47 min read

Assisted Suicide

I recently watched Better Off Dead? a BBC documentary authored by actor and disability rights activist Liz Carr. It raises valid concerns and questions about the repercussions of the Assisted Dying Bill, a proposed law to legalise Assisted Suicide in England and Wales, currently in Lords Committee Stage (April 2026). I decided to draft my own conceptual framework to develop and encourage my own thinking around the topics raised. This is not a legal document.

I recognise this is a deeply sensitive subject that touches on personal values, lived experience, and strong convictions for many people — and rightly so; what follows is not a polished argument or a settled position, but an honest attempt to think out loud for myself, and I share it only in the hope it might help others do the same.

My proposed approach — one sentence

"A terminally ill adult with confirmed mental capacity may request medically assisted suicide — provided the decision is entirely their own, voluntary, recorded, and free from all coercion."

Five gates — all must be met
Gate 1
Terminal illness confirmed
The patient has a terminal illness likely to end their life. Confirmed by two independent doctors.
Critical: At least one doctor must have an established professional relationship with the patient — ideally their long-term GP or familiar Consultant. This is not about time, it is about understanding the person rather than just the illness. A doctor who knows the patient is far better placed to judge whether a request reflects their genuine, long-held values and to detect coercion or a change in circumstance. Equally, if a patient has had little or no contact with a GP or Doctor, it is a reasonable and logical indicator that they are unlikely to be persistently seeking assisted suicide — the absence of a professional relationship is itself a natural barrier, not a loophole.
Gate 2
Mental capacity confirmed
The patient is capable of making an informed, rational decision. Assessed independently — not by a doctor with any conflict of interest in the outcome.
Where capacity is in any doubt, a specialist psychiatrist must assess before the process continues.
Advance consent exception: Where a terminal and incurable disease is diagnosed that will progressively destroy the patient's capacity to consent — such as Alzheimer's — the patient must be able to provide advance written consent while still capacitous. This written advance consent must be formally recorded and taken into full consideration by all healthcare professionals involved, and remains valid unless explicitly withdrawn by the patient while they still retain the capacity to do so.
Gate 3
Request for medically assisted suicide — individual's own choice
The request for medically assisted suicide must come from the patient alone — repeated, uncoerced, and documented over time. Not a single moment of despair. This gate is distinct from Gate 5 (DNR) — both must be met independently.
A doctor may not initiate or suggest this option. The patient must raise it. Coercion by any party risks a criminal offence.
Gate 4 — if under 18
Parental consent required
Gate 4 is the hardest gate to write. In an ideal world it would not need to exist. But to exclude it entirely would be to ignore a reality that some families face — that a terminally ill child may reach a point of suffering that no treatment can adequately relieve, and may themselves ask for a choice that no child should ever have to ask for alone. This gate does not invite that question. It simply acknowledges that the question can exist, and that when it does, it deserves a framework that takes both the child's voice and the parents' impossible position with the utmost seriousness.
If the patient is terminally ill and under the age of 18, full informed parental or guardian consent is required — in addition to Gates 1, 2, 3, and 5.
Both the child's expressed wish and parental consent must align. Neither overrides the other without formal judicial review.
Gate 5
The DNR rule — no medical override

A Do Not Resuscitate (DNR) order must be in place. The request must come from the patient alone — repeated, uncoerced, and documented.

A Do Not Resuscitate order may only be placed at the patient's own explicit, recorded request. A doctor may never assign a DNR against a patient's stated wishes. To do so is not medical judgment — it is a decision about whether a life is worth saving, and that belongs only to the person whose life it is.

Where a patient cannot write or speak — whether due to disability, illness, or cognitive impairment — a written record alone is not a reasonable benchmark. The following mechanisms must be recognised as equally valid means of recording a patient's expressed wish:

  • A witnessed verbal statement, recorded on video or audio by an independent party
  • Communication through an established assistive technology or AAC device
  • A formally witnessed non-verbal expression — such as consistent and deliberate responses to yes/no questions — documented by at least two independent healthcare professionals
  • A legally appointed advocate or lasting power of attorney acting on the patient's previously expressed and documented wishes — not on their own judgment

Every person registering a DNR preference should be able to choose from a clearly defined set of treatment preference categories so their wish is recorded precisely and cannot be misinterpreted in an emergency. A trained facilitator — not a doctor — should guide this conversation. The patient's choice should be recorded and stored in a recognised system and available to all medical professionals so that wishes cannot be misinterpreted or overridden in an emergency.

