I. Introduction and basic conceptual distinctions

On the one hand, the term Euthanasia may denote "assistance throughout the dying process", that is, support and accompaniment during the time leading up to death. In this sense, euthanasia entails the support of the dying person by giving care, pain-relieving treatment and personal comfort. As such, its urgent necessity in the dying process is undisputed. Yet on the other hand "euthanasia" can also denote "assistance in achieving death", then entailing the killing or "letting die" of a dying, seriously ill or suffering person in accordance with their own expressed or assumed wishes or interests. 
The issue of "assistance in achieving death" is discussed in the context of varying situations. 
The debate frequently distinguishes four types of euthanasia in the sense of "assistance in achieving death":

  1. "Letting die"/"Passive euthanasia": renunciation of life-prolonging measures (while continuing to give "basic care" and pain-relief treatment
  2. "Indirect euthanasia"/"Indirect active euthanasia": pain-relief treatment while tolerating a (non-intended) risk of shortening the patient's life span
  3. "Assisted suicide"/"Support for voluntary death" / "physician-assisted": assisted suicide e.g. by procuring and supplying the lethal drug
  4. "Active euthanasia"/"Direct active euthanasia"/"Termination of life on request": Intentional and active acceleration or bringing about of death. Contrary to indirect euthanasia, death is not only tolerated but intended. Contrary to assisted suicide, the ultimate decisive impulse is not given by the patient but by a third party.

The range of meaning of the term euthanasia is a wide one. It includes dying persons, seriously or incurably (physically or mentally) ill persons who are suffering inbearably or who see no purpose in continuing to live and thus express an urgent desire to be "released" through euthanasia. It also includes patients who are in a long-term coma or whose consciousness is already impaired in the terminal phase of a disease who can lo longer personally express any opinion regarding the implementation or termination of medically and technically viable, but therapeutically doubtful life-prolonging measures. It ranges to seriously damaged newborn babies incapable of expression, whose life expectancy is very short or who are expected to suffer greatly in life. 

However, not all forms of "letting die" are being summarized under the keywords "medically assisted suicide" or "euthanasia". Any therapeutic, palliative (meaning analgetic) or life-prolonging intervention requires the consent of the patient. If the patient refuses a certain measure and its omission leads to the patient's premature death, this situation is widely regarded as the manifestation of a patient's "right to a natural death". 

From a medical-ethical perspective, there is a general responsibility of the physician to preserve life, but not under all circumstances. Furthermore, life-prolonging measures cannot be responsible if they are ineffective, if their efficiency is questionable or if they involve disproportionately large suffering for the patient. The differentiation between the usage of ordinary and exceptional treatment methods is being discussed here, both from the medical perspective as well as from the moral perspective.

II. Central discussion topics

In the discussion about the licitness of the various types of euthanasia, many different aspects play a role. The main topics of discussion are as follows:

Licitness of suicide

A prerequisite for assuming the licitness of killing a person in accordance with his own wishes is that a person is permitted to end his own life intentionally in the first place. Whether or not this is the case – and if so under what circumstances – is the subject of debate. Basically, there are two approaches, both of which set different limits to an individual's right to self-determination concerning life and death:  

Proponents of the first approach assume that human life is "inviolable" or "sacred". Human life is hence not only not at other people's disposal but also not at one's own disposal. This approach is rooted not least in Jewish-Christian traditions and is supported above all by the churches. The given reason is that life is God-given and that therefore God alone has the jurisdiction over life and death. If life is already coming to an end, there is no absolute obligation to prolong it by any means possible; however, its active shortening through suicide is objectively prohibited as a violation of God's sovereignty. Yet the subjective capacity for bearing responsibility may be diminished in such cases. Based on this approach, passive or indirect euthanasia in the case of a person whose dying process has already begun may be permissible under certain circumstances. However, under no circumstances shall it be permissible to assist suicide or carry out active euthanasia.

From a legal-ethical perspective, it is principally being argued that in a liberal legal order a prohibition such as that of euthanasia can only be demanded if reasons can be given that are ideologically neutral and are thus, in general, comprehensible for everyone.  

In their argumentation as regards the content, which also opposes the argument of a general elusiveness of human life, supporters of the second approach refer to the capacity of humans to determine their own actions. The grounds of human dignity lie in this ability of self-determination. The obligation to protect this dignity is tied to this ability. Against this background, they argue, there is also an obligation to protect human life from life-threatening acts by third parties, as life is the prerequisite for human self-determination. However, a self-determined ending of one's own life, whether active or passive, cannot be unconditionally prohibited in the name of human dignity. This also applies to all types of voluntary euthanasia. However, the decision must have been carefully taken while in a clear state of mind and with an acute awareness of all circumstances; moreover, the way in which one's own life is ended may not imply any danger for third parties. Neither, therefore, is euthanasia overall nor are its various types and the desire for euthanasia to be prohibited per se. Rather, its permissibility should be assessed with regard to the extent to which the criteria mentioned are or can be fulfilled.

Irrespective of the varying limits of self-determination, the respect for self-determination is a core aspect in the entire euthanasia debate. In order to protect one's right of self-determination one can make a living will.

Licitness of active euthanasia

Independently of the question of whether suicide is permissible, one must also consider whether killing by third parties, an aspect of active euthanasia, is permissible. There is debate as to whether the categorical prohibition of killing allows for any exceptions in this respect, what reasons there could be for these exceptions and whether the exceptions may create a "slippery slope" towards increasing their number.

From a moral perspective, too, the question concerning the difference between active euthanasia and other forms of euthanasia arises. It depends on the possibility or impossibility of such a differentiation whether active euthanasia can be unconditionally prohibited if the other forms of euthanasia are, at least conditionally, being permitted.  

Opponents of the unconditional prohibition of active euthanasia argue that a moral distinction between killing someone and letting someone die is impossible to draw if either takes place for the same unselfish reasons. This is the case because in either case the result is the death of the patient. Further, it is argued that a "gradual", passive "letting die", to the extent that it involves unbearable, untreatable pain, may in certain cases be less humane than "quick" active euthanasia (e.g. by the administration of an intended overdose of pain-relieving medication).

