Canadian Charter of Rights and Freedoms is the foundational document that informs this legal policy, which is accurately captured in section 1. With regards to the arguments presented in support of assisted suicide, Section 7 confers everyone a right to life, liberty, and security as well as the right not to be deprived of either in line with the principles of fundamental justice.

Criminal code

This stipulates the federal laws of Canada by codifying most of criminal procedures and offences. With regards to assisted suicide, the practice is still outlawed in Canada as set out in Section 241(1), but an exemption for physician-assisted suicide is was introduced to the criminal code under section 241(2).

Case law

Rodriguez v. British Columbia (Attorney General), [1993] 3 S.C.R. 519

The applicant was a 42-year-old woman suffering from amyotrophic lateral sclerosis (ALS) who sought to have the court allows her to seek medical assistance in dying when her condition deteriorated that she was no longer able to enjoy life. She sought for the invalidation of section 241 (b) of the Criminal Code as it violates her rights under section 7 of Constitutional Law and section 12 which states “Everyone has the right not to be subjected to any cruel and unusual treatment or punishment.” Which living in insufferable pain amounted to.

However, the court dismissed the appeal where it held that section 241(b) was constitutional, and it did not contravene any of the rights set out under section 7. Specifically, the court ruled that the interests captured in section 7 cannot be considered separately from sanctity of life, which implies that one should not have a conscious choice over death whereby life is a value. Therefore, the court ruled that a blanket prohibition serves to balance the interests of the state and those of the individual. Thus, it allows the government to meet its mandate of protecting the vulnerable, which is informed by the interest of the state to protect life. As such, allowing life to be taken depreciates this objective.

Finally, with regards to section 12, the court held that the section relates to a situation where an individual is subject to the state’s justice or administrative system. Hence, the matter fell outside the bounds of the provision.

Carter v Canada (Attorney General), 2015 SCC 5, [2015] 1 SCR 331

As was the case with the prior case, the applicant challenged the constitutionality of the provisions set out in the criminal code that prohibited assistance in dying. Specifically, section 241 (b) and section 14 which states that no one can consent to death being exacted on them. For this case, the trial judge ruled that the prohibition against physician assisted suicide/dying was a contravention of section 7 of the Charter for a competent adult who clearly consents and has a grievous and irremediable medical condition that results in intolerable and enduring suffering. With regards to the provisions offered in section 1 that the Rodriguez case had relied on, the trial judge round that the infringement caused by the prohibition cannot be justified by section 1 of the Charter. In addition to finding the prohibition unconstitutional, the trial judge went on to grant a year long suspension of invalidity whilst also offering the applicant a constitutional exemption.

Based on the legal doctrine of stares decisis, the dissenting judge concluded that the trial judge was bound by the conclusion made in Rodriguez v. British Columbia (Attorney General), [1993] 3 S.C.R. 519 that any infringement by the prohibition was justifiable under section 1 of the charter. However, it is presented that the trial judge was entitled to re-examine the Rodriguez ruling. This is because, there exists a provision that trial courts can reconsider settled rulings by higher courts, “(1) where a new legal issue is raised; and (2) where there is a change in the circumstances or evidence that fundamentally shifts the parameters of the debate.” And both conditions were satisfied in the current case. That is, the legal concept of section 7 had changed, and the legislative and social facts the case was grounded on differed in comparison with the evidence presented in Rodriguez.

Bill C-14

This legislation on medical assistance in dying was prepared in response to the evidence presented in, and the ruling made for the Carter case. As such, it was aimed at ensuring there is a balance between autonomy of those seeking the procedure and the protection of vulnerable persons and society. This was attained through the amendment of the Criminal Code to permit nurse practitioners and physicians to help in dying for competent adults as stipulated in the safeguards.