Important note: Great Britain already has a centralised, national Blood Donor and Transplant Register, which is accessible to medical professionals, so adding a specific DNR Declaration function to its records seems reasonable and very feasible. However it is worth acknowledging that the UK is four nations and some have devolved health powers. Any law of this kind would likely apply only to England, or require separate legislative processes in Scotland, Wales, and Northern Ireland. This complexity does not make the proposal unworkable — but it is an important consideration for implementation.

Every person registering a DNR preference should be able to choose from a so their wish is recorded precisely and cannot be misinterpreted in an emergency. A trained facilitator — not a doctor — should guide this conversation.

Proposed treatment preference categories
Informed by research into POLST (USA) and ReSPECT (UK). Studies show three plain-English categories work best — the extremes are clear, and a single middle category covers the grey area. Seven or more categories cause confusion for both patients and emergency clinicians. Categories are ordered from most to least intervention, as research shows starting with full treatment avoids patients feeling steered toward less care.
Category 0 — Default (no declaration made)

I have not made an explicit DNR declaration. Resuscitation decisions are at the discretion of medical professionals.

In the absence of an explicit declaration, medical professionals will use their clinical judgment to decide whether to attempt resuscitation, in accordance with best practice guidelines and the patient's best interests as they understand them.

Category 0 is the recognised default for anyone who has not yet made a declaration. It is not a choice — it is the absence of one. Every person is encouraged to make an explicit declaration so that their wishes are known and cannot be misinterpreted or overridden in an emergency.

My proposal: Category 0 should be the automatic opt-in for every person registered with the NHS — recorded as part of the national Blood Donor Register, which already holds individual records accessible to medical professionals in an emergency. A DNR preference declaration (Categories 1–3) would then be a deliberate, active upgrade from Category 0, made by the patient at any time through the same system.

Category 1 — Full treatment

Do everything possible to keep me alive.

Attempt resuscitation in all circumstances. I want all available medical interventions used to keep me alive, regardless of my condition or prognosis.

Category 2 — Selective treatment

Attempt resuscitation only if I have a reasonable chance of recovering enough to communicate my own wishes.

Do not resuscitate if medical assessment confirms I would permanently lose the ability to express myself — verbally, non-verbally, or through assistive technology. Do not resuscitate if I would survive only on permanent life-sustaining machines with no realistic prospect of removal. In all other situations, attempt resuscitation and provide appropriate medical treatment.

Category 3 — Comfort-focused / Do not resuscitate

Do not attempt to resuscitate me under any circumstances.

Keep me comfortable and free from pain. I do not want any intervention whose primary purpose is to restart my heart or extend my life.

This category is specifically aligned with Gate 3 (a recorded request for medically assisted suicide) and Gate 5 of this framework. Selecting Category 3 on its own does not constitute an assisted suicide request — it is a separate, independent decision about resuscitation that any person may make at any time.

These categories must be defined in primary legislation and maintained by a standing medical panel. Selection must always follow a facilitated conversation with a trained, independent advocate — not a doctor with a clinical interest in the outcome. The conversation matters as much as the form.

My proposal — integrate with the national Blood Donor Register: Rather than creating an entirely new national infrastructure, this DNR preference system should be built into the existing national Blood Donor Register — a system already held by NHS Blood and Transplant, already linked to individual NHS records, and already accessible to medical professionals in emergencies. Every NHS-registered person would be automatically enrolled at Category 0 (no declaration). Moving to Categories 1, 2, or 3 would be a deliberate, patient-initiated action through the same portal — online, via GP, or through a trained facilitator. This avoids building a parallel system from scratch, uses trusted infrastructure, and keeps all critical patient preferences in one place.

Changing your category

A patient may change their declared category at any time, for any reason, without explanation or justification. To change a declaration the patient must notify their GP or registered healthcare provider in writing, or through any of the accessible communication methods recognised under Gate 5. The change takes effect immediately upon receipt. Once confirmed on the patient's record by the GP or registered healthcare provider, it is binding — and must be reflected in any centralised register without delay. A previous category is never reinstated automatically — only the most recently recorded declaration is valid. No medical professional, family member, or legal representative may challenge, delay, or override a patient's decision to change their category.