Advocates of the unconditional prohibition of active euthanasia above all point out that the "permission to kill" – more precisely, the permission to kill innocent people in situations not involving self-defence – is linked to a "weakening of the prohibition to kill". This could provoke misinterpretations and misuse, thereby destroying any trustful relationships between humans. This is the case even if the permit is only conditional. Besides, they assume that such a "weakening of the prohibition to kill" could lead to an increase in the readiness to kill. This, again, could entail a more widespread application of active euthanasia, possibly extending it to more groups of people than originally intended. Even if the permission to kill originally only refers to dying persons who, at the time in question, are capable of judgement and expression and who request their killing of their own free will, it could eventually still extend. Seriously ill but not yet dying patients as well as elderly or disabled people without an exhibition of their will could be affected by a further development of this permission. Thinkable is even an extension to (involuntary) euthanasia against the wishes of those concerned, out of "pity" or for "economic reasons". Advocates of the unconditional prohibition consider it impossible to eliminate these risks of “slippery slope”, neither by means of fully comprehensive regulations governing exceptions nor by exempting active euthanasia conditionally from being a punishable offence while maintaining its unconditional illegality. This latter approach is pursued by proponents of partially allowing active euthanasia.

Furthermore there is an argument concerning the question whether or not more people would choose active euthanasia, if it were made legal. It is expected, that there would be a higher death rate due to the medically assisted, pain free bringing about of death. It is feared, that, given these circumstances, people would prematurely choose to die, not regarding alternatives, like for example palliative care. There is an interesting survey concerning this topic that was published in “Lancet”, which does not support the mentioned concerns. Scientists of the Universities Rotterdam and Amsterdam analyzed death rates by reference to the register of deaths of the Netherlands in the years 1990, 1995, 2001, 2005 and 2010. What the scientists found was that, in the midterm, there was no significant increase of cases of active euthanasia after it was legalized in the Netherlands in the year 2002. The percentage of people who died by active euthanasia in the year 2010, which is 3% (475 in 6861 death cases) was higher than the percentage in the year 2005, which is 1,7% (294 in 9965 death cases), but it is comparable to the years 1995 and 2001.

The physician as a "killer"

When physicians are involved in the euthanasia process, the implied weakening of the categorical prohibition of killing has significant impacts on the patient-physician relationship. Traditionally, the physician's role vis-à-vis the patient is that of a "healer" and "helper". However, by practising active euthanasia the physician becomes an "active agent" in the achievement of death. This, it is argued, is in fundamental conflict with the basic principles of the profession and is accordingly viewed with scepticism or even rejected by the medical community. Instead, the German Medical Association and the German Medical Assembly agitate for a stronger palliative care. In August 2010, the German Medical Association, the German Society for Palliative Medicine (Deutsche Gesellschaft für Palliativmedizin), and the German Hospice and Palliative Association (Deutscher Hospiz- und Palliativverband) issued a "Charta for the care of seriously ill and dying humans" (Charta zur Betreuung schwerstkranker Menschen) as a recommendation for palliative care. With its 5 guiding principles, it is supposed to indicate a type of palliative care that is oriented on the needs of terminally ill and dying people.

The question whether physicians are allowed to provide assisted suicide continues to arouse debate. The medically assisted suicide falls within the domain of assisted suicide and is not subjected to prosecution in Germany. Nevertheless, recently a legal insecurity has developed due to the so-called “professional” euthanasia in the newly passed Act 217 of the German Criminal Code. Also, practising physicians and palliative doctors regarded themselves as affected by this law. Altogether, 13 constitutional appeals have been filed to this end. With the decision of February 26, 2020, the Federal Constitutional Court has agreed with the appeals on the whole and has declared the respective passages in Act 217 as unlawful.

More restricted than the criminal law is nevertheless the code of medical ethics for physicians working in Germany. In § 16 “Assistance for the dying” an update took place on the 114th congress of physicians 2011. It states: “Physicians should help dying patients while maintaining their dignity and respecting their will. They are prohibited to kill patients at their request. They are not allowed to provide assisted suicide”. It is however the task of the medical chamber of the German federal states to incorporate this formulation in its code of medical ethics und hence legally apply it. So far ten chambers out of 17 have applied it. Additionally, two chambers (of Schleswig-Holstein and of Rhineland-Palatinate) even prohibit active euthanasia explicitely. The formulation in § 16 is moreover an object of dispute among legal experts and physicians. In April 2012 the formulation was held by the Berlin administrative court to be unconstitutional, because it doesn’t allow physicians the necessary discretionary power.

The danger of a latent destruction of solidarity

"Slippery slope" arguments are not only brought forward against allowing active euthanasia – they also play a role in the debate surrounding other types of euthanasia. The main concern is that too liberal a treatment of the euthanasia issue could lead to a destruction of society's solidarity with ill, suffering and dying people, and maybe even to pressure being put on ill and weak persons to seize the opportunity of euthanasia in order to "take their burden" off society.

Such considerations do not necessarily oblige society to reject all forms of euthanasia unconditionally. However, they do call for prerequisites to be put into place in order to prevent the according developments.

Issues relating to the "authenticity" of the desire for euthanasia and the lack of alternatives to euthanasia

If a person who wishes to die expresses his desire for euthanasia, it must be considered whether or not his desire is "authentic", i.e. whether he*she genuinely wants to die, and whether this wish could be fulfilled in some other way.
Here, too, various points of view have been put forward: 

It is often pointed out that dying persons experience typical stages of dying which can be accompanied by major mood swings. If a dying person requests euthanasia in such a situation, – according to the respective opinion – that may not be the expression of a genuine wish to die but rather a "natural" and transient accompanying phenomenon of the dying process.

It is also frequently maintained that the desire for euthanasia is rooted in great pain, feelings of abandonment and loneliness, but also in shame about one's helplessness and the resulting depression. These causes can be met by pain-relief treatment and/or personal comfort measures – an approach also pursued by the hospice movement in their support of dying patients.  

Opponents of these theories state that although personal comfort and pain-relief treatment and, in the case of mentally ill patients, psychotherapy, can often lead to a reversal of the wish to die, there are also patients whose severe physical and/or psychological suffering cannot be relieved by such measures. That, they argue, is the reason why – if only in exceptional cases – there may in fact be no alternative to euthanasia.

