This chapter discusses whether if Medical Assistance in Dying (MAiD) is available, people working in suicide prevention should continue to strive to prevent all suicides, or if there are some circumstances where we should abstain from preventing a death by suicide, or even encourage people to seek MAiD. Despite mandates and ethical standards to help all suicidal people, in practice, suicide workers face moral dilemmas in some circumstances. Our analysis shows the proposals that present a clear distinction between MAiD and suicide are empirically unjustified, and people requesting MAiD could benefit from suicide prevention interventions that respect autonomy. We conclude that there are no ethically justifiable distinctions between how to respond to people requesting MAiD and suicidal individuals.

A minority of countries or parts of countries have thus far accepted the legal practice of Medical Assistance in Dying (MAiD) (euthanasia and assisted suicide), but legalising MAiD is expanding worldwide. More countries are debating legalisation of euthanasia or assisted suicide, but the nature of laws and legal practices vary greatly and both ethical and empirical assessments of current practices are the subject of much controversy. We examine the premises and evidence in the rhetoric of assisted suicide and euthanasia. We illustrate the trend with the rationale and political concerns that led to the legalisation of euthanasia in Quebec as “Medical Assistance in Dying” (MAiD), and its subsequent expansion in Canada to include persons who do not suffer from a terminal illness, including persons who suffer only from a mental illness. The values of autonomy, “dying with dignity“ and their ethical and legal bases for justifying MAiD are critically analysed. The implications of practicing euthanasia, as opposed to assisted suicide are discussed, as well as proposals for a duty to die in some circumstances. We conclude by proposing that besides debating the legal, moral and practical concerns with MAiD, we should also focus on the psychological roots of our fears and ways to reduce those fears in individuals and societies.

This chapter summarises the book, focusing on our analyses of ethical challenges based upon the three core ethical perspectives we presented in Chapter 1: moralist, libertarian and relativist. The moralists, who contend that suicide is always unacceptable and must be prevented, have occupied the mainstream position through a long period of history. Attacks on the moralistic point of view were highlighted in the twentieth century by the libertarian writings of such anti-psychiatrists as Szasz, who argued that all suicide prevention should be abandoned, and thereafter by more philosophical critics such as Foucault. Today, relativist approaches often predominate, where some people are seen as needing suicide prevention and with others, their wanting to die is ignored or facilitated, as in the case of Medical Assistance in Dying (MAiD), euthanasia and assisted suicide. Suicide prevention should be seen as a central issue that has to be assessed alongside the anti-paternalism promotion of freedom of choice. The concern of this book has not been to find a middle ground. We have sought a social and moral conscience that mandates a duty to respond to suicide and the desire to end life prematurely, first and foremost, by responding to cries for help, rather than to a clarion call for freedom

This chapter documents the array of tools and techniques judges use when carrying out their adjudicative role as part of a broader collaborative enterprise. Whilst the theoretical literature often presents courts as speaking in prospective, prescriptive, and peremptory terms, this chapter uncovers a vast array of collaborative devices which courts use in subtle but significant ways. Presenting the courts ’as catalyst’, and foregrounding the idea of ’judge as nudge’, this chapter explores the varied phenomena of judicial alerts, prods and pleas, soft suggestions, and judicial advice. It uses the controversial Nicklinson case on assisted suicide as a vehicle through which to examine collaborative constitutionalism before the courts. The chapter concludes by arguing that the devices canvassed in this chapter are best conceived as collaborative devices, rather than the ’passive virtues’ defended in Alexander Bickel’s canonical account of adjudication by the US Supreme Court.

This chapter discusses the right to life and the prohibition of the death penalty as laid down in the European Convention on Human Rights, in Council of Europe instruments, in EU law and in international instruments. It also pays attention to matters such as the beginning and end of life and preventive and investigative positive obligations. In the final section, a short comparison between the different instruments is made.

The chapter focuses the attention, firstly, on the origins of the right to die and its intersections with the development of life-maintaining medical technologies. Then, the analysis goes on by distinguishing between a right to refusal (current or by an advance directive) medical supports, and the recognition of some form of active aid in suiciding, taking into account the principal elements of the American, Canadian, European and Chinese legal frameworks.

UK law on assisted suicide is stuck in a cycle: courts uphold its illegality and defer to parliaments to enact change, but parliaments are reluctant to cross that threshold. This chapter deconstructs the case law on maintaining the status quo and constitutionally deferring to the legislature. It also considers reasons why legislators have declined to enact legal reform – autonomy issues, safeguards, palliative alternatives and the slippery slope. It looks at three jurisdictions in which this matter is overtly constitutional, and finds similarities among the criminal provisions that litigants sought to overturn and the rights on the basis of which they were overturned, leading to legislative change. The contested criminal provisions reflect the Suicide Act 1961 and the constitutional provisions against which they were considered to mirror the Human Rights Act. Currently, the only evidence of escape from liminality is a de facto policy of non-prosecution. With the UK Supreme Court poised to declare incompatibility with the European Convention on Human Rights, the ground has been laid for a constitutional answer that forces the legislature’s hand and enables a move beyond liminality.

In 1993, Sue Rodriguez was unsuccessful in her efforts to persuade the Supreme Court of Canada that the Canadian Criminal Code prohibitions on voluntary euthanasia and assisted suicide violated her rights under the Canadian Charter of Rights and Freedoms.  Some twenty years later, in February 2015, the Supreme Court of Canada unanimously struck down the very same prohibitions in Carter v. Canada (Attorney General).  The next year, the Canadian Parliament passed Bill C-14 – An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying).  Medical assistance in dying is now legal in Canada and it has become an illuminating case study for other jurisdictions contemplating assisted dying.  This chapter describes the journey from Rodriguez to Carter to Bill C-14 and reflects on the lessons to be learned from the two interconnected yet distinct pathways to law reform taken in Canada (a court challenge and federal legislation).  While there are obviously critical differences between jurisdictions such that the Canadian path cannot simply be replicated, this chapter draws out transferable lessons about law reform in this area.

An Act Respecting End of Life Care came into force in the province of Québec, Canada on 10 December 2015.  This new law aimed to ensure that all adults with decisional capacity in Québec had access to the full range of health care options at the end of their lives including for the first time, medical assistance in dying (euthanasia). This chapter describes how the province’s medical regulator, the Collège des Médecins du Québec (CMQ), laid the groundwork for the passage of this law.  Although not necessarily setting out to play a role in law reform as such, the CMQ’s proposal to frame assisted dying as a therapeutic act enabled the legislator to introduce a bill which already had the support of the medical profession as well as a regulatory structure in place to guide practice.  This allowed the regulator to be more than a stakeholder in a process of law reform but a driver of reform itself.

This chapter describes the content and protection of the right to life with respect to both euthanasia (active and passive, as well as voluntary, non-voluntary, and involuntary) and suicide, including assisted suicide. In most States, euthanasia is punishable as murder. But State practice is evolving, gradually, towards more permissive regulation of either euthanasia or assisted suicide or both.