Introduction
The current scope of global access to assisted dying is unprecedented. It is also expanding. Assisted dying is legal in fifteen countries and parts of two others,1 and at least four other countries are actively considering legalization.2 The vast majority of jurisdictions with assisted dying frameworks decriminalized or legalized the practice within the past fifteen years, and 37.5% did so within the past five years.3 Within this wave of new legislation roil debates about how assisted dying frameworks do and should affect vulnerable individuals. Some advocacy groups cite specific risks to the autonomy of vulnerable people, maintaining that “no number of safeguards . . . could be put in place that [would] offset the pressure” on vulnerable individuals to access assisted dying services.4
There are myriad ways to structure legal frameworks that govern assisted dying. Whatever their forms and particulars, they ought to be attentive to the unique needs of vulnerable individuals. The UK House of Commons’ Public Bill Committee recently considered, extensively debated, and rejected the possibility of excluding prisoners and unhoused people from accessing assisted dying.5 Several members criticized the proposed exclusion as a mechanism for discrimination,6 while another expressed concern that omitting the exclusion would create opportunities for vulnerable individuals to be improperly pressured into seeking assisted deaths.7 But neither these concerns nor the legal measures taken to address them have been robustly tested.
It can be difficult to discern whether carefully constructed legislative strategies actually protect the interests of vulnerable people as intended. Recent analyses suggest that people with relatively low socioeconomic status are less likely to access assisted dying services, across international jurisdictions.8 There are probably a host of reasons behind that finding: People with lower socioeconomic status tend to have reduced access to health care services generally9 — and particularly end-of-life care10 — as a function of rural geography, difficulty navigating administrative complexities, health care costs, and ancillary costs like transportation.11 Another contributing factor could be how lawmakers choose to structure frameworks for assisted dying administration. If the systems we’ve designed to protect vulnerable patients actually exclude them, as UK legislators suggest they might, is there a misalignment between the actual and intended effects of existing assisted dying safeguards?12
This Note makes two contributions: First, Part II summarizes existing literature and supplies novel statistical analyses to reveal that, even in jurisdictions with supposedly permissive assisted dying frameworks, there’s no conclusive evidence of an association between socioeconomic vulnerability and an increased likelihood of accessing assisted dying. Second, Part III compares all international assisted dying frameworks across twelve axes, providing a comprehensive matrix of the restrictions that judges and lawmakers have imposed on assisted dying access. The first contribution undermines an established ethical critique of assisted dying legalization — which is outlined at Part III — by challenging the idea that assisted dying poses special risks to socioeconomically vulnerable people. The second contribution offers an infrastructure for scholars and lawmakers searching for ways to protect the interests of socioeconomically vulnerable patients who seek assisted dying services, and to assess the efficacy of those protective measures.
Before proceeding, a brief note on terminology is in order: This Note uses the term assisted dying to describe all methods by which a person acts to hasten the death of another person, at the recipient’s voluntary request.13 Different jurisdictions and scholars use various labels to describe assisted dying practices.14 The analysis below adopts the following definitions: Assisted dying encompasses both physician-assisted dying, where a health care provider helps a person to terminate their own life by providing medication for self-administration, and forms of assisted dying where a person (generally a health care provider15) administers medication to end the life of the recipient.16
I. Vulnerability and Autonomy Discourse: The Background Inequality Critique
There are many ways to define and measure vulnerability, from both legal and bioethical perspectives.17 Some authors frame the concept by identifying specific at-risk groups whose members are more likely to experience undesirable outcomes, like coercion.18 Professor Martha Fineman, on the other hand, emphasizes universality: Each of us will be vulnerable at some point in our lives, by virtue of age, illness, injury, or social factors, so it’s a mistake to define vulnerability in binary at-risk/not-at-risk terms.19
This Note focuses on the socioeconomic facet of vulnerability, which has become a critical part of discussions about assisted dying.20 When the U.S. Supreme Court heard Vacco v. Quill21 in 1997, amici curiae from across the country wrote to warn the Court of the danger assisted dying might pose to impoverished people.22 Individual cases continue to inspire (often heavily sensationalized23) headlines.24 Debating the UK’s recent assisted dying bill, Member of Parliament Lewis Atkinson said the following about the nexus of socioeconomic vulnerability and end-of-life decision making: “At the moment, at the end of life, wealth clearly is advantaged. Those who are wealthy and are able to go to Switzerland do have choice at the end of life. Dignity and independence and autonomy should not be based on ability to pay.”25
