More and more countries are legalizing voluntary assisted dying. This allows a doctor, or sometimes a nurse practitioner, to administer life-ending medication to an eligible person who requests it.
By 2023, 282 million people lived in areas where voluntary assisted dying is legal. Jurisdictions such as the Netherlands, Belgium and Oregon have had these laws in place for decades. Other countries, including Canada, Spain, New Zealand and Australia, have recently passed reforms.
The trend toward legalization continues. Many countries are actively considering this issue with strong public support. In November, the House of Commons of the United Kingdom supported an assisted dying bill for the first time after years of unsuccessful attempts.
Debates about voluntary assisted death are often highly polarized. Understanding the drivers of assisted death is essential for evidence-based debate and to improve care for people with serious conditions.
In a recent study, we examined data on people accessing voluntary assisted death in 20 jurisdictions around the world. In particular we looked at what diseases they had.
What are the rules?
The legal rules for voluntary assisted dying vary by country (and what it is called also varies).
In countries including Australia and New Zealand, voluntary assisted death is only available to those who are terminally ill. For example, in Australia a person must have an advanced, progressive condition that is generally expected to result in death within a certain time frame (6 to 12 months, depending on the state).
Countries such as the Netherlands, Spain and Canada also allow entry to eligible people suffering from non-terminal conditions. Canada allows voluntary assisted death for people who are suffering intolerably from “serious and irreparable” conditions. Although a person’s condition does not necessarily have to be terminal, additional safeguards apply when a person’s natural death is not “reasonably foreseeable”.
That said, voluntary assisted death for non-terminal conditions is rare. In 2023, 95.9% of people availing themselves of voluntary assisted dying in Canada were projected to die a natural death.
Who can give the medicine also varies. In the United States and Switzerland, people must take the medicine themselves, usually by swallowing liquids (known as “self-administration”).
In Quebec, Canada, physicians or nurse practitioners must administer it, usually intravenously. In many jurisdictions, including Australia, both self-administration and practitioner administration are available.
our research
With an international team of researchers, we looked at the role of disease in voluntary assisted death. We analyzed publicly available data from 20 jurisdictions in eight countries between 1999 and 2023.
Overall, the majority of people availing themselves of voluntary assisted death had cancer (66.5% of cases). Neurological diseases were the second most common (8.1%), followed by heart (6.8%) and lung (4.9%) diseases.
We also looked at how many people with each disease took advantage of voluntary assisted death, versus those who died in other ways. Even though voluntary assisted mortality rates and eligibility criteria varied by location, rates for specific diseases were surprisingly similar across regions and time periods.
For example, people with amyotrophic lateral sclerosis (ALS) — a rare, progressive, fatal disease that damages the brain and spinal cord — had the highest rates of dying with voluntary assistance. The voluntarily assisted mortality rate for people with ALS is approximately seven times higher than that of people with cancer.
Meanwhile, cancer patients were four times more likely to reach voluntary assisted death than those with lung disease, and ten times more likely than those with heart disease.
What does this tell us?
Cancer and ALS, which appear to be the main causes of people reaching voluntary assisted death, have little in common. But both often cause a more rapid decline in health and greater perceived loss of dignity than other conditions.
Our findings match other research showing that people typically request voluntary assisted dying because they have lost autonomy, dignity, or the ability to do things that are meaningful to them.
Critics of voluntary assisted dying worry that people may be pressured into choosing this option. One of the concerns is that people will opt for assisted death due to the lack of palliative care. It refers to specialized care and treatment that helps people with serious life-limiting conditions live comfortably and fully.
Interestingly, while people with lung or heart conditions make less use of palliative care than people with cancer, our study showed that they are less likely to reach voluntary assisted death. If voluntary assisted deaths were due to less access to services, we would expect higher rates for heart and lung disease.
Similarly, recent data from Canada and Australia show that the majority of people requesting voluntary assisted death receive palliative care.
From here to where?
Our study does not rule out that multiple factors, including poor access to services, may influence some cases. But it helps clarify common misconceptions about the causes of voluntary assisted death.
Further research should look into why cancer and ALS cases are at their highest. If voluntary assisted dying is primarily about rapid deterioration and loss of dignity, then we must focus on new ways to support patients facing these challenges.
And while voluntary assisted dying may promote autonomy and compassion by allowing suffering people to choose when and how they will die, our findings do not diminish the importance of protecting vulnerable people.
Strong safeguards to ensure that decisions are voluntary and only eligible people have access, as well as high-quality palliative and supportive care, are essential in any voluntary assisted dying framework.
This article was developed with input from Brandon Heidinger, a medical student at the University of Western Ontario.
,Author: Eliana Close, Senior Research Fellow, Australian Center for Health Law Research, Queensland University of Technology and James Downer, Head and Professor, Division of Palliative Care, Department of Medicine, L’Université d’Ottawa/University of Ottawa)
,disclosure statement: Eliana Close Has received funding from the Commonwealth Government for research and training about law, policy and practice relating to end of life care (Australian Department of Health, End of Life Legislation for Clinicians). In relation to voluntary assisted dying, she is working on an Australian Research Council Future Fellowship project funded by the Australian Government (Enhancing end-of-life decision making: optimal regulation of voluntary assisted dying, Principal Investigator, Professor Ben White). He has also been appointed on projects funded by the Victorian, Western Australian and Queensland governments to design and deliver legislatively mandated training for health practitioners involved in voluntary assisted dying in those states. james downer Juul, Inc. to develop educational materials related to medical assistance in dying. Has received consulting fees from. He is the former unpaid chair of the Clinical Advisory Council for Dying with Dignity Canada, a group advocating for the legalization of medical assistance in dying in Canada.)
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