Assisted dying is a modern term for an ancient idea and practice that has been a topic of discourse throughout history. It encompasses two forms: euthanasia and physician-assisted suicide (PAS). Euthanasia involves deliberately ending a person’s life by (a) administering lethal medications; or (b) withholding or withdrawing life-sustaining medical treatments. PAS, on the other hand, involves deliberately assisting another person to end their life by prescribing lethal medications for them to self-administer. Both share the same objective: relieving someone from irreversible and intolerable suffering, particularly caused by medical conditions.
Although driven by compassionate intentions, assisted dying has sparked controversy because it involves debates about the autonomy individuals have over their lives, the moral and ethical conundrums faced by physicians, and the State’s role in regulating matters of death and suffering. Furthermore, assisted dying is inherently political, as evident in the labels attached to the ‘primary actors’: “patients,” “dying people,” or “murder victims” for those who request assistance in ending their lives; “physicians” or “murderers” for those who assist in ending others’ lives; and “grieving relatives,” “victims,” or “murder accomplices” for the families. These labels reflect the different positions in the ongoing discourse surrounding assisted dying.
At the center of this controversy stands the right-to-die movement. For decades, it has been advocating for the decriminalization and legalization of assisted dying worldwide. More significantly, it champions the right and autonomy in choosing or refusing medical treatments. Given the importance and contentious nature of the movement and the cause it fights for, it is essential to explore its roles and impacts on the global politics of assisted dying.
Social movements and four core questions
Social movements are defined as distinct social processes, in which a plurality of actors, connected through informal networks and shared collective identities, are engaged in conflictual relations with clearly identified opponents. Their dynamics involve four key aspects: (1) Networks of informal interaction, ranging from loose and dispersed links to tightly clustered networks; (2) Shared beliefs and solidarity that delineate the boundaries between internal actors and external observers; (3) Collective action on conflictual issues aimed at either promoting or opposing social change; and (4) ‘Unusual’ patterns of behavior primarily occurring outside the institutional sphere and the routine procedures of social life.
Based on the locus of change (individual or supra-individual) and its extent (partial or total), social movements can be classified into four types: alterative, redemptive, reformative, and transformative Alterative movements seek to bring about partial change in individual beliefs and behaviors, e.g., birth control movements. Redemptive movements also target individual beliefs and behaviors, but their ultimate goal is to create a total change (often through a search for purpose and meaning), e.g., religious movements. Reformative movements strive for partial change in the social system, e.g., the women’s suffrage movement. Transformative movements are the most radical because they aim to completely change the social system, e.g., the civil rights movement.
Four sets of questions serve as guidelines for comprehending the intricate and multifaceted nature of social movements. The first question (“How does social change create the conditions for the emergence of new movements?”) refers to the correlation between structural change and the transformation of social conflict patterns. One of the many reasons behind the emergence of social movements is a desire to reject political-administrative intervention in daily life and to defend or reclaim individual rights and autonomy.
The second question (“How are issues and actors defined as worthy objects and subjects?”) refers to the role of cultural representations in social conflicts. Social movements are not just reflections of social crises—they are catalysts for change. Therefore, social movements signify endeavors to alter the status quo and are always accompanied by the emergence of new rules, norms, and solidarities.
The third question (“How is collective action possible?”) refers to the process of translating values, interests, and ideas into collective action. To achieve their goals, conscious actors involved in social movements strategically evaluate the costs and benefits of mobilizing collective resources, whether they are material (e.g., work, money, concrete benefits, and services) and/or nonmaterial (e.g., authority, moral engagement, faith, and friendship). This mobilization derives from the movements’ ability to effectively organize discontent, minimize the costs of action, establish and utilize solidarity networks, distribute incentives among members, and attain external consensus.
The final question (“What determines the forms and intensity of collective action?”) refers to the impact of specific social, political, and/or cultural contexts on the success and manifestations of social movements. Elements such as political opportunity structure, cultural context, dominant discourses in the public sphere, and transnational opportunities play crucial roles in determining the ‘longevity’ of a social movement.
Regulating death and suffering
The historical narrative of assisted dying can be traced back to ancient Greece and Rome. The Hippocratic Oath, one of the oldest and most renowned medical texts, contains an explicit condemnation of assisted dying: “I will not give a lethal medication to anyone if I am asked, nor will I advise such a plan.” Nonetheless, physicians in ancient times would sometimes still provide lethal substances to their patients upon request. This practice was rooted in the widespread beliefs that it was (a) understandable for an individual suffering from severe illness and excruciating pain to contemplate ceasing to live; (b) deemed justifiable for someone to choose death as a way to escape torturous agony, maintain their dignity, and preserve their essence as a person in the face of conditions that would diminish their quality of life; and (c) unethical to prolong the life of a dying person whose suffering has already exceeded humanly bearable limits.