Atkinson clips the surface of a rich debate. Among the arguments relevant to that debate is the background inequality critique, which proceeds in two steps: First, socioeconomically vulnerable individuals might choose assisted dying as a result of their vulnerability26 — for example, because they feel like burdens on their support networks27 or socioeconomic suffering leaves them unable to access supportive care.28 Even if these individuals want to access assisted dying, that preference may therefore be “adaptive” or “inauthentic.”29 Second, no number or arrangement of safeguards would be sufficient to alleviate this concern, insofar as background social inequalities in access to palliative care and other resources continue to effect pressure on the decisions of vulnerable people.30
The background inequality critique doesn’t address socioeconomic vulnerability alone, and this Note’s focus on socioeconomic aspects of vulnerability shouldn’t be read to imply as much. Proponents highlight meaningful intersections between poverty and disability, articulating a concern that people will seek assisted deaths not only as a direct result of poverty,31 but also because of the way poverty confounds proper treatment of their existing health conditions.32 More surreptitiously, poverty across an individual’s lifespan can make them more likely to develop health conditions, and specifically poor prognoses stemming from those health conditions, that could underlie a decision to seek assisted dying.33
This critique is also not an ethical slippery slope argument. Proponents of slippery slope arguments posit that legal frameworks seeming at first blush to be sufficiently protective of vulnerable people will necessarily engender “unwanted, unintended, and undesirable events,”34 like extending assisted dying to certain minors.35 But according to the background inequality critique, the proverbial slope has no peak — the argument is not that one regulation will spur the promulgation of other, less desirable ones, but that no conceivable set of restrictions can produce a just system of assisted dying administration.36
Scholars have offered compelling counterarguments to the background inequality critique. Adapting language that Justice Lynn Smith had used in an appellate decision37 that “paved the way” for the Supreme Court of Canada to announce the decriminalization of assisted dying in Carter v. Canada (Attorney General),38 Professor Udo Schüklenk argues that the critique “hold[s] decisionally capable people . . . hostage to the establishment of [a] perfect system” that will almost certainly never materialize.39 And the critique doesn’t provide much guidance as to how harms should be mitigated after legalization. Professors Alexandra Mullock and Jonathan Lewis argue that banning assisted dying out of concern for the autonomy of vulnerable individuals can have the paradoxical effect of creating “pathogenic vulnerability”40 because it presents new threats to autonomy, like being unable to afford travel to a permissive jurisdiction.41
One question central to ethical conversations about assisted dying is therefore whether its recipients tend to have, empirically speaking, relatively limited financial means. The literature review and analyses at Part II suggest that they do not; this undercuts the background inequality critique because it provides descriptive evidence that patients may be choosing, in the statistical aggregate, to access assisted dying for reasons other than socioeconomic vulnerability or its effect on their physical and mental health.
II. Documenting and Interpreting Rates of Assisted Dying Uptake by Socioeconomically Vulnerable Patients
Socioeconomic vulnerability, even apart from its intersections with other forms of vulnerability, can be defined malleably and expansively. One common strategy is to aggregate various factors contributing to socioeconomic status,42 like financial stability, educational attainment, housing security, and employment.43 This descriptive plurality also pervades the ways that international jurisdictions choose to structure centralized reporting on assisted dying. Almost every jurisdiction that has decriminalized or legalized assisted dying maintains a reporting system and issues annual descriptive analyses,44 but they rarely agree on precisely which data should be reported.45 Data collection is particularly scattershot with respect to socioeconomic indicators.46
To investigate the impact of socioeconomic vulnerability on assisted dying access is therefore to navigate a thicket of proxies. No local authority has directly linked assisted dying data to household income data. But, as discussions about socioeconomic vulnerability plainly contemplate more than just gross income levels,47 so too should statistical analyses of socioeconomic vulnerability. An individual’s employment status, education history, insurance coverage, and location of residence can also tell us something about whether they are likely to live on higher or lower incomes, or to have done so in the past, and how resilient they are against the economic pressures of a serious illness.48
This Part divides publicly reported descriptive analyses into two subject matter categories — income data and education data — to summarize available information that can be used to assess how socioeconomically vulnerable people use assisted dying services. Neither the results of independent studies nor novel analyses of government summary reports support the contention that socioeconomic vulnerability makes affected individuals more likely to choose an assisted death.