Nevertheless, as opposed to repealing section 241 of the Criminal Code, an exemption under the section was incorporated to absolve any medical or nurse practitioners as well as those who would aid them in helping suicide from criminal culpability. Hence, in essence the legislature still maintains that assisted suicide is illegal unless conducted by a medical or nurse practitioner. Subsections 241.2(1) and 241.2(2) were also suggested to set out some eligibility criteria to allow competent adults suffering intolerably, whose natural death is foreseeable, and are at an advanced state of irreversible decline in their capability to seek medical assistance in dying if they wish to. 

Bill C-7

This proposed legislation seeks to expand access to medical assistance in dying by amending the eligibility to include individuals experiencing intolerable suffering although their condition is not terminal. However, the bill still maintains a ban for the individuals whose only diagnosis is mental illness. This amendment is in response to a Quebec Superior Court ruling, Truchon v. Canada (2019). In this case, Justice Christine Baudouin ruled that the requirement for patients to prove that their natural death was “reasonably foreseeable” was unconstitutional as it infringed on their “life, liberty and security.” As a result of the ruling, the court ruled that these shortcomings should be addressed before December 18, 2019. Under the new bill, individuals with degenerative diseases would now have access to medical assistance in dying. With this introduction, as with the case with terminally ill patients, those suffering from degenerative diseases have to prove they are experiencing intolerable suffering.

Trends in public sentiment

Morality and ethics largely operate at the societal level. Although Canada has permitted assisted suicide, religion is still a significant factor that impacts attitudes even among medical practitioners. That is, there is less resistance to withdraw treatment compared to actively being involved in assisted suicide and its forms.[48] Religion was found to be a key predictor variable for the willingness of a practitioner to participate in assisted suicide. That is, those strictly practicing religion were less willing to participate. In addition to this, the concern for vulnerable patients, the impact it would have on the physician/patient therapeutic alliance, and personal moral objections are also key factors that influence the objection to assisted suicide.[49] With regards to the support of assisted suicide, most physicians support it for some general circumstances but not for mental illness, which the legislation covered by outlining that mental illness diagnosis by itself is not grounds enough to request for assisted suicide.

With regards to members of society, it is held that assisted suicide is only ethical when it is limited to competent, informed adult patients who voluntarily elect to have the procedure to alleviate their intolerable suffering and terminal illness.[50] What is more, patients suffering from terminal and debilitating illnesses were outlined to have contemplated suicide and they find it morally acceptable, hence supporting its legalisation. For patients, prior palliative care involvement served as a positive indicator for the consideration of assisted suicide.[51] In this regard, it is evident that the right to personal liberty and autonomy are key underlying factors that influence the ethical and moral evaluation of the assisted suicide, which has significantly influenced the right to die formulation.[52] That is, since it is subjective whilst also being influenced by norms especially religious norms, there is a significant compartmentalization with an overall support for the legalisation of assisted suicide albeit there existing some concerns. Hence, ethically and morally, life and death are perceived as though they exist on the same plane but on opposite ends but still within the confine of human will and the legislature.

Discussion

To some degree, the law in both countries has more similarities than differences but the difference is mainly how it is implemented. Inherently, both the UK and Canada have taken different stances to protect vulnerable populations. That is, Canada has taken a form of harm reduction whilst UK has adopted an absolutist position on the issue. With regards to the infringement of rights such as liberty and dignity, Canada has argued that prohibition of assisted suicide goes against the enjoyment of these rights and hence it cannot be justified under Section 1 of its Charter. Conversely, the UK outlines that article 8(2) justify these infringements as necessary. What is more, Canadian judicial system offers an avenue to re-examine a case despite their existing a precedent based on the facts of the case. On the other hand, it is not clear if UK has such a provision and if it does, it has not yet been invoked owing to the overarching view on the sanctity of life shared by most groups in UK. 