In the centuries that followed, with the rise and ascendancy of the Church, there was a dramatic turnabout: taking one’s own life was considered abhorrent. Those who attempted against their own lives would face social ostracism, be denied a proper burial, and be stripped of their possessions. Unlike the beliefs held in ancient Greece and Rome, enduring pain and suffering was now seen as a path to glorification—a part of God’s plan that should not be tampered with, whether by prolonging or hastening it. These principles were later codified into common law, resulting in “self-murder” being deemed a criminal offense in many countries.
During the Enlightenment, people began to challenge the Church’s previously unquestionable authority and teachings. This intellectual movement led to the secularization of society and reshaped people’s understanding of issues such as liberty, equality, and individual rights. As a result, the idea that everyone has the right to ownership over their body (and, by extension, life) was born. According to this thinking, the State has no right to punish people who choose to end their lives (or those who assist them in doing so), especially if the motive is to relieve the suffering caused by medical conditions—which are also beyond the State’s control.
The advent of modern science during the Enlightenment also led to a shift toward a more secular approach to medical ethics. Instead of focusing solely on the commitment to healing and preserving patients’ lives, this new approach emphasizes the need for physicians to understand and alleviate patients’ suffering, as well as to respect their autonomy—even if that means allowing them to choose death. Related to this development, Samuel Williams, in his 1870 essay, introduced the idea of using analgesics to give a swift and painless death at patients’ request in cases of hopeless and agonizing illness—although similar practices had been reported throughout the 19th century.
Entering the 20th century, the support for assisted dying—mostly focused on voluntary euthanasia—waxed and waned. There was a rise in euthanasia societies in the 1930s. However, it diminished quickly in the 1940s due to systemic murder committed by the Nazis under the Aktion T4, a eugenics-based involuntary euthanasia program. Two decades later, advancements in medical technology, which offered new interventions in the health-disease process, revived interest in euthanasia. This, combined with increased life expectancy and the prevalence of chronic illnesses, started to change people’s perceptions of the terminal state of life and the options that should be available to those with incurable conditions.
From the 1960s onwards, there have been significant developments that reconfigured the landscape for the discourse about assisted dying. One pivotal development was the wave of suicide decriminalization. The U.K. and New Zealand initiated this in 1961, followed by Hong Kong in 1967, Canada in 1972, Ireland in 1993, and Sri Lanka in 1998—it is worth noting that some countries had already done it much earlier, including Germany in 1751, France in 1791, Norway in 1842, Sweden in 1864, Denmark in 1868, Finland in 1910, and Australia in 1958. This trend reflects a growing understanding and tolerance of end-of-life choices. However, complicity in “self-murder” remains a criminal offense in many countries, punishable with fines to imprisonment.
Another important development was the reframing of the “right to die,” prompted by high-profile court cases, such as Karen Quinlan (1976), Elizabeth Bouvia (1983–1986), Claire Conroy (1985), Paul Brophy (1986), Nancy Cruzan (1990), and Terri Schiavo (1998–2005). These cases brought to the forefront questions of who holds the authority to determine when a patient may end their suffering, what is the basis of this authority, and what is permissible in the eyes of medical ethics and law. In addition, these cases provided new perspectives on the primacy of patients’ autonomy in end-of-life decision-making, emphasizing their right to refuse life-sustaining treatments or seek assistance in hastening their death.
The long history of changing narratives surrounding assisted dying and the “right to die” contributed to the emergence of the right-to-die movement. This movement is a response to the State’s ‘entitlement’ to regulate death and suffering, along with unjustified paternalism from the legal system and medical professionals that insist on extending the lives of dying people (and their agony). Moreover, the movement represents a struggle to reclaim personal rights and autonomy in determining the acceptable extent of suffering, as well as when and how it should be brought to an end.
Freedom to live (and die) with dignity
“Everyone is entitled to live a free and dignified life” is a statement that is widely accepted and almost impossible to challenge. It is rooted in the Universal Declaration of Human Rights (UDHR), supported by numerous international bodies and agreements, and integrated into national practices. For many, this concept encompasses not only the freedom to live but also the freedom to die in a humane manner.
Regarding the aforementioned argument, the right-to-die movement strives to promote the coexistence of the “right to life” and “right to die.” It argues that the former cannot be upheld without honoring the latter, thus there is a need for recognition of the fundamental right to choose to live rather than being forced to keep living. This movement asserts that individuals should not be unduly constrained by medical regulations and excessive safeguards when making a final decision based on a desire for autonomy and self-determination: to bring their lives to a close peacefully, painlessly, and with dignity.