A. Geographically Estimated Income Data
No jurisdiction in the world directly collects data respecting the personal incomes of assisted dying recipients,49 so scholars and governments have used patients’ residential addresses to estimate their income quintiles. The literature boasts five comparisons of estimated incomes among assisted dying recipients to income levels in a reference population — four from Canada50 and one from Switzerland.51 None revealed that individuals with relatively low estimated incomes were disproportionately likely to access assisted dying.52 A few other studies have assessed socioeconomic distribution among assisted dying recipients, but without comparison to a broad reference population.53 Provincial and federal governments in Canada have also used marginalization indices to describe the socioeconomic statuses of assisted dying recipients as opposed to those of people in a baseline population — with mixed results.54
B. Education Data
Formal education is a useful indicator of socioeconomic vulnerability because it correlates with higher incomes.55 U.S. states consistently document the educational attainment level of assisted dying recipients,56 while other jurisdictions don’t report educational data57 or do so inconsistently.58 And while other scholars have aggregated these data in the past, they don’t situate their analyses using a baseline reference population.59 This omission is meaningful because the proportions of assisted dying recipients with certain educational attainment levels tell us precious little unless we know what we should expect to observe. Assume, for example, that 25% of people who access assisted dying don’t hold high school diplomas — this value could be disproportionately low or high, depending on the percentage of people in the baseline population who hold diplomas.
One limitation affecting U.S. analyses is a lack of public access to information about individual patients (or microdata). While other jurisdictions maintain microdata sets and carefully restrict access,60 every U.S. state that provides for centralized reporting prohibits disclosure of microdata to any member of the public.61 California’s statute forbids disclosure even to a court of law.62 This poses a transparency issue because it heavily restricts analysis of whether U.S. assisted dying frameworks are being implemented safely, fairly, and equitably.
Nonetheless, summary data offered by various U.S. states can facilitate meaningful comparisons between assisted dying recipients and reference populations. Table 1 shows the most recent four years of assisted dying and educational attainment data across states who report it and compares these values to state-specific estimates of educational attainment from the Census Bureau’s 2023 American Community Survey.63
The analysis at Table 1 is limited in the following ways: First, it uses census data as a reference, which is generally useful in the U.S. context because all but three states limit access to permanent in-state residents.64 Data from one of these three states suggest that very few nonresidents use the service.65 It would have been preferable to use a more narrowly tailored reference population, such as data respecting everyone who requested access (which is unavailable because U.S. states don’t report data for requests that were ruled ineligible66), everyone who was eligible to make a request (which is unavailable because eligibility is assessed only for those who make requests67), or everyone who died of any cause within the reporting year (which is unavailable because U.S. states don’t publicly report educational data for this group68). Second, educational attainment is an imperfect proxy for income. While individuals with relatively high educational attainment earn more, on average, than those without,69 the financial circumstances of specific individuals may vary. (A tenured professor with a doctorate, for example, could become impoverished because illness left her unable to work.) And third, the analysis is confounded by age. While some of the people within the samples are too young to have earned postsecondary degrees, they must be included because it isn’t possible to stratify assisted dying educational data by age without information about individualized entries.70 As a robustness check pertaining to age, Table 1 also provides a reference value for people aged sixty-five years and up to facilitate assessment of whether older adults (who are more likely to suffer from terminal illnesses71) are disproportionately more educated than their younger counterparts. If this were true (which Table 1 reveals is not the case72), using a reference population of all adults could have overestimated the expected proportion of assisted dying recipients with relatively little formal education because recipients are older, on average, than the reference group.73