From both an ethical and a moral stance, it is key to note that both opponents and proponents have an understanding that terminal and debilitating conditions can result in intolerable suffering and pain. However, both these factions as evidenced by UK and Canada differ on how a solution to this is sought. What is more, it is key to note that the permissibility of assisted suicide is determined by the prevalent legislative environment whereby, as aforementioned, this does not explicitly rely on the ethical and moral evaluation of an action. This is evidenced by Canada whereby, while in both countries there is some degree of criticism for assisted suicide especially for religious reasons among both the public and physicians, Canada has gone ahead to legalise assisted suicide and is currently working on how to enhance the breadth of access to assisted suicide to more patient categories.[53] This is after the Supreme Court ruled the prohibition was a contravention of an individual’s basic rights in the Carter v. Canada case. What is more, the ruling established that the sanctity to life covered death. Hence, making a decision on when and how to die becomes also a life-decision. In this way, the Canadian Supreme Court did away with the pre-eminence of the right to life, stipulating that absolute outlawing transforms the right to life to a duty to live, which is unconstitutional.

Consequently, through the right to autonomy, personal liberty and self-determination, Canada has gone on to show that a right to life implies a right to die. In the interest of ensuring flexibility to the progressive views Canadians have over the sanctity of life and to respect the right to autonomy, the Canadian have set out a legislative foundation for the right to die. However, in an understanding that the practice brings with it a slippery slope, the country has sought to protect the vulnerable by maintaining the illegality of assisted suicide with the only exception being physician-assisted suicide, which is an attempt at the preservation of life, especially from the influence of undue influence from friends, family and society. From a Canadian perspective, the right to die is not presented as an antithesis to the right to life, but it structured with regards to how they can both coexist.

Conversely, the UK has contributed to the right to life vs. the right to die dichotomy by structuring the right to die as a risk for the preservation of life. This is evidenced by the overall lack of support not only for the legalisation of the procedure, but also its administration. That is, if there are no effective safeguards for the risks presented by the legalisation of assisted suicide both with regards to its misuse and to vulnerable populations, the costs are perceived as being higher than the benefits.[54] Instead, UK physicians and the public while they do support the progression, they outline that it is much safer to improve end of life care services. Hence, unlike Canadians, UK leans more towards the preservation of life but they also outline that quality of life is important for which the support for physician-assisted suicide for terminally ill individuals receives significant support.[55] However, with the existence of procedures such as withdrawal of life support and the right to decline treatment for patients, it is posited that the legal environment has the necessary affordances for patients with terminal and debilitating conditions.

CONCLUSION AND RECOMMENDATIONS

Debates surrounding the role people should play in the termination of their life or that of another have historically been approached with great caution and have often been controversial. The issue of assisted suicide is one such issue in contemporary society. This is because medical advancements have significantly enhanced life expectancy rates both from advances in the pharmaceutical field and the continued enhancement of life prolonging techniques. However, for some individuals, those suffering from debilitating and terminal conditions, the increased number of years does not translate to enhanced quality of life. This is because these conditions influence one’s capacity to enjoy their life due to intolerable suffering and the gradual inability to tend to oneself and hence continued reliance on the help of others. However, while the right to life is inherent and inalienable, continued developments in society and legislature have focused on not only the preservation of life but also enhancing the quality of life. This debate has furthered this regarding whether allowing patients suffering from degenerative or terminal conditions is against their right to life or whether the decision on when and how to die is part of life making this provision in accordance with the right to life focused on enhancing the quality of life for such individuals.

Literature on this dilemma has shown that the decision on the permissibility of assisted suicide is ethically, morally, and legally justifiable which shows the fluidity of these principles. Specifically, proponents of the legalization of assisted suicide have mainly presented the issue as an exercise of one’s autonomy over the course of their life. On the other hand, opponents have been mainly influenced by the concept of the sanctity to life, which is interpreted to infer an absolute mandate for the state to ensure the preservation of life, which is grounded on the perception that one should not have the right to intentionally consent to the termination of their life.