The problem of determining the assumed wishes of patients unable to make decisions

Any kind of euthanasia can only be permissible if it is in line with the wishes of the person in question. The permissibility of euthanasia in cases involving patients who are no longer (or in the case of newborns, not yet) capable of judgement or expression is therefore only permissible if it is possible to previously determine the patient's assumed wishes. Basic issues here include first and foremost the "medical criteria", i. e. diagnosis and prognosis.  

Moreover, various tools for determining the assumed wishes of a patient have been discussed as further steps. One possibility is a "living will" (or "patient's directives") drawn up by the patient himself in which he has expressed relevant wishes while still fully competent. Another option is consultation with a caretaker or legal guardian appointed beforehand by the patient or, if such was not appointed, one or more persons close to the patient.  

Whether or not these tools are really adequate is a matter of some controversy. Sceptics point out that the period of time between drawing up a living will and its application can often be very long, that a healthy person cannot always adequately envisage their own dying process and that such a living will cannot account for every possible scenario and set forth instructions accordingly. In addition, the question is raised whether a patient's representative – a lawyer or a close relative – assesses or can assess the patient's wishes accurately, or whether such a representation may be open to possible abuse. For these reasons, none of these tools can be used in good faith; determining the patient's precise wishes is sometimes not even possible at all.

III. Legal regulations

From a legal point of view the euthanasia issue touches primarily upon criminal law and, insofar as physicians are involved, medical professional law. As euthanasia is rarely explicitly regulated by the respective national legislation, court rulings reflecting the current legal assessment of this issue must be taken into account.

The view of the European Court of Human Rights

The European Court of Human Rights has hitherto reached two verdicts concerning euthanasia. The case Pretty involved active euthanasia, whereas the case Lambert dealt with passive euthanasia.

On 29 April 2002 the European Court of Human Rights (ECHR) in Strasbourg announced its Judgement in the case Pretty vs. the United Kingdom. The decision ruled that legal prosecution of assisted suicide as laid down in the 1961 UK Suicide Act does not violate the basic human rights formulated in the European Convention for the Protection of Human Rights and Fundamental Freedoms. According to Section 2 § 1 of the 1961 UK Suicide Act "a person who aids, abets, counsels or procures the suicide of another, or an attempt by another to commit suicide, shall be liable on conviction on indictment to imprisonment for a term not exceeding fourteen years." On 21 December 2001 Diane Pretty, a 43-year-old British citizen suffering from motor neurone disease, had taken legal action against these provisions of the Suicide Act and the refusal of the national courts to grant her husband prior freedom from prosecution if he were to assist her in committing suicide. Mrs Pretty died of her disease on 11 May 2002 in a hospice.

In its verdict in the case Lambert and Others vs. France on 5. June 2015 the ECHR approved the disconnection of the artificial feeding of Vincent Lambert with twelve of fourteen votes. Lambert has been in a coma due to severe brain injury resulting from a car accident in 2008. As reported by his doctors there is no chance of his situation improving. The doctors, his wife Rachel Lambert and some of his brothers supported disconnecting the artificial feeding and letting Lambert die. According to the Leonetti law of 2005, doctors are allowed to decide about the termination of life-support measures as long as the patients cannot communicate their wishes themselves. The French Constitutional Council approved this decision in June 2014. Lambert's parents and two of his siblings filed an appeal to the ECHR. They argued their son's impairment and the discontinuation of the artificial feeding to be "hidden euthanasia", which violates the right to life. In addition, the physicians would be violating the prohibition of torture if they let Lambert starve to death. This view was dismissed by the ECHR: Passive euthanasia is, in this case, not a violation of the right to life of the European Convention of Human Rights.

The situation in the Federal Republic of Germany

After the BVerfG repealed the controversial paragraph 217StGB, euthanasia is not governed by explicit legal regulations in Germany. In concrete cases it is assessed whether the criteria for the offences of "killing by a third party" ("Fremdtötung") as defined by § 211 (murder), §§ 212 and 213 (manslaughter) and §216 (termination of life on request) of the German Criminal Code (Deutsches Strafgesetzbuch; StGB) are satisfied. According to German law, suicide does not constitute a criminal act, meaning that assisted suicide is also not punishable by law. What is looked at in court practice, however, is the question of whether other facts and circumstances constituting a criminal offence, such as manslaughter or omission (§ 323c StGB), apply. If assistance in committing suicide is given by a physician or close relative, the legal duty that such persons assume vis-à-vis the patient wishing to die is additionally of significance since omission can also be considered a criminal offence in such cases. 

Discussion for a new legal regulation of euthanasia in Germany
In the year 2014, Germany was nudged into a debate about a new legal regulation of euthanasia. The most important question therein was, if the then allowed actions for assisted suicide such as preparation of drugs should be prohibited from then on. A further issue in the debate was the question whether the so called organized euthanasia should be banned. On 5. November 2015, after an 18-month-long discussion the Bundestag approved a law proposal presented by members Michael Brand (CDU) and Kerstin Griese (SPD) that criminalized businesslike assistance of suicide. "Businesslike" is to be understood as the repeated, organized and profit-oriented behavior of societies or individuals. Concretely, the law provided the inclusion of a new offense in the German Criminal Code (Strafgesetzbuch). The paragraph 217 now stated: "Every person who, with intent to facilitate the suicide of another person, businesslike grants, provides or conveys this person the opportunity to do so, is punishable by imprisonment in prison for up to three years or by a restitution fine." Case decisions of doctors that guarantee assistence for suicide should remain unpunishable. Relatives and related persons of the dying should be excluded from this penalty in specific cases. However, the expression "businesslike" has led to feelings of uncertainty among medical staff. As medial action is set on repitition, doctors feared they might fulfil the criterium.  Therefore, several constitutional appeals have been filed. With the decision of February 26, 2020 the Federal Constitutional Court has agreed with the appeals and declared the respective passages of Act 217 as unlawful. As a justification, the Act refers to the high value of the right of self-determination and free development of the individual which, even for the purpose of ensuring other rights, should not be disproportionally limited. According to the constitutional judge, these general personal rights, which are laid down in Article 2 of the Basic Law, include, “the right to self-determined death as an expression of personal autonomy”. The freedom to take one’s life also comprises the freedom to seek help from a third party and, provided this help is offered, to make use of it.