Table 1: Educational Data
Reference Population74 | Assisted Dying Data75 # of cases (% of annual cases) | ||||||||
Aged 18+ yrs | Aged 65+ yrs | 2021 | 2022 | 2023 | 2024 | ||||
California76 n=30,527,864 | HS/GED/Unreported77 | 36.8% | 121 (23.2%) | 201 (23.6%) | 222 (22.9%) | 256 (24.8%) | |||
Some/AD78 | 28.6% | 121 (23.2%) | 210 (24.6%) | 252 (26.0%) | 262 (25.4%) | ||||
Bachelor’s/Higher79 | 34.6% | 33.8% | 280 (53.6%) | 442 (51.8%) | 495 (51.1%) | 514 (49.8%) | |||
Colorado80 n=4,666,930 | HS/GED/Unreported | 28.4% | 43 (21.0%) | 58 (19.7%) | 85 (23.5%) | 116 (27.0%) | |||
Some/AD | 28.8% | 39 (19.0%) | 58 (19.7%) | 80 (22.1%) | 94 (21.9%) | ||||
Bachelor’s/Higher | 42.8% | 43.1% | 123 (60.0%) | 179 (60.7%) | 197 (54.4%) | 219 (51.0%) | |||
District of Columbia81 n=552,446 | HS/GED/Unreported | 21.6% | 1 (16.7%) | 0 | Unpublished | ||||
Some/AD | 16.8% | 0 | 0 | ||||||
Bachelor’s/Higher | 61.6% | 49.7% | 5 (83.3%) | 8 (100%) | |||||
Hawaii82 n=1,141,251 | HS/GED/Unreported | 35.2% | 16 (55.2%) (12 unreported) | 18 (48.6%) (10 unreported) | 26 (51.0%) (23 unreported) | Unreported | |||
Some/AD | 30.5% | 1 (3.4%) | 3 (8.1%) | 5 (9.8%) | |||||
Bachelor’s/Higher | 34.3% | 35.1% | 12 (41.4%) | 16 (43.2%) | 20 (39.2%) | ||||
New Jersey83 n=7,281,676 | HS/GED/Unreported | 35.4% | 11 (22.0%) | 33 (36.3%) | Excluded84 | 41 (33.6%) | |||
Some/AD | 23.3% | 6 (12.0%) | 5 (5.5%) | 17 (13.9%) | |||||
Bachelor’s/Higher | 41.3% | 35.0% | 33 (66.0%) | 53 (58.2%) | 64 (52.5%) | ||||
Oregon85 n=3,403,557 | HS/GED/Unreported | 32.2% | 72 (28.2%) | 73 (26.3%) | 112 (29.0%) | 122 (32.4%) | |||
Some/AD | 32.8% | 66 (25.9%) | 69 (24.8%) | 95 (24.6%) | 86 (22.9%) | ||||
Bachelor’s/Higher | 35.0% | 34.5% | 117 (45.9%) | 136 (48.9%) | 179 (46.4%) | 168 (44.7%) | |||
To provide conservative estimates, Table 1 adds unreported entries to the “High School Diploma, GED, or Less” category. This mitigates any concern that unreported entries could be concealing the true proportion of recipients within this category because patients and physicians are, for some reason, less likely to document education levels for patients with lower levels of attainment. This strategy also has the effect of skewing results in favor of finding disproportionate access by individuals with relatively low educational attainment.
Across all four reporting years, there are five instances where the proportion of assisted dying recipients within the “High School Diploma, GED, or Less, or Unreported” attainment level exceeds the corresponding reference proportion. According to careful analysis using hypothesis tests of proportions, none of these five results establishes that people occupying these (relatively low) educational attainment categories are accessing assisted dying at a disproportionate frequency.
1. New Jersey. — One of the five instances arose in New Jersey during the 2022 reporting period, where the proportion of recipients in the lowest educational attainment category was 0.9 percentage points higher than the reference proportion. This Note uses a one-sided, one-sample test of proportions based on the binomial distribution to assess whether this deviation from the reference proportion was statistically significant, using a standard significance level of 5%.86
Assuming the null hypothesis is true, there was a 47.1% probability of observing thirty-three or more individuals within the “High School Diploma, GED, or Less, or Unreported” category, as New Jersey officials did in 2022.87 Since this p-value exceeds the 5% threshold, these data do not justify the rejection of the null hypothesis that the relatively high proportion in 2022 can be attributed to random chance.
2. Oregon. — In Oregon’s 2024 reporting year, the proportion of assisted dying recipients within the lowest attainment category exceeded the baseline proportion by 0.2 percentage points. Applying the same hypothesis test of proportions as in subsection III.B.1 above,88 the resulting p-value is 0.479. This result likewise does not justify the rejection of the null hypothesis.
3. Hawaii. — The remaining three highlighted instances arose in Hawaii during the 2021, 2022, and 2023 reporting years. Applying the same hypothesis test produces the following results89: p-values of 0.022 for the 2021 reporting year,90 0.064 for 2022,91 and 0.015 for 2023.92 At first glance, these results indicate that we should reject the null hypothesis as to 2021 and 2023 — in other words, that the elevated representation of individuals within the lowest attainment category during these reporting years cannot be attributed to random chance alone.