This is accurately embodied by the positions taken by the UK and Canada. While the practice is outlawed in both countries, Canada has an exemption that allows terminally ill individuals to seek medical assistance in dying, and that absolves medical and nurse practitioners any criminal culpability for offering assisted suicide. This is because, the Supreme Court found the blanket provision against the right to liberty and autonomy for such individuals who may need such services because of the unbearable life they were leading. Conversely, the UK holds that while the prohibition does infringe on these rights, the infringement is justifiable for the protection of the weak and vulnerable. Hence, these two countries embody the right to life versus the right to die debate from where it is evident the role played by moral and ethical principles as well as that of the legal framework in a country.

Innately, the right to life versus the right to die debate as it relates to physician-assisted suicide embodies the conservative vs. liberal debate. This is because, the sanctity of life as it relates to religion significantly influences overall support for the assisted suicide. Other key factors are the concern for vulnerable patients, the impact it would have on the physician/patient therapeutic alliance, and personal moral objections of physicians. However, with regards to how moral, ethical and legal perspectives influence the position adopted on the permissibility of physician-assisted suicide, it can be outlined that both factions have valid ethical, moral and legal foundations with none being better than the other.

Nevertheless, it can be outlined that the right to life vs. the right to die debate has contributed to the understanding of the quality of life in assessing the worthiness of a life. In line with this, there is some degree of consensus that terminally ill patients whose death is foreseeable should be allowed to seek physician-assisted suicide and physicians should be allowed to administer it to such patients. However, caution should be applied for vulnerable patients such as those with debilitating and mental conditions who experience pain and suffering although these conditions are not terminal.

Therefore, while ethical, legal and moral principles are fluid to some degree, religiosity was found to significantly influence moral evaluations whilst value maximization/harm reduction significantly influence ethical foundations. With regards to the permissibility of physician-assisted suicide, the right to life vs. right to die are the key perspectives that underlie legal reforms or the lack thereof. Nevertheless, it is outlined that these principles have influenced the degree to which the right to life and right to die are perceived as either an antithesis of each other or whether they can coexist with either serving to temper the excesses of other.

BIBLIOGRAPHY

Table of Authority

Legal instruments

Coroner and Justice Act (1988)

Criminal Code, RSC 1985

Human Rights Act (1998)

Suicide Act (1961)

The Constitution Act 1982

The European Convention on Human rights (ECHR)

Cases

Carter v Canada (Attorney General), 2015 SCC 5, [2015] 1 SCR 331

Hass v Switzerland (2011) 53 EHRR 33

Nicklinson v United Kingdom (2015) 61 EHRR SE7

R (Conway) v Secretary of State for Justice [2017] EWHC 2447

R (Nicklinson) v Ministry of Justice [2014] UKSC 38

R (Pretty) v Director of Public Prosecutions (Secretary of State for the Home Department Intervening) [2002] 1 AC 800

R (Purdy) v DPP [2009] UKHL 45

Rodriguez v. British Columbia (Attorney General), [1993] 3 S.C.R. 519

Truchon v Canada 2019 QCCS 3792

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FOOTNOTES

[1] Nicola Davis, 'Euthanasia and Assisted Dying Rates Are Soaring. But Where Are They Legal?' (The Guardian, 2019) <https://www.theguardian.com/news/2019/jul/15/euthanasia-and-assisted-dying-rates-are-soaring-but-where-are-they-legal> accessed 25 January 2021.

[2] Ibid.

[3] Nargus Ebrahimi, 'The Ethics of Euthanasia' (Australian Medical Student Journal, 2012) 477-478 <https://www.amsj.org/archives/2066> accessed 9 January 2021.

[4] Adam Greif, 'The Morality of Euthanasia' (2019) 26 Organon F.

[5] Robert Young, 'Voluntary Euthanasia (Stanford Encyclopedia of Philosophy)' (Stanford Encyclopedia of Philosophy, 2020) <https://plato.stanford.edu/entries/euthanasia-voluntary/> accessed 9 January 2021.

[6] 'OHCHR | What Are Human Rights' (Ohchr.org, 2020) <https://www.ohchr.org/en/issues/pages/whatarehumanrights.aspx> accessed 25 January 2021.