Following the Federal Constitutional Court's ruling in 2020, the debate on regulating assisted suicide continues. On 06 July 2023, two draft laws for a new regulation of assisted suicide were presented in the Bundestag, both of which, however, fell short of a majority. At the same time, a proposal to expand state suicide prevention was passed by a large majority. It provides for the development of a draft law by 2024 as well as a draft concept for a stronger expansion of suicide prevention services and a nationwide prevention service.

Position of the German Ethics Committee
The German Ethics Committee reacted to the debate on the new legal regulations concerning euthanasia with an Ad-hoc recommendation. A majority of the committee rejected legal regulations for suicide assistance of doctors or other occupation groups as thus, “permitted usual cases” of assisted suicide would be defined. However, for critically ill people, discussing assisted suicide with their doctor could be of high importance. Therefore, the majority of the committee recommends that the medical associations express unanimously, notwithstanding the principle that assisting suicide is not a medical task, that in exceptional cases, conflicting decisions of conscience should be granted respect. With regards to the organised assisted suicide, a majority of the Ethics Committee opts for a ban. Offers should be prohibited if they are aimed at repetition and take place in public and in that way create the impression of social normality. The criminal law, however, should not be changed. Apart from that, the ethics committee demands to increase the prevention of suicides. 

In the Ad-hoc recommendation, the ethics committee puts their opinion on self-determination and end of life support from July 13, 2006 into concrete terms.

Advance decisions
In June 2009, the German Bundestag decided in their “third law on the amendment of the guardianship law” on the regulation and management of living wills, in order to achieve more legal security for all people concerned when a written living will exists. This law clarifies a controversial issue and declares that the will of the patient is to be considered unconditionally, regardless of the nature of his disease or its stage and therefore also in cases when the disease will not unavoidably lead to death. The condition for the validity of the living will is its written form (or a similar reliable form of record such as a video). In cases in which a living will is missing or in cases in which the circumstances described in the living will do not apply to the current situation of treatment, the attendant and the physician should identify the alleged will of the patient and act accordingly. Living wills which refer to the illegal assisted suicide still remain illegal. 

Access to drugs for euthanasia
According to a decision of the Federal Administrative Court of March 2, 2017, critically ill people “under exceptional circumstances” have a right to means of assisted suicide. The jurisdiction was caused by a husbands’ dismissed case whose wife is paralysed from the neck down. Despite her clear and strong desire for suicide and the immense and degrading pain she was not given permission by the Federal Institute for Drugs and Medical Devices to purchase a dose of the fatal injection pentobarbital for the purpose of suicide. Therefore, she made use of assisted suicide in Switzerland. The court justified the case and set aside all previous judgements. In their justification the court referred to the general right of personality, documented in the Constitution. According to the court, it also contains “the right of a critically and incurably ill patient to decide how and at what stage his life should be ended.” Even though, as stated in the legislation on narcotics, a fundamental prohibition of the purchase of lethal drugs still applies, the right to self-determination allows exceptions for incurably critically ill people under extreme circumstances and in cases of lacking treatment alternatives.

In November, a legal report of the constitutional federal judge Udo di Fabio, which was commissioned by the Federal Institute for Drugs and Medical Devices, declared the judgment of the Federal Administrative Court as “not admissible on constitutional grounds”. To that end, di Fabio writes: “The free individual decision, which places the individual at the centre of the legal system, has an exceptional weight as it includes the right to suicide. Personal self-determination does, however, not lead to an absolute validity resulting in a governmental duty of participation in a highly personal decision.” Due to the “substantial constitutional doubts”, di Fabio recommends the responsible federal minister to issue a non-application decree until the induction of a legal clarification. The Federal Institute for Drugs and Medical Devices is subordinate to the Federal Ministry of Health and a non-application decree was decreed by the Federal Health Minister Jens Spahn (CDU) in July 2018. In a letter to the president of the Federal Institute for Drugs and Medical Devices, Karl Broich, the health secretary Lutz Stroppe urges the institute to reject application for drugs with the object of suicide. The “Deutsche Apotheker Zeitung”, the “Ärzte Zeitung” and others quote the letter: “It cannot be a governmental task to actively support suicide actions by officially and administratively granting permissions concerning the purchase of concrete suicide drugs.”

Meanwhile, the legal situation has become clear. Since the decision of the Federal Constitutional Court of February 26, 2020, the provision of drugs for the purpose of suicide by doctors and assisted suicide associations is considered lawful and not pursued by law. However, the Constitutional Court emphasises that the general right to freedom does not imply a legal claim towards third parties to effectively offer such support. They thereby emphasise that doctors cannot be bound to offer support for assisted suicide and, therefore, help can only be offered voluntarily.

Verdicts of the Federal Court of Justice of Germany
As the highest legal organ the German Federal Court of Justice has already delivered six judgments on assisted suicide which can be regarded as precedents. Especially in its judgment from June 25th, 2010, the implications of the “Third law for change of the care law” were emphasized once again. In its most recent judgment on September 17th, the Federal Court of justice declared that passive euthanasia in the case of coma patients is possible even without an advance decision. In this case a termination of the life-sustaining measures must be authorized by a guardianship court when this termination is in accordance with the will of the patient in question. The presence of an underlying disease with an “irreversible fatal progression” is no necessary condition of a legitimate termination of life-sustaining measures.

Position of the German Medical Association
In 2004, the German Medical Association drew up principles regarding the accompaniment of the dying process by physicians. These principles have been revised in 2011. In the 2004 version of the principles it states "deliberate curtailment of life by measures which bring about death or accelerate the dying process" as assisted suicide (active euthanasia) which is therefore rejected as "impermissible and subject to punishment. However, it also states that "the relief of suffering can be of such importance that a possible shortening of life may be inevitable and hence tolerated". According to these principles, life-prolonging measures can only be terminated or omitted if "they only delay the moment of death and the illness cannot be prevented from worsening". In cases of patients who are unable to give their informed consent, the physician must obtain a relevant declaration from the legal guardians who may have to be appointed by a guardianship court. Especially remarkable of the revised version from 2011 is the formulation about “assisted suicide”. In the version from 2004 it is said that physicians are not allowed to assist a suicide, because such actions would come into conflict with the medical ethos and can therefore be culpable. In the version from 2011 it is stated that the physicians’ assistance of suicide is not a medical task.