But per Table 1, nonreporting was unusually prevalent in Hawaii, where up to 45.1% of entries (in 2023) did not include educational data. Table 1 assumes, for the sake of caution, that every unreported entry was a recipient in the lowest attainment category. But if one excludes all unreported entries from the analysis, access by individuals falling into the lowest category doesn’t exceed the reference proportion in any of the three relevant reporting years: As opposed to 35.2% in the reference population, 23.5% of recipients from the 2021 sample,93 29.6% from the 2022 sample,94 and 10.7% from the 2023 sample95 fall within the lowest category. The disappearance persists if one imputes unreported entries according to the proportions observed in reported entries, such that 24.1% of 2021 cases,96 29.7% of 2022 cases,97 and 9.8% of 2023 cases98 fall into the lowest category.
4. Low Educational Attainment Is Associated with Lower Uptake of Assisted Dying Services. — To summarize, the four most recent years of data respecting the educational attainment characteristics of assisted dying recipients don’t indicate that people with relatively low educational attainment are accessing assisted dying with greater frequency than those with relatively high attainment. In fact, hypothesis testing at Table 2 reveals that the opposite is true: People with relatively low educational attainment are disproportionately unlikely to access assisted dying services, and this difference is statistically significant. Table 2 applies the same methodology described at subsections III.B.1 to III.B.3 to every instance where the number of assisted dying recipients in the lowest educational attainment category fell below the reference proportion.
Table 2: Low Educational Attainment Is Associatedwith Reduced Uptake of Assisted Dying99
2021 | 2022 | 2023 | 2024 | |
California | < 0.0001*** | < 0.0001*** | < 0.0001*** | < 0.0001*** |
Colorado | 0.0098*** | 0.0004*** | 0.0204** | 0.286 |
Hawaii100 | 0.146 | 0.305 | < 0.0001*** | Unreported |
New Jersey | 0.0301** | Higher than reference proportion | Excluded from Table 1 | 0.378 |
Oregon | 0.0979* | 0.0186** | 0.0821* | Higher than reference proportion |
P (X≤x) x=number of people in the lowest educational attainment category in a given year P=probability of observing the “High School Diploma, GED, or Less,or Unreported” result within the census baseline n=total number of assisted dying recipients in the same year Stars indicate significance level: *** p < 0.01; ** p < 0.05; * p < 0.1 | ||||
Thus, on most occasions when assisted dying uptake by individuals in the lowest educational attainment category was lower than the reference proportion, the magnitude of that difference was not attributable to random chance. One possible explanation for this result is that U.S. frameworks impose barriers to assisted dying access that are disproportionately burdensome to individuals living on relatively low incomes.
Table 2’s results — as well as existing efforts to assess the socioeconomic distribution of assisted dying recipients101 — therefore reveal no trend toward disproportionate access by people with relatively low socioeconomic status. This finding both undermines the background inequality critique’s premise that socioeconomic vulnerability (among other forms of social vulnerability) is likely to drive people to choose assisted dying, and also raises concerns that assisted dying frameworks may be disproportionately excluding socioeconomically vulnerable people as a side effect of various measures to safeguard access.102
But this conclusion merits a few important qualifications: First, in spatially large jurisdictions with vast disparities in urban and rural health care access, the socioeconomic distribution of assisted dying uptake may look different as to urban or rural residents than it does in the aggregate — so optimally, reference data would be specific to each region. But data from one state suggest that rural residents make up a very small proportion of assisted dying recipients,103 so these disparities are difficult to assess and unlikely to make a meaningful analytical difference. Second, variability in jurisdictions’ data collection practices means that direct comparisons aren’t always possible. Third, it’s often impossible to resolve this comparability issue because many jurisdictions don’t allow public access to assisted dying microdata. U.S. states, for example, are bound by statute to withhold this data from the public.104 And fourth, descriptive analyses like this one can show how many people from a specific socioeconomic group accessed assisted dying, but cannot assess confounding demographic factors — like the prevalence of terminal underlying diagnoses due to poor preventive care access — that could help to explain those results. Available data are therefore by no means irrefutably conclusive on the question of how legislative decisionmaking impacts the probability that socioeconomically vulnerable people will access assisted dying.