[7]Young (n 5).

[8] Leon R. Kass, 'Is There A Right to Die?' (1993) 23 The Hastings Center Report. 34-43.

[9] Health Canada, 'Medical Assistance in Dying - Canada.Ca' (Canada.ca, 2020) <https://www.canada.ca/en/health-canada/services/medical-assistance-dying.html> accessed 9 January 2021.

[10] Carter v Canada (Attorney General), 2015 SCC 5, [2015] 1 SCR 331 [Carter].

[11] n 9.

[12] Alexander McCall Smith, 'Euthanasia: The Law in The United Kingdom' (1996) 52 British Medical Bulletin. 334-340.

[13] 'The Law - Dignity in Dying' (Dignity in Dying, 2020) <https://www.dignityindying.org.uk/assisted-dying/the-law/> accessed 9 January 2021.

[14] Angelika Albaladejo, 'Fear of Assisted Dying: Could It Lead to Euthanasia on Demand or Worsen Access to Palliative Care?' [2019] BMJ <https://www.bmj.com/content/364/bmj.l852/rr-1> accessed 4 February 2021.

[15] Julia Nicol and Marlisa Tiedemann, 'Euthanasia and Assisted Suicide in Canada' (n 1)

[16] Ibid.

[17] Ibid.

[18] Lois Snyder, 'Bioethics, Assisted Suicide, And The “Right to Die”' [2001] Annals of Clinical Psychiatry.

[19] Albaladejo (n 14).

[20] Snyder L, 'Bioethics, Assisted Suicide, And The “Right to Die”' [2001] Annals of Clinical Psychiatry.

[21] Albaladejo (n 14)

[22] Mark A. O’Rourke, M. Colleen O’Rourke and Matthew F. Hudson, 'Reasons to Reject Physician Assisted Suicide/Physician Aid in Dying' (2017) 13 Journal of Oncology Practice, 683-686, <https://ascopubs.org/doi/10.1200/JOP.2017.021840> accessed 4 February 2021.

[23] Marie-Estelle Gaignard and Samia Hurst, 'A Qualitative Study on Existential Suffering and Assisted Suicide in Switzerland' (2019) 20 BMC Medical Ethics <https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-019-0367-9>.

[24] Snyder (n 20)

[25] Jonathan V. Llamas, 'The Dilemma of Physician-Assisted Suicide' (Medpagetoday.com, 2018) <https://www.medpagetoday.com/nursing/nursing/76398> accessed 4 February 2021.

[26] Mark A. O’Rourke, M. Colleen O’Rourke and Matthew F. Hudson, 'Reasons to Reject Physician Assisted Suicide/Physician Aid in Dying' (n 22)

[27] Ibid.

[28] D Harris, B Richard and P Khanna, 'Assisted Dying: The Ongoing Debate' (2006) 82 Postgraduate Medical Journal.

[29] Božidar Banović, Veljko Turanjanin and Anđela Miloradović, 'An Ethical Review of Euthanasia and Physician-Assisted Suicide' (2021) 46 Iranian Journal of Public Health <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5402774/> accessed 4 February 2021.

[30] Ibid.

[31] Young (n 5)

[32] Božidar Banović, Veljko Turanjanin and Anđela Miloradović, 'An Ethical Review of Euthanasia and Physician-Assisted Suicide' (n 29)

[33] Maria Vangouver, 'Physician Assisted Suicide - Ethically Defendable or Not? A Qualitative Ethical Analysis' (Undergraduate, Orebro University 2019).

[34] Božidar Banović, Veljko Turanjanin and Anđela Miloradović, 'An Ethical Review of Euthanasia and Physician-Assisted Suicide' (n 29)

[35] Vangouver (n 33).

[36] Ibid.

[37] Božidar Banović, Veljko Turanjanin and Anđela Miloradović, 'An Ethical Review of Euthanasia and Physician-Assisted Suicide' (n 29)

[38] Ibid.