Position of the Bioethics Commission of the state of Rhineland-Palatinate
In its report on euthanasia of 23 April 2004, entitled "Sterbehilfe und Sterbebegleitung. Ethische, rechtliche und medizinische Bewertung des Spannungsverhältnisses zwischen ärztlicher Lebenserhaltungspflicht und Selbstbestimmung des Patienten" ("Assisting and accompanying the dying process. Ethical, legal and medical assessment of the conflict between the physician's duty to sustain life and patient self-determination"), the Bioethics Commission of the State of Rhineland-Palatinate calls for sustained support for home care services and the wider provision of hospices and palliative medical services. Moreover, a majority of members on the Bioethics Commission argue that lawmakers should lay down clear rules on active, passive and indirect euthanasia. In particular, a law is needed to establish that "neither the omission or cessation of a life-sustaining measure at the express wish of a patient nor the shortening of life accepted as an indirect consequence of a necessary medication desired by the patient is unlawful". Diverging from the demands of the bioethics commission, a provision to this effect would apply whether or not "the patient's underlying illness is leading irreversibly towards death". The majority view of the Commission is that the courts should not have to prosecute a physician who terminates life at the request of a patient in cases where extreme suffering cannot, objectively, be alleviated. Moreover, medically assisted suicide should be deemed justifiable under certain circumstances, though only as an exception.

The situation in Switzerland 

Similarly to Germany, Swiss legislation does not explicitly regulate euthanasia. Active euthanasia – the deliberate killing of a person in order to terminate suffering – is however a punishable offence in accordance with §§ 111 (premeditated killing), 113 (manslaughter) or 114 (termination of life on request) of the Penal Code (Strafgesetzbuch). Article 115 of the Swiss Penal Code states that "a person who, for selfish reasons, leads somebody to carry out suicide or assists that person in doing so, will be punished with a term of up to five years in a penitentiary or with imprisonment if the suicide attempt is successful." It follows that assisted suicide is not a punishable offence if it is done for non-selfish reasons. 

The Swiss Academy of Medical Sciences (SAMS), as the competent professional body, published the two guidelines "Treatment and care of patients with chronic severe brain damage" ("Medizinisch-ethische Richtlinien für die ärztliche Betreuung sterbender und zerebral schwerst geschädigter Patienten" (27 November 2003)) and "Care of patients in the end of life" (Betreuung von Patienten am Lebensende (5 February 2004)), which supersede the 1995 "Medical ethical guidelines for the medical care of dying persons and severely brain-damaged patients" ("Medizinisch-ethische Richtlinien für die ärztliche Betreuung sterbender und zerebral schwerst geschädigter Patienten"). Under the old guidelines assisted suicide was not considered to be "part of the physician's activity". The acceptance of shortening life within the framework of palliative care of dying patients as well as the discontinuation of treatment or the omission of life-prolonging measures in futile cases in accordance with the patient's wishes were, however, recognised as permissible. Under the revised guidelines on "Care of patients in the end of life" ("Betreuung von Patienten am Lebensende"), the SAMS advocates a narrowly defined legal scope for the possibility of for physician-assisted suicide. Although the new guidelines reaffirm the SAMS view that "giving assistance to suicide is not part of the physician's mission", they deviate from the 1995 version by emphasising that the physician also has a duty to "take into account the patient's wishes", which can mean that "in certain special cases a doctor's personal decision to assist a dying patient to commit suicide is in accordance with his or her conscience and has to be respected".

Against the backdrop of the setting up of assisted suicide organisations and the associated so-called "suicide tourism", the Swiss National Advisory Commission on Biomedical Ethics (NEK) drew up an opinion on "Assisted Suicide" in April 2005 in which it sets out the current legal situation and interpretative practice. The Commission supports the liberal provisions of Article 115 StGB, which states that providing assistance for suicide is legal provided it is not driven by self-interest. Mentally ill patients, however, are to be considered an exception; they should not receive assistance with committing suicide if the suicide wish is an expression or symptom of mental disorder. The NEK also urges that assisted suicide organisations should be subject to government regulation in order to ensure "compliance with quality criteria for the clarification of assisted suicide decisions".

In its statement "Duty-of-care criteria for the management of assisted suicide" of October 27th 2006 the NEK exposed which "minimum requirements need to be reviewed, fulfilled and documented", "for assisted suicide to be permissible from an ethical perspective". The suggested minimum requirements of the NEK state that there must be no question about the "mental capacity" of the person wishing to die. Farther, the wish to die has to occur from "severe, illness-related suffering". The wish to die must neither arise "impulsively or from a crisis of a temporary nature" nor as a symptom of mental illness. Besides it is essential that the wish to die is achieved in the "absence of external pressure" and "all other options" were clarified with the person who wishes to die. To assess the situation properly, "repeated personal contacts and intensive discussions" as well as confirmation by an independent "second opinion [...], a person with the necessary expertise", are indispensable. To prevent abuse of assisted suicide, which is exempt from punishment, in assisted suicide organisations the NEK suggests a surveillance of assisted suicide organisations "by internal and external agents".

A reference of the Federal Council from May 31st 2006 to the parliament not to enact any new legislation on the authorisation and surveillance of assisted suicide organisations preceded the NEK statement. The reference of the Swiss Federal Council predicated on a corresponding report of the Federal Department of Justice and Police. The statement arrived at the conclusion that malpractice with assisted suicide could be prevented at cantonal and municipal level by the consistent application and enforcement of applicable law as well as enacting regulations in terms of the sector of hospital, care and home management. The report rejected legislative measures through which assisted suicide organisations were under specific governmental supervision. Such activities would be disproportional as well as being unqualified as they would lead to unwanted bureaucratisation, institutionalisation and a national certification of the work of assisted suicide organisations.