III. A Comprehensive Descriptive Matrix for the Restrictiveness of International Assisted Dying Programs
The empirical analyses at Part II supply a partial answer to the background inequality critique. They suggest that, at least in the statistical aggregate, socioeconomically vulnerable people are not rushing to access assisted dying services more frequently than their relatively less vulnerable counterparts. But a second and equally critical question is whether specific individuals, apart from the statistical whole, are adequately protected from coercion by existing safeguards. While “[p]overty is not incompatible with autonomous decision-making,”105 “economically disadvantaged individuals do in fact make decisions differently as a result of their experience of poverty.”106 The contention that poverty is not itself a ground to withhold assisted dying access should not be confused for a declaration that no one can exert financial pressure against a patient,107 or that remediation of suffering — including suffering exacerbated by financial scarcity — needn’t be prioritized.
Though the background inequality critique doesn’t reflect statistical reality, it may yet encourage scholars and legislators to think carefully about how assisted dying delivery frameworks can best respect the needs of vulnerable individuals. This Part does more to contextualize the background inequality debate by articulating the ways that legal decisionmakers have tried to address the potentially coercive effect of socioeconomic vulnerability. It also sets the stage for future inquiries into whether these safeguarding measures are up to that task — or perhaps overreaching it, as UK lawmakers feared.108
There’s considerable uniformity of thought among jurisdictions with comprehensive assisted dying legislation. In Germany,109 Italy,110 and Montana,111 constitutional courts have overturned criminal prohibitions on assisted dying, but legislators have yet to implement frameworks for access, and in Switzerland, legislators decriminalized assisted dying in 1937112 but never enacted a comprehensive framework. In all other relevant jurisdictions, the following requirements hold fast: Requests must be voluntary and enduring, in that they’re repeated over time and may be withdrawn at any time;113 recipients must have an underlying illness or condition;114 and health care providers must inform recipients about their illnesses or conditions, the alternatives available to them, and the assisted dying procedure.115
But in other respects, legislative approaches differ widely. Required waiting periods between initial and final requests range from ninety days to twenty-four hours, and may or may not be waivable.116 Some jurisdictions allow mental illnesses to satisfy diagnostic requirements for accessing assisted dying, while others specifically foreclose that possibility,117 treat individuals experiencing mental illnesses with elevated scrutiny,118 or leave this question entirely open.119 Commenters often refer qualitatively to the restrictiveness of assisted dying frameworks,120 but to date have taken few pains to compare different frameworks in terms of the safeguards they impose. As a result, different voices use permissive, restrictive, and similarly polar terminology to describe the same frameworks: Commenters have described the Netherlands’s decades-old framework as both “really strict”121 and “worryingly permissive.”122 This creates difficulties for scholars and legislators by obscuring how different legislative safeguards have actually affected vulnerable patients and how these effects should inform future lawmaking.
In response to this confusion, this Note proposes a comprehensive descriptive matrix — detailed in full at the Appendix123 — that outlines each jurisdiction’s assisted dying framework in twelve categorical respects. Each of these twelve restrictions has been selected because evidence indicates that it curtails access, procedurally and/or substantively, for a meaningful number of people who might otherwise use assisted dying services. In other words, this Note defines “restrictiveness” as a measure of an assisted dying framework’s capacity for exclusion of particular groups of people from access; the more categorical restrictions a framework imposes, the more restrictive it is.
It’s important to note that a relatively low number of “restrictions” doesn’t necessarily make it logistically easier to access assisted dying. For example, Colombia’s Ministry of Health and Social Protection amended assisted dying regulations in 2021 to extend eligibility to patients lacking terminal diagnoses,124 but six months would pass before the first patient without a terminal illness accessed assisted dying, amid much debate and frustration.125 In the Netherlands, a shortage of psychiatrists means that it takes an average of two years for a patient to access assisted dying for suffering stemming from a mental illness.126 So legislative restrictions on who may access assisted dying and how eligible persons may do so are just one set of barriers, or safeguards, to access.