[39] Martin Levin, 'Physician-Assisted Suicide - Moral, Legal & Ethical Issues' (Levin Papantonio Rafferty - Personal Injury Law Firm, 2001) <https://www.levinlaw.com/physician-assisted-suicide-legality-and-morality> accessed 4 February 2021.

[40] Adam Greif, 'The Morality of Euthanasia' (2019) 26 Organon F.

[41] Smith (n 12).

[42] Ibid.

[43] 'Ethical Standards and Procedures for Research with Human Beings' (World Health Organization, 2021) <https://www.who.int/ethics/topics/research/en/>.

[44] R (Conway) v Secretary of State for Justice [2017] EWHC 2447

[45] Katherine Sleeman, 'The Murky Issue of Whether the Public Supports Assisted Dying' (The Conversation, 2017) <https://theconversation.com/the-murky-issue-of-whether-the-public-supports-assisted-dying-85279> accessed 16 February 2021.

[46] Ibid.

[47] Panagiotis Pentaris and Lucy Jacobs, 'UK Public’s Views And Perceptions About The Legalisation Of Assisted Dying And Assisted Suicide' [2020] OMEGA - Journal of Death and Dying <https://www.researchgate.net/profile/Panagiotis_Pentaris/publication/343416079_UK_Public's_Views_and_Perceptions_About_the_Legalisation_of_Assisted_Dying_and_Assisted_Suicide/links/5f290a2ca6fdcccc43a8a1c8/UK-Publics-Views-and-Perceptions-About-the-Legalisation-of-Assisted-Dying-and-Assisted-Suicide.pdf> accessed 16 February 2021.

[48] Patricia Hizo-Abes, Lauren Siegel and Gil Schreier, 'Exploring Attitudes Toward Physician-Assisted Death in Patients with Life-Limiting Illnesses with Varying Experiences of Palliative Care: A Pilot Study' (2018) 17 BMC Palliative Care <https://bmcpalliatcare.biomedcentral.com/articles/10.1186/s12904-018-0304-6#:~:text=On%20February%206th%2C%202015%2C%20the,as%20medical%20assistance%20in%20dying%2C>.

[49] Skye Rousseau and others, 'A National Survey of Canadian Psychiatrists’ Attitudes Toward Medical Assistance in Death' (2017) 62 The Canadian Journal of Psychiatry.

[50] Legislative Background: Medical Assistance in Dying (Bill C-14) (Government of Canada 2021) <https://www.justice.gc.ca/eng/rp-pr/other-autre/ad-am/ad-am.pdf> accessed 13 February 2021.

[51] Patricia Hizo-Abes, Lauren Siegel and Gil Schreier, 'Exploring Attitudes Toward Physician-Assisted Death in Patients with Life-Limiting Illnesses with Varying Experiences of Palliative Care: A Pilot Study' (n 63).

[52] Udo Schüklenk and others, 'End-Of-Life Decision-Making in Canada: The Report by The Royal Society of Canada Expert Panel on End-Of-Life Decision-Making' (2011) 25 Bioethics.

[53] Amanda Coletta, 'Canada Debates Offering Physician-Assisted Death to Patients Who Aren’t Terminally Ill' (The Washington Post, 2020) <https://www.washingtonpost.com/world/the_americas/canada-trudeau-medical-assistance-dying-physician-suicide/2020/03/29/bd98c4a0-5751-11ea-8efd-0f904bdd8057_story.html> accessed 16 February 2021.

[54] Ruaidhri McCormack, Margaret Clifford and Marian Conroy, 'Attitudes of UK Doctors Towards Euthanasia and Physician-Assisted Suicide: A Systematic Literature Review' (2012) 26 Palliative Medicine.

[55] Panagiotis Pentaris and Lucy Jacobs, 'UK Public’s Views and Perceptions about the Legalisation of Assisted Dying and Assisted Suicide' (n 47).