Core principles
The autonomy principle — the individual is sovereign
Only the individual defines whether this choice is right for them. No doctor, family member, system, or financial pressure may substitute their judgement. The patient's expressed wish always overrides a medical opinion. The independent assessments in Gates 1, 2, and 4 are verification processes — not overrides. They exist to protect the patient's right to choose, not to replace it.
The equality protection — parity of life
The wish to live — of a disabled person, an older person, someone with a long-term condition, or anyone among society's most vulnerable — must be supported with the same urgency as anyone else's. No one should ever be made to feel a burden, too expensive to treat, or "better off dead" because of their condition, age, or circumstance. The right to die and the right to live are equal. Neither may undermine the other.
What the law can never become
Not for disability
Disability alone is never a qualifying condition. A disabled person's wish to die must be met with the same support to live that a non-disabled person receives.
Not for social deprivation
Poverty, loneliness, inadequate housing, or lack of care are never qualifying reasons. These are state failures — not reasons to offer death.
Not for mental illness alone
Psychiatric suffering without a co-existing terminal illness never qualifies. Mental illness can improve — people need more time, not a final decision.
Not a cost-saving tool
Government cost, NHS resource pressure, or the expense of keeping someone alive is never a factor — implicitly or explicitly — in any assessment.
No family pressure
Any family member, carer, or heir who coerces a patient's decision has committed a criminal offence — treated with the same seriousness as elder abuse.
No scope expansion
The law is fixed at terminal illness. Any expansion requires entirely new primary legislation — never a reinterpretation of this one. Shaping or amending laws of this kind carries serious risks: the international comparison table below shows how quickly and significantly such laws can change once passed. This is precisely why extreme caution and awareness of other countries' experience is essential before and after any legislation is introduced.
A note on terminology

"Assisted Dying" is a deliberate softening of language that reduces public scrutiny. The accurate term is Assisted Suicide. If we cannot name the act accurately, we cannot debate it honestly — and if we cannot debate it honestly, we cannot build a law that holds.

"Terminally ill" must also be precisely defined in law. Vague language is where scope creep begins. A working definition:

An end-stage disease or condition that cannot be cured, or adequately treated to a standard that avoids constant pain, unbearable suffering, or severe mental distress — and from which death is the expected and foreseeable outcome.

The law should name a so there is no ambiguity or legal scope creep. Each qualifying illness automatically defines eligibility, it does not require or predict prognosis timelines. In line with the autonomy principle — the individual is sovereign — only the individual defines whether this choice is right for them and what timeline is right for them.

Proposed list of qualifying terminal illnesses
Terminal — capacity typically preserved Progressively destroys capacity to consent Variable — depends on type or stage
End-stage cancer Includes all cancer types at end stage with no curative treatment. Mental capacity typically intact until very late.
End-stage heart failure Terminal cardiac conditions where curative treatment is no longer possible. Capacity generally preserved.
End-stage chronic obstructive pulmonary disease (COPD) Advanced lung disease at end stage. Cognitive capacity typically preserved.
End-stage liver disease / cirrhosis Terminal liver failure with no transplant option. Capacity generally intact unless hepatic encephalopathy is present.
End-stage renal (kidney) failure Terminal kidney failure where dialysis is no longer viable or chosen. Cognitive capacity typically preserved.
End-stage cystic fibrosis Progressive and ultimately fatal. Lung and organ failure in later stages. Mental capacity preserved.
End-stage HIV/AIDS Where antiretroviral treatment has failed and disease is terminal. Capacity typically preserved absent neurological complications.
Motor neurone disease (MND) / ALS Physical capacity deteriorates rapidly; cognitive capacity is usually preserved. However, a subset (ALS-FTD) involves frontotemporal dementia — in those cases, capacity can be progressively affected. Advance consent should be made early.
Brain tumours (high-grade glioma / GBM) Prognosis is terminal. Cognitive impact depends heavily on tumour location — frontal lobe tumours can impair judgment and personality. Advance consent recommended at time of diagnosis.
Advanced Parkinson's disease Physical deterioration is severe and inevitable. Cognitive capacity is preserved in many patients but Parkinson's disease dementia (PDD) affects a significant proportion in later stages.
Alzheimer's disease Terminal and incurable. Systematically destroys the capacity to consent over time. Gate 2 advance consent provision applies — written consent must be made while the patient is still capacitous.
Other dementias (vascular, Lewy body, frontotemporal) All progressive and terminal. Each destroys cognitive capacity at varying rates. Gate 2 advance consent provision applies in all cases.
Huntington's disease Genetic, progressive, and fatal. Causes both physical and cognitive decline. Capacity is eroded progressively — often over many years. Advance consent should be made shortly after diagnosis.
Prion diseases (e.g. Creutzfeldt-Jakob disease / CJD) Rapidly progressive and invariably fatal. Destroys brain function — including capacity — very quickly, often within months of onset. Advance consent must be made immediately upon diagnosis.