Nonetheless, the public control of euthanasia-organisations in Switzerland remains an issue. The canton Zurich functions as a precursor regarding this discussion: On the one hand, one of the organisations operating in Switzerland has signed an according agreement with the canton; on the other hand, massive civilian protest has formed against the work of the euthanasia-organisations. Consequently, a referendum in the canton, the result of which is still being awaited, was brought about by means of collecting signatures due to an initiative by the citizens. The initiative by the citizens „No to assisted suicide tourism in the Canton of Zurich!” was however rejected by the government. The reason for this rejection was the breach of superior law. Furthermore, the initiative is regarded as problematic concerning the act of equality guaranteed by the federal constitution. The initiative had called for the permission of assisted suicide only to those who had been living in the canton for more than one year.

The situation in the Netherlands

On April 1, 2002, the Dutch "Euthanasia and Assisted Suicide Act" ("Wet toetsing levensbeëindiging op verzoek en hulp bij zelfdoding") came into force. The Act provides for amendments to the Criminal Code such that the facts and circumstances constituted by Article 293 (termination of life on request) and Article 294 para. 2 (assistance in a suicide) shall not be considered punishable offences if they are performed by a physician who fulfils special duties of care. These include requirements that the physician should have

  1. become convinced that the patient had made a voluntary and well-considered request;
  2. become convinced that the patient had no prospect of improvement, and was experiencing unbearable suffering;
  3. informed the patient about his or her condition and prospects;
  4. come to the conclusion in consultation with the patient that there was no other reasonable solution given the patient's situation;
  5. consulted at least one other independent physician, who had seen the patient and provided a written opinion on the criteria of due care, as described in items a to d, and
  6. performed the euthanasia or assisted suicide with due medical diligence.

In the case of patients who can no longer express their wishes but have previously put in writing their desire to end their life, the physician may comply with these wishes.

The law enables minors to request Euthanasia. If a patient is aged between 16 and 18, the physician may correspond to the patient’s wish if the parents or guardians are involved in the decision-making process. For patients aged between 12 and 16, the parents or guardians must give their consent.

The physician must report the procedure followed in terminating the patient's life or assisting their suicide to the competent coroner and submit a report documenting his compliance with the requirements of due care. The report is audited by a review commission, the composition and competencies of which are set forth in the new law. If the review commission has any doubt as to the legality of the physician's procedure, it informs the public prosecutor's office.

On  June 12, 2013, the Royal Dutch Medical Association (KNMG) decided to allow Dutch doctors to accelerate the dying process of severely sick newborns, for example by providing muscle relaxants. The practice has existed for years now and has always led to controversy. In the report, regulations for assisted suicide for terminally ill babies were laid out. Each case must be notified the the corresponding committee (Central). This is the government's response to the so-called "Groningen Protocol" that was approved by the Groningen University Medical Centre as a foundation to deal with these cases. The committee consists of three different doctors (who's professional qualifications are decided upon depending on the case), an ethicist and an jurist.

For many years, the expansion of legalised assisted suicide has been discussed in the Netherlands. In particular, the discussion revolves around the question whether physically healthy people who have lost their will to live or who regard their lives as sufficiently fulfilled should be given the opportunity of medical assistance for suicide. The “Association For Self-Determined Dying” and the citizen’s initiative “Of free will”, who speak up for the euthanasia requests of healthy people who regard their lives as fulfilled, have stimulated this debate. Suicide should be facilitated with the means of dying guides and so called “last will pills” which should be purchasable above a defined age limit.

Most recently, this debate has been encouraged by an advance from the political front. The health minister Edith Schippers and the minister of justice Ard van der Steur have started an initiative in order to amend the law on assisted suicide. According to this law, people who make the well-reasoned decision that their lives are fulfilled are allowed to make use of assisted suicide. It is planned that the new version of the law should be introduced after the consultation of doctors, ethicists and other experts at the end of 2017.   

Between 2011 and 2012, the cases of euthanasia in the Netherlands have risen by approximately thirteen percent from 3695 to 4188 cases. In the years 2013 (4829 cases), 2014 (5306 cases), 2015 (5516 cases) and 2016 (6091 cases) this trend continued. By now, books have been published in the Netherlands – both in English as well as in German translations –, which provide information about opportunities to committing suicide.

The situation in Belgium

On May 16, 2002, the Belgian Chamber of Representatives passed the "Act on Euthanasia" by a majority of 86 to 51 votes with 10 abstentions. The Belgian Senate had already approved the bill on October 25, 2001. The new Act permits a physician to carry out killing on request under certain conditions. 

On December 13, 2013, the Belgian senate decided to expand the scope of the law. It now includes minors. The Belgian Chamber of Representatives agreed to the legislative amendment in February 2014. Shortly after that the Belgian king signed the amendment and made it become final. By virtue of that amendment minors of any age are now enabled to request assisted suicide from their attending physician if certain circumstances exist. The amendment was controversial and accompanied by protests both on the part of the church as well as patient associations.

In 2016, the first active euthanasia of a minor has reignited the debate. This was strongly criticised on the part of the church. Cardinal Sgreccia (Vatican) declared that the decision “is not only against the perception of all religions who have all raised their voices in Belgium but also against human instinct because especially minors require help by the means of medication, moral, psychological and spiritual support.” Even the chairman of the German Foundation of Patent Protection, Eugen Brysch has criticised the approach: “The killing on request of children has nothing to do with dignified death. In this way, the Benelux nation leaves the human rights standards of the EU.”

The situation in Luxembourg

On 17 March, 2009, a law concerning euthanasia became effective in the grand duchy of Luxembourg ("Loi du 16 mars 2009 sur l'euthanasie et l'assistance au suicide"). According to this law, the assistance in suicide is permitted under certain circumstances, as is also the case in the Netherlands and Belgium.

In the future, patients shall be given the opportunity to wilfully put an end to their lives under medical assistance. The exemption from punishment for this medical assistance is dependent on various conditions: The affected patient has to be of full age and to be caught in a situation that is hopeless from a medical perspective. The patient has to suffer from mental or physical pain without having any improvement of this situation in sight. The wish to decease has to be made voluntarily, well-considered, without any external pressure and it has to be formulated in writing.
In the case of 16 to 18-year-olds, euthanasia is only allowed to be provided if the parents or legal representatives have previously given their consent. Regarding a patient who is unable to express his or her will, the will set out in the living will is decisive. According to the law, the doctor has to have several detailed conversations with the patient regarding the patient's decision; he has to inform the patient about his or her condition as well as all available medical opportunities. Furthermore, as a basic principle, a second doctor has to be consulted regarding his opinion on the severity and incurability of the disease.
All cases of euthanasia have to be reported to a controlling commission, which is in charge of inspecting the adherence to the conditions set out in the law.