To describe assisted dying frameworks in terms of their restrictiveness, this Note identifies a comprehensive scheme of twelve constraints on access that policymakers have incorporated to date: (1) prohibiting anyone other than the patient from administering assisted dying medication;127 (2) requiring that death be expected within a specific timeframe;128 (3) barring the use of mental illness as a diagnosis justifying a request;129 (4) prohibiting the use of advance directives for individuals who lose decisionmaking capacity;130 (5) requiring that patients satisfy certain diagnostic criteria, like incurability;131 (6) excluding patients who are minors;132 (7) imposing a citizenship or residency requirement;133 (8) requiring confirmation of eligibility from two health care providers;134 (9) requiring that a committee confirm eligibility;135 (10) requiring a written declaration of intent from the patient;136 (11) imposing a waiting period between an initial request and receipt of assisted dying;137 and (12) enforcing centralized monitoring and reporting.138
This comprehensive matrix yields surprising results. For example, some sources characterize Canada’s requirements as “among the broadest in the world”139 and “looser than those of Belgium and the Netherlands,”140 but this claim doesn’t bear out empirically. Among seventeen countries that have decriminalized or legalized assisted dying across the nation or in specific states, eleven impose fewer categorical restrictions than Canada or contain at least one state that does.141 Even excluding countries where the practice is decriminalized by way of a constitutional court decision without any legislative framework,142 Canada surfs the middle of the restrictiveness wave. A similar phenomenon afflicts Belgium’s framework, which commenters have erroneously called “the world’s most liberal euthanasia law.”143 The matrix also clarifies various similarities and distinctions among international frameworks. Centralized reporting, for example, is a nearly universal restriction, whereas only four jurisdictions allow mental illness to be a ground for an assisted dying request144 and roughly half impose residency or citizenship requirements.145
Sometimes, generalizations about the restrictiveness of an assisted dying framework may reveal more about whether an author approves of a particular component thereof than the comprehensive picture of relevant law within the jurisdiction. For example, one source argues that Canada originally had “strict eligibility criteria” but is now exceedingly permissive, and attributes that change to the legislature’s 2021 decision to remove a requirement that death be “reasonably foreseeable.”146 And the lack of a categorical restriction against nonterminal diagnoses is a common subject of discourse on so-called “suicide tourism” in Switzerland,147 though it’s only one factor contributing to the overall restrictiveness of an assisted dying framework.
Objective, systematic descriptions of assisted dying frameworks are therefore critical to facilitating productive discussion about how legislation can serve the particularized needs of socioeconomically vulnerable people seeking assisted death. While any attempt to describe the restrictiveness of legislation is vulnerable to potential bias — for example, stemming from the selection of the categories — a descriptive matrix mitigates (or at least elucidates) those biases by forcing them into the open.
Another important use of the matrix is to situate future comparisons of international data respecting assisted dying uptake. At present, no one has attempted a direct comparison of international data on the socioeconomics of assisted dying access, and indirect comparisons are necessarily imperfect. But if we do observe differences in socioeconomic indicators as between different jurisdictions, we can assess whether those differences correlate with specific access restrictions. For example, both existing Swiss research and the section II.B U.S. education analyses revealed a statistically significant correlation between higher (estimated) socioeconomic status and the probability of accessing assisted dying.148 So this correlation seems to hold even among countries that impose vastly different legislative safeguards on assisted dying access.
This descriptive scheme should be qualified twice over. First, its author was responsible for selecting the categorical restrictions. This selection process was not arbitrary, but it was necessarily vulnerable to bias — to mitigate this concern, this Note provides a detailed explanation of the justifications for including and excluding specific variables. Second, the scheme doesn’t address extralegal constraints on the delivery of assisted dying services, like professional guidelines. While some professional bodies may ground disciplinary decisions on noncompliance with professional guidelines, these guidelines don’t carry the coercive force of law. Also, the restrictiveness scheme is intended in part to guide legislative decisionmaking, and lawmakers cannot predict before enacting or amending a statute which guidelines professional organizations might impose.
Conclusion
As a statistical matter, available data indicate that people with indicators of socioeconomic vulnerability aren’t accessing assisted dying at an outsized frequency; this distinctly undermines the background inequality critique of assisted dying legalization. But this doesn’t mean that any given individual is impervious to the risk of coercive pressures stemming from a lack of financial resources. Understanding existing restrictions on assisted dying access is necessary for determining how the interests and wishes of socioeconomically vulnerable people can be best respected as they make existential decisions about the ends of their lives. With the understanding that assisted dying has arrived on the global scene and is here to stay, this Note posits a comprehensive matrix of twelve categorical restrictions that will facilitate productive assessment of how lawmakers’ choices affect vulnerable people.