This list is illustrative, not exhaustive. The final list must be defined and maintained by a standing medical panel, reviewed regularly, and enacted through primary legislation. Inclusion on the list does not automatically qualify a patient — all five gates must still be met.

An open question: This list is anchored around terminal prognosis and capacity to consent. However, there is a separate and harder category of conditions where the primary concern is progressive loss of bodily function and dignity — rather than death or cognitive decline alone. Conditions such as advanced Multiple Sclerosis (MS), Progressive Supranuclear Palsy (PSP), Multiple System Atrophy (MSA), Corticobasal Degeneration (CBD), Locked-in Syndrome, and severe treatment-resistant epilepsy with progressive brain damage may all cause profound and permanent suffering with no prospect of improvement — yet would not currently qualify under this list. Whether and how such conditions should be recognised is a question this framework does not yet resolve, and one that any standing medical panel must carefully consider. It is also precisely the kind of question that, if answered too broadly, risks becoming the first step on the very slippery slope that this conceptual framework exists to highlight and guard against.

A note on palliative care

Assisted suicide is in no way a replacement for palliative care. This framework does not argue that the right to die makes the right to live comfortably any less important. Critics of assisted dying legislation often argue that if palliative care were properly funded and universally excellent, this debate would become unnecessary. That is a legitimate point and it deserves a direct response.

The honest answer is: palliative care is imperfect, and even the best palliative care cannot always resolve every form of suffering — physical, psychological, or existential. Some patients, even when receiving excellent care, will still want control over the manner and timing of their own death. That is not a failure of palliative care. It is an expression of autonomy that palliative care, by its nature, cannot provide.

This framework calls for both: the right to excellent palliative care and the right to choose assisted suicide within a tightly bounded law. These are not competing positions — they are complementary ones. Investing in palliative care and legislating for assisted suicide are not either/or choices. A society that genuinely respects its most vulnerable members must pursue both simultaneously.

A note on cultural pressure and the most vulnerable

This framework cannot and does not seek to govern freedom of speech, artistic expression, journalism, or public debate — the right to free speech is not restricted here.

It does, however, acknowledge that the most vulnerable people in society — including the elderly, disabled people, those with long-term conditions, and those dependent on others for their care — are disproportionately subject to cultural narratives in film, media, and public discourse that frame their lives as burdens, their suffering as undignified, and their deaths as merciful or inevitable.

We must ensure that no person in these groups ever finds themselves being murdered, euthanised, coerced, or pressurised into a decision about their own death — whether by family, medical professionals, financial systems, or the quiet weight of a society that has decided, implicitly or explicitly, that they would be better off dead.

The anti-coercion provisions in this framework, and the equality protection above, exist in direct response to that risk. Robust safeguards are not bureaucracy — they are the difference between a law that protects people and one that is used against them.

International comparison table
CountryTerminal onlyTerminal illness timelineDisability excludedMental illness excludedAdults 18+ onlyCoercion criminalisedDNR register reliability
My Proposal This framework (as above)
✔✔ None required✔✔✘ (Gate 4 for under-18)✔⚠ My Proposal

My Proposed Framework — a conceptual ethical framework by @fellowcreative, April 2026