The first reading to the law on euthanasia took place on February 19, 2008, and was accepted with 30 yes-votes, 26 no-votes and three abstentions from voting. Since there were, according to the privy council, judicial inconsistencies with the law on palliative care ("Loi du 16 mars 2009 relative aux soins palliatifs, à la directive anticipée et à l'accompagnement en fin de vie"), which had been proposed at the same time, the parlamentarians were not excused from the second reading. The revote regarding the law on euthanasia from December 18, 2008, yielded a result of 31 yes-votes, 26 no-votes and three abstentions from voting and thus confirmed the parlamentarians' positioning in the first vote.

On March 17, 2009, the official register Memorial was released, in which the law was printed and thus came into effect. The law carries the date of March 17, 2009, and was signed by grand duke Henri.

This delay in publication has to be attributed to a constitutional amendment concerning the rights of the grand duke. Prior to this constitutional amendment, the grand duke not only had to sign a law but to approve of it as well in order to have the law come into effect. It was made public in early December 2008 that grand duke Henri would not sign the law because he could not reconcile it with his personal conscience. The grand duke was then to be deprived of the right to veto by means of an amendment to Article 34 of the constitution: In the future, the grand duke shall now only pronounce laws but not approve of them anymore. The first reading concerning this amendment proposal was held on 11th December 2008 and was accepted. Since, in cases of a constitutional amendment, the Luxemburg Parliament can, however, not be excused from a second reading and this second reading is allowed to take place earliest 3 months after the first reading, a revote was carried out on 11th March 2009. The constitutional amendment was adopted unanimously and with the approval of grand duke Henri.

The situation in France

The "Loi n° 2005-370 relative aux droits des malades et à la fin de vie" was adopted in France on April 22, 2002. It amends the Public Health Code (Code de la santé publique) in such a way that discontinuation of medical treatment at the request of a patient is not punishable in cases where the patient is in an advanced or terminal phase of a severe and incurable disease – even if this termination accelerates death. If the patient is no longer able to take a decision and there is no living will, the patient's family or a person of trust and an additional physician must be consulted. Living wills are taken into account, provided they were drawn up no more than three years prior to the date on which loss of consciousness occurred and have not been revoked. Active euthanasia, on the other hand, continues to be prohibited in France.

On 17. March 2015 the French National Assembly decided on an amendment of the Assisted Suicide Law. The supplementary text conceived by members Alain Claeys (PS) and Jean Leonetti (UMP) provides a right to a "deep and continuous sedation" for incurably ill patients as long as this matches the will of the patient. By this the so-called terminal sedation is meant, that resembles a strong sedative and which shall protect patients in their very last life stage from unbearable pain. In addition, physicians are bound by the amendment to follow the patient's will even in cases where it is more than three years old. An amendment proposal for the legalization of active assisted suicide had been revoked by the Assembly. Active assisted suicide thus remains forbidden in France.

The situation in Italy

Contrary to the situation in Germany, in Italy euthanasia is not specifically regulated by law. However active euthanasia in principle belongs to the field of criminal law regarding premeditated killing ("omicidio volontario", Art. 575 codice penale). This regulation holds a minimum penalty of 21 years imprisonment. For a reduced sentence in the case of killing due to compassion, for individual cases there is a certain margin for judgement: Section 62 codice penale acknowledges as mitigating circumstances when the offender acted out of certain moral or social motives defined by values ("motivi di particolare valore morale o sociale"). In the case of consent of the person wishing to die, the corpus delicti "killing with consent" ("omicidio del consenziente", Art. 579 codice penale) is applied with a range of sentences from 6 up to 15 years imprisonment. Different from the German legal situation, incitement to commit or assistance with suicide, acc. Section 580 codice penale ("istigazione o aiuto al suicido") is a punishable offence. Section 580 codice penale holds a range of sentences from 5 to 12 years.

In the case of consent by the patient who wishes to die, passive euthanasia is covered by the right of self-determination (Section 32 § 2) concerning medical treatment guaranteed by the Italian constitution. There it is said that apart from cases regulated by law, nobody may receive medical treatment by force. These exceptions on their part may in no case breach the imposed boundaries set by the 'respect for the human being' ("respetto della persona umana") (Section 32 § 2 Sentence 2). In Italy, cases of artificial nourishment are seen as especially controversial. While some see herein a medical treatment that can be refused, others see primary health care that is commanded by the respect for the human being. However, on 14 December, 2017, the Italian Senate passed a law, which declares patients' advance decisions (biotestamento) binding. In these advance decisions, artificial nourishment can now be refused by the patient.

In case of the absence of consent, for the guarantor, who is the person (e.g. parents, spouse or physician) who is legally bound to vouch for the prevention of death, passive euthanasia is in principle the same as "killing by omission" and punishable under the law regarding active killing (Art. 575 i.V.m. Art. 40/2 codice penale).

Only in cases of brain death, the termination or omission of life-sustaining measures is permitted provided that the brought in relatives of the brain dead, the concerning head physician, the attending physician as well as a forensic pathologist agree. If physicians and relatives disagree, a decision by the court is needed.

The death of coma-patient Eluana Englaro in 2009 resulted in the discussion about euthanasia being resumed intensively in Italy; this debate had also been taken on by politics.