The lawA terminally ill adult with confirmed mental capacity may request medically assisted suicide — provided the decision is entirely their own, voluntary, recorded, and free from all coercion.
Gate 1Terminal illness confirmed by two independent doctors. At least one must have an established professional relationship with the patient — ideally their long-term GP or familiar Consultant. This is about understanding the person, not just the illness. A patient with little prior contact with a healthcare professional is unlikely to be persistently seeking assisted suicide — the absence of a professional relationship is itself a natural, reasonable barrier. Unique requirement
Gate 2Mental capacity confirmed independently. Includes an advance consent exception for diseases that progressively destroy capacity — such as Alzheimer's — where written consent made while capacitous must be recorded and honoured.
Gate 3The request for medically assisted suicide must come from the patient alone — repeated, uncoerced, documented over time. A doctor may never initiate or suggest it. Coercion by any party risks a criminal offence.
Gate 4If the patient is under the age of 18, full parental or guardian consent is required in addition to Gates 1, 2, 3, and 5. Both the child's wish and parental consent must align; neither overrides the other without formal judicial review.
Gate 5 — DNRA Do Not Resuscitate order must be in place, requested by the patient alone. Recognises accessible communication methods for patients who cannot write or speak. Proposes integration with the national Blood Donor Register, with Category 0 (medical discretion) as the automatic default for all NHS-registered persons.
Terminal illnessQualifying illnesses defined in a fixed list enacted through primary legislation — no prognosis timeline required. Eligibility is defined by the illness, not the clock. The individual alone defines when the time is right. Unique position
DisabilityDisability alone never qualifies. A disabled person's wish to live must be supported with the same urgency as a non-disabled person's.
Mental illnessPsychiatric suffering without a co-existing qualifying terminal illness never qualifies.
CoercionExplicitly criminalised. Any family member, carer, or heir who coerces a patient's decision has committed a criminal offence, treated with the same seriousness as elder abuse.
ScopeHard-coded to terminal illness. Any expansion requires entirely new primary legislation — never a reinterpretation of this law. The slippery slope is prevented structurally, not by aspiration.
TerminologyAssisted Suicide, not Assisted Dying. Accurate language is a safeguard in itself — softened language reduces public scrutiny.
DNR categoriesFour proposed categories: 0 (default — medical discretion), 1 (full treatment), 2 (selective treatment), 3 (comfort-focused / do not resuscitate). Category 3 aligns with a Gate 3 and Gate 5 declaration. Any category changeable at any time by the patient, effective immediately once confirmed on the patient's record by their GP or registered healthcare provider.

Status: This is a conceptual ethical framework for debate — not a legal document. It was created by @fellowcreative to encourage thinking around the topics explored in the OU/BBC documentary Better Off Dead? (2024, Liz Carr), compiled with the help of AI (Claude Sonnet 4.6). It may contain factual errors — please comment to help identify any.

UK 🇬🇧 In progress — Lords 2026
✔6 months✔✔✔⚠ Partial2/10

United Kingdom 🇬🇧 (England & Wales only) — Terminally Ill Adults (End of Life) Bill, introduced October 2024 by Kim Leadbeater MP. Currently in Lords committee stage, April 2026. Applies to England and Wales only.

Who qualifiesAdults who are terminally ill and reasonably expected to die within 6 months. Terminal illness is defined as a progressive illness or disease that cannot be reversed by treatment. Aligned
DisabilityDisability alone does not qualify. The bill applies only to terminal illness within a 6-month prognosis. Aligned
Mental illnessMental illness alone does not qualify. A psychiatrist sits on the review panel and must assess capacity. Aligned
AgeAdults 18 and over only. Aligned
Two doctorsTwo doctors must independently assess eligibility and confirm the request is voluntary, clear, settled, and free from coercion. If both agree, the case goes to a review panel. Aligned
Doctor — prior relationshipNo requirement that either doctor has an established prior relationship with the patient. Gap vs. proposed
Review panelAn Assisted Dying Review Panel — consisting of a psychiatrist, a social worker, and a senior legal figure — must approve each case. Court approval was removed at committee stage and replaced by these panels. Stronger than most
CoercionBoth doctors must confirm the decision is voluntary and without coercion. However, coercion by a third party (family, carer) is not explicitly criminalised as a standalone offence under the bill as currently drafted. Gap
TerminologyThe bill uses the term "Assisted Dying" rather than "Assisted Suicide" — the deliberate softening of language that this framework specifically flags as a concern. Concern
DNR requirementNo specific DNR requirement is included in the bill. Gate 5 of this proposed framework has no equivalent. Gap vs. proposed
ScopeRestricted to terminal illness with a 6-month prognosis. No provision for disability, mental illness, or social deprivation. Lords amendments debated include clarifying that conditions manageable by treatment do not qualify. Aligned
Current statusPassed the Commons in June 2025. Currently in Lords committee stage — significant amendments being debated including safeguards for disabled people, capacity assessments, and the definition of terminal illness. Not yet law as of April 2026.

DNR register (2/10): England has no national DNR register. Decisions are recorded on fragmented, locally-varied paper or electronic forms held within individual NHS trusts. The burden falls on the patient to carry their own paperwork — in an emergency, an ambulance crew may have no way of knowing a DNR exists. A doctor can assign a DNACPR without the patient's consent, provided they inform them. During the Covid-19 pandemic, blanket DNACPRs were applied to care home residents and people with learning disabilities without individual assessment — a practice NHS England subsequently described as unlawful. The absence of a centralised, patient-controlled register is a critical gap: without it, Gate 5 of this framework cannot be reliably enforced or verified.

Verdict: The UK bill is broadly aligned with My Proposed Framework on the most critical points — terminal illness only, 6-month prognosis, adults 18+, two-doctor assessment, and a multi-disciplinary review panel. The meaningful gaps are: no requirement for a doctor with a prior relationship with the patient, coercion by a third party not explicitly criminalised, no DNR provision, and the continued use of the term "Assisted Dying" rather than "Assisted Suicide." The Lords committee stage is actively debating many of these safeguard gaps — the final bill may address some of them. View the bill on Parliament.uk →

Oregon 🇺🇸 Closest match
✔6 months✔✔✔✔5/10

Oregon 🇺🇸 — Death with Dignity Act 1997

Who qualifiesAdults with terminal illness and a life expectancy of 6 months or less. Aligned
DisabilityDisability alone does not qualify. Aligned
Mental illnessMental illness alone does not qualify. Aligned
MethodPatient must self-administer. The patient's final agency is fully preserved. Aligned
CoercionBoth doctors independently verify voluntariness; coercion is a punishable offence. Strong
Doctor — prior relationshipNo requirement that either assessing doctor has a prior relationship with the patient. Gap vs. proposed
Scope creepOregon's terminal illness boundary has held for nearly 30 years — the strongest evidence that a hard boundary can be sustained in practice. Aligned

DNR register (5/10): Oregon operates a POLST (Physician Orders for Life-Sustaining Treatment) system — a portable, standardised medical order that travels with the patient across care settings. It is more robust than England's approach and Oregon maintains a statewide electronic POLST registry. However it is not a full national register, and patient wishes can still be missed if the form is not immediately to hand in an emergency.

Verdict: Oregon is the closest single-country model to this framework. The terminal illness boundary has held for nearly 30 years without significant expansion — the strongest available evidence that a hard line can be sustained in practice.

Australia 🇦🇺 Closest match
✔6 months / 12 months neurodegenerative✔✔✔✔4/10

Australia 🇦🇺 — Voluntary Assisted Dying Acts 2019–2023 (all 6 states)

Who qualifiesAdults with terminal illness and a life expectancy of 6 months or less (12 months for neurodegenerative conditions). Aligned
DisabilityDisability alone does not qualify. Aligned
Mental illnessMental illness alone does not qualify. Aligned
MethodPatient self-administers where possible. A doctor may administer if the patient is physically incapable. The patient's final agency is preserved. Aligned
CoercionThree separate requests required with a minimum 9-day waiting period. Patient must initiate — a doctor may not suggest the option. Strong
Doctor — prior relationshipNo requirement that either assessing doctor has a prior relationship with the patient. Gap vs. proposed
Scope creepTerminal illness boundary maintained firmly across all six states since implementation. Aligned

DNR register (4/10): Australia's advance care planning system varies by state with no unified national database. Most states support advance care planning documents but these are not guaranteed to be accessible across all care settings or providers in an emergency. A patient's end-of-life wishes could be missed if they are treated outside their home state or by a provider without access to their local records.

Verdict: Australia's state-by-state approach is a well-designed conservative model with strong safeguards — particularly the requirement that patients initiate the request and make three separate requests over time. The terminal illness boundary has held firmly. The main gap versus this framework is the absence of a prior-relationship requirement for assessing doctors.