The situation in Great Britain

As the case Pretty has shown emphatically, the "Suicide Act" expresses a general prohibition of euthanasia. Euthanasia is punished with a prison sentence of up to 14 years. Concerning the actual sentence in an individual case, the legal situation in Great Britain allows for a wide scope of discretion. It is, indeed, possible for British citizens to travel to Switzerland in case they want to call upon euthanasia. However, if they are accompanied and assisted in this undertaking, the accompanying person acts illegally. In practice, prosecutions occur only rarely but as of yet, persons concerned could nonetheless not rely upon themselves not being charged. In July 2009, a single-case decision has fuelled the debate. Debbie Purdy, a British citizen fallen ill with multiple sclerosis and willing to commit suicide, was successful in the House of Lords where she could move the highest judges to assure her husband immunity from prosecution in case that he should help her travel to Switzerland. In consequence to this case, the law lords commanded that the British prosecuting body (GPP) enact concrete guidelines, which give information about the conditions under which, in cases of assistance in committing suicide, there will indeed be prosecutions. As a result, the British prosecuting body in September proclaimed corresponding guidelines. According to these guidelines, for example the differentiation between "aid" and "encouragement" to suicide as well as the question concerning whether the accompanying person benefits from the patient's death are decisive.

In 2013 the Commission on Assisted Dying published a proposal for the liberalization of assisted dying in England and Wales under the leadership of Lord Falconer. According to the proposal every person of age with a life expectancy amounting to less than six months shall be able to choose assisted suicide. This proposal is currently being discussed in the House of Commons and the Brithish people.

The situation in the USA

As criminal legislation in the USA is primarily drawn up by the individual states, there are no nationwide compulsory regulations regarding euthanasia and assisted suicide. The federal courts must clarify whether the individual states' legislation complies with the federal constitution.

Active euthanasia is prohibited in all states, while the termination and refusal of treatment in accordance with the patient's wishes in futile cases (passive euthanasia) is generally accepted. The same applies to indirect euthanasia.

Suicide and assisted suicide are also classed as an offence in some states. In some states there are initiatives aimed at legalising assisted suicide. On 27 October 1997 Oregon's Death With Dignity Act came into force in accordance with which 'an adult who is capable [...] and has been determined by the attending physician and consulting physician to be suffering from a terminal disease' can make a written request "for the purpose of ending his or her life in a humane and dignified manner". Upon approval of the application, the patient receives a prescription for medication which will enable him to terminate his life himself. The states of California, Washington, Montana and Vermont legalised assisted suicide within constraints of comparable standards in the years between 2008 and 2015. In the state of New Mexico, judge Nan G. Nash of the Second Judicial District Court in Albuquerque reached a verdict in April 2014 finding the right to an "Aid in Dying" for incurably ill patients to be constitutional. Assistance from doctors in corresponding cases should thus be decriminalized. In response, doctors and jurists of the organization "Alliance Defending Freedom" have petitioned for appeal. The New Mexico Court of Appeals reached a verdict in August 2015 finding no basic right to assisted dying in the Constitution of New Mexico. The Supreme Court of the United States repealed judge Nan G. Nash's decisions in the last instance of appeal.

With the so-called "End of Life Options Act, representatives Deborah A. Armstrong, Bill McCamley and Elizabeth "Liz" Stefanics pursue regulation for New Mexico akin to that of Oregon. The act has been presented on 20 January 2017; as of now, however, it passed neither the House of Representatives nor the Senate.

At the beginning of 2005 the case of Terri Schiavo in the United States provoked a fresh debate about the right to die and the handling of euthanasia. Terri Schiavo has suffered severe brain damage in 1990 when she collapsed and had been in a vegetative state since that time. While her husband and legally appointed guardian urged that her artificial feeding should be stopped and the patient allowed to die, supposedly in accordance with her (albeit only verbally expressed) wish, her parents wanted feeding to continue. In early 2005 President George W. Bush ordered that the legal dispute – which had been ongoing in the state of Florida for seven years and in the course of which artificial feeding has been stopped and resumed on several occasions – should be continued on the federal level. A legislative initiative was drafted specifically with the aim of ensuring that Terri Schiavo would be kept alive for as long as it took a federal court to reach a decision. In February the US Supreme Court ultimately decided the case in favour of Terri Schiavo's husband.

The situation in Australia

In Australia's Northern Territory, the Rights of the Terminally Ill Act came into force in 1996. It permitted physician-assisted suicide for terminally ill patients whose suffering had reached unbearable limits. Four patients subsequently terminated their lives aided by a computer which released a lethal overdose of medication by injection when a button was pressed. The Act was overturned in 1997 by a law passed by the Australian parliament. Other Australian states also had legislative initiatives similar to that in the Northern Territory. Only recently a draft bill on the legalisation of euthanasia was presented to both houses of parliament of South Australia at the same time.

On November 22, 2017, the Victoria State Government passed the so-called Voluntary Assisted Dying bill. The bill intends that henceforth lethal drugs can be prescribed to terminally-ill patients. Numerous conditions apply. Applicants for euthanasia must have been “ordinary residents of Victoria” for at least 12 months. They must be adults with decision-making capacity and suffering from an incurable disease or condition that will cause death within six months, respectively 12 months in the case of neurodegenerative illnesses. Patients must experience suffering that cannot be relieved in a way tolerable to them. Applicants must make three requests to access the scheme, including a written request. Two experienced doctors will assess the patient, one of whom is a specialist, who decides about the patient’s eligibility. Patients must initiate discussion of assisted dying – physicians may not raise the topic to patients first. In case assisted dying is granted, drugs will be prescribed to the patient, who can take them at a time of her choosing. If the patient is physically unable to take the drugs herself, a lethal injection can be administered. The bill came into force on Wednesday, June 19, 2019.

The situation in Canada

Euthanasia had been illegal in Canada until very recently. Representatives of the province Quebec sparked the debate by passing a law on "medical aid in dying" in June 2014. The term "euthanasia" is not mentioned in the legislative text. Instead, the terms "palliative sedation" and "medical aid in dying" have been used. The Parliament of Quebec argues that euthanasia is to be classified as end of life care and that it is therefore to be considered an integral part of health care provisions. In Canada, health care is administered not by the central government, but by the provinces. In February 2015, the Supreme Court of Canada decided, that a prohibition of assissted suicide contradicts the Canadian Charta of Rights and Freedoms. Following this, in June 2016, the Canadian Parliament passed a law on legislation of assissted suicide (Bill C-14). The legislative text also uses the term "medical aid in dying". This aid is, however, strictly regulated. For example, it can neither be provided to minors, nor on the basis of a psychological disorder or long-term disability.

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