New Zealand 🇳🇿 Broadly aligned, gaps
✔6 months✔✔✔⚠ Not explicit4/10

New Zealand 🇳🇿 — End of Life Choice Act 2019, in force November 2021

Who qualifiesTerminal illness likely to end life within 6 months, with advanced and irreversible physical decline. Aligned
DisabilityDisability alone does not qualify. A disabled person may only qualify if they independently meet all terminal illness criteria. Aligned
Mental illnessMental disorder or illness alone does not qualify. Aligned
Doctor requirementTwo doctors must confirm eligibility, but only one needs to confirm that the request is voluntary — not both. No prior-relationship requirement. Gap
CoercionCoercion by a non-medical party is not explicitly a criminal offence under the Act — a notable gap versus the proposed framework. Gap
Waiting periodNo minimum waiting period specified. The process can take as few as 4 working days in a hospital setting. Concern
InitiationThe request must come from the patient — a doctor may not initiate or suggest the option. Aligned

DNR register (2/10): New Zealand supports advance care planning and has a standardised Advance Care Plan document, but there is no centralised national DNR register. Records are held locally by GPs or hospitals and are not guaranteed to be accessible across all care settings. A patient's expressed wish not to be resuscitated could go unrecognised in an emergency if they are treated by a provider who does not have access to their records. This is a meaningful gap in a framework where Gate 5 requires a DNR to be reliably on record.

Verdict: New Zealand is well-designed and holds the terminal illness boundary, but has meaningful gaps — particularly that coercion is not explicitly criminalised, only one doctor needs to verify voluntary intent, and there is no minimum waiting period. These are precisely the details that matter in practice.

Canada 🇨🇦 Significant scope creep
✘ Removed 2021✔ None required✘ Disability included⚠ Delayed to 2027✔⚠ Concerns raised2/10

Canada 🇨🇦 — Medical Assistance in Dying (MAID), C-14 2016, expanded by C-7 2021

Who qualifiesOriginally terminal illness only (2016). After 2021: anyone with a "grievous and irremediable" condition. Death no longer needs to be foreseeable. Breach
DisabilityPhysical disability qualifies if it causes intolerable suffering — terminal diagnosis not required. Cases have been documented where socioeconomic deprivation was cited as the primary driver. Breach
Mental illnessMental illness as sole condition was due to become eligible in 2024, repeatedly delayed, now set for March 2027. The direction of travel is toward inclusion. Warning
AgeAdults 18+ only. Under-18s not eligible. Aligned
Doctor requirementTwo independent assessors required. No requirement that either has any prior relationship with the patient. Gap
CoercionVoluntary request is required, but disability rights groups argue that safeguards are insufficient when socioeconomic deprivation is the underlying driver. Concern

DNR register (2/10): Canada has no national DNR database. The system is managed province by province with no unified standard — a CBC News investigation specifically highlighted Ontario's lack of a database for DNR documents. In practice, patients are often required to carry physical paperwork. Where socioeconomic deprivation has been cited as a driver of MAID requests, the absence of a robust DNR register compounds the concern that end-of-life decisions are not being made freely and on the patient's own terms — a fundamental gap in patient protection.

Verdict: Canada is the primary cautionary tale. Beginning with terminal illness in 2016, it removed that requirement entirely by 2021. The framework proposed here would be incompatible with Canada's current law on several critical points — most importantly the removal of the terminal illness requirement and the inclusion of disability as a qualifying condition.

Belgium 🇧🇪 Significantly broader
✘✔ None required✘✘✘ Minors included✔7/10

Belgium 🇧🇪 — Act on Euthanasia 2002, amended 2014 to include minors of any age

Who qualifiesAny patient with an "incurable illness" causing "constant, intolerable suffering." Terminal illness is not required. Breach
DisabilityPhysical disability and chronic conditions qualify if they meet the suffering threshold. Breach
Mental illnessPsychiatric illness — including depression — is legally eligible where deemed "incurable and intolerable." Breach
MinorsSince 2014, terminally ill minors of any age may qualify with parental consent and a psychiatric assessment. Broader than proposed
Advance directivesAdvance directives for euthanasia in the event of future incapacity — including dementia — are legally recognised. Significant concern

DNR register (2/10): Belgium has the most developed system among the countries reviewed. Citizens can register an advance euthanasia declaration with their municipal administration; it is added to the Federal Public Health Service's national database and is accessible to physicians. The declaration remains valid indefinitely and can be revoked at any time. Digitalisation of the process has been underway since 2025. However, this register covers advance euthanasia declarations specifically — it is not a general DNR register. Standard resuscitation preferences outside the euthanasia process are not covered by the same national infrastructure.

Verdict: Belgium has moved far beyond terminal illness — psychiatric illness, chronic disability, and dementia through advance directives all qualify. This is precisely the trajectory this framework is designed to prevent. Belgium is the European cautionary tale, in the same way Canada is the Commonwealth one.

Netherlands 🇳🇱 Significantly broader
✘✔ None required✘✘✘ From age 12✔4/10

Netherlands 🇳🇱 — Termination of Life on Request and Assisted Suicide Act 2002

Who qualifiesAnyone experiencing "unbearable suffering with no prospect of improvement." No terminal illness requirement. Includes Alzheimer's, Parkinson's, MS, and chronic conditions. Breach
DisabilityPhysical disability qualifies under the general suffering criterion. Breach
Mental illnessPsychiatric conditions can qualify in principle. Breach
AgeChildren from age 12 may apply. Parental consent required for ages 12–16; independent from age 16 upward. Far beyond proposed
NeonatalNeonatal euthanasia is regulated under the Groningen Protocol — for severely ill newborns. Unique globally. Far beyond proposed

DNR register (2/10): The Netherlands legally recognises advance directives — including written requests to withhold resuscitation — but there is no centralised national register. Documents are typically held by GPs or kept by patients themselves. The Dutch system relies heavily on the doctor-patient relationship to ensure wishes are known and respected, which works well in planned care settings but creates real risk in emergencies where the treating team may have no prior knowledge of the patient's wishes. The lack of a national register is a gap that undermines the principle that a patient's expressed wish to refuse resuscitation should always be honoured.

Verdict: The Netherlands operates the world's most expansive euthanasia regime for adults. The absence of a terminal illness requirement and the inclusion of children from age 12 places it entirely outside the boundaries proposed here. It represents the furthest point of expansion that a Western democracy has reached.

Switzerland 🇨🇭 Most permissive globally
✘✔ None required✘⚠ Varies by org.✔✘ No formal law1/10

Switzerland 🇨🇭 — Swiss Criminal Code Art. 115 (1942) — no dedicated national legislation

Who qualifiesAny adult with serious physical or mental suffering and no prospect of improvement. No terminal illness requirement. Legal provided the helper has no "selfish motive." Breach
ResidencyOpen to non-residents. Switzerland is the only country that accepts people travelling from abroad specifically for an assisted death — approximately one UK citizen per week. Unique risk
LegislationNo dedicated national law. Operated through private non-profit organisations (Dignitas, EXIT, Pegasos) under their own internal rules. No independent state oversight. No state safeguards
Mental illnessIn principle eligible. Practical application varies by organisation — no national standard. Significant concern

DNR register (2/10): Switzerland has no state-administered DNR register of any kind. Assisted dying is operated entirely through private non-profit organisations (Dignitas, EXIT, Pegasos) under their own internal processes. There is no national oversight body, no centralised database, and no requirement that a patient's resuscitation wishes be formally recorded or accessible across care settings. In a country where end-of-life decisions are already made outside formal state structures, the absence of any DNR infrastructure means a patient's right to refuse resuscitation is entirely dependent on the goodwill of the organisations and individuals involved — with no independent verification possible.

Verdict: Switzerland's model is the most permissive in the world — not because of active legislation but because of the absence of it. Private organisations with no state mandate, open to anyone internationally, with no terminal illness requirement. It is the polar opposite of the bounded, transparent framework proposed here.

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This is not a legal document. This is a conceptual ethical framework created by @fellowcreative to encourage his own and others thinking around the topics discussed/explored in the OU/BBC documentary Better Off Dead? (2024, presented by Liz Carr). International data sourced from the Canadian Department of Justice, New Zealand Ministry of Health, Library of Congress Global Legal Research Directorate (March 2024), and Death with Dignity's international tracker. Compiled with the help of AI (Claude Sonnet 4.6) this conceptual framework may contain factual errors, please comment below to help report, identify and resolve any issues.

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