The “right to die” embodies the personal convictions and desires of individuals seeking autonomy and dignity, specifically those facing debilitating and irreversible conditions that cause them immense pain and slowly take away what makes them who they are, leaving them with a cruel dilemma: die now with their dignity intact or die later and suffer longer. Opponents argue that improved palliative and hospice care is the best solution to this dilemma. However, they often overlook the fact that for some, the prospect of being forced to keep existing and go through medical treatments—or in more severe cases, to be put under sedation for the rest of their biological life—while knowing that they are all for naught is a fate worse than death.
By advocating for the “right to die,” the movement aims to ensure that no one is forced to endure a life that is no longer deemed worth living. It also opposes the denial of access to assistance in dying and the castigation of those involved in the process by the State, as this is perceived as a disregard for what should have been a fundamental right and can severely harm dying people (and their families).
Advocacy for compassionate reform
The development of the right-to-die movement is significantly influenced by the debate sparked by its prominent supporters. One of them was Dr. Jack Kevorkian, an American pathologist who gained massive public attention in the 1990s for his unorthodox practice as a “death counselor,” responsible for aiding in the deaths of 130 patients. While many hailed him as an angel of mercy, others saw him as a murderous psychopath attempting to play God. This difference underscores the polarized perception of Dr. Kevorkian and his convictions. Nevertheless, it is undeniable that Dr. Kevorkian pushed the conversation about end-of-life decisions forward in profound ways, prompted States to re-examine the idea of autonomy in medical treatments, and caused people to reflect (and change their feelings) about an issue that was rarely talked about: the freedom to die on one’s own terms.
While individuals like Dr. Kevorkian made substantial contributions to the advancement of the discourse on assisted dying, the true strength of the movement lies in the strategies carried out by the numerous right-to-die societies operating across different countries. These Societies are the ones with the capacity to mobilize collective resources in order to support the process of reforming the politics of assisted dying.
As previously stated, the primary focus of the movement in the early 20th century was the promotion of voluntary euthanasia. This is evident from the orientation of early Societies, such as the Voluntary Euthanasia Society (VES) founded in the U.K. in 1935. The VES’ chosen strategy was to bring about legislative reform by building a network of distinguished sympathizers able to influence policy at high levels. Led by progressive physicians, thinkers, and humanists, the VES made its initial attempt to change the law by introducing the Voluntary Euthanasia (Legalisation) Bill into the House of Lords in 1936. Despite the bill being defeated by 35 votes to 14, the Society gained significant publicity and support from eminent individuals in various fields. Nearly two decades later, the VES once again tried to change the law by introducing a motion on the same subject as the 1936 Bill to the House of Lords, but due to substantial opposition, the motion was withdrawn shortly after.
The Euthanasia Society of America (ESA)—another early Society that was established in 1938 and comprised a group of clergymen, doctors, lawyers, and intellectuals—shared the VES’ profound belief in legalizing voluntary euthanasia for terminally ill patients. The Society strategically positioned itself as a public champion of suffering alleviation through the dissemination of messages on various platforms, such as speeches, radio broadcasts, and magazine articles. Moreover, the ESA attempted to introduce euthanasia legislation to the New York State Legislature through a proposed law in 1947, a petition from physicians in 1947, and a petition from ministers in 1949—all of them met with failure.
In 1952, both Societies sought to play a bigger game by submitting a petition to the UN Commission on Human Rights (UNCHR). This petition, signed by 356 and 2,157 prominent Britons and Americans, urged the inclusion of “the right of incurable sufferers to euthanasia or merciful death” in the UDHR. The Chairperson of the Commission, Eleanor Roosevelt, expressed sympathy toward the petition. However, she believed it was an inopportune time to present the petition to the Commission, and so it, like all the prior initiatives at the national level, was also unsuccessful.
Recognizing the futility of further efforts due to the extremely contentious nature of the issue, it was imperative for the Societies to change their strategy. Rather than directly pushing for legislative reforms, creating a more favorable climate of public opinion was considered a higher priority. Therefore, the Euthanasia Educational Council (EEC) was established in 1967 to educate the public about their rights as patients. The EEC promoted “living wills,” a notion that enables patients to delineate their preferences for end-of-life care. Over time, the concept garnered support, leading to a new wave of public endorsement for end-of-life choices.
With the reframing of the “right to die” in the 1970s, there was a significant shift in the focus and strategy of national Societies. Many rebranded themselves to reflect their new direction as advocates for patients’ right to refuse life-prolonging treatments, living wills, and right-to-die directives. For instance, the ESA changed its name to the Society for Right to Die (SRD) in 1975 and the EEC became the Concern for Dying (CFD) in 1978—the VES also rebranded itself as Dignity in Dying, but this change occurred later in 2006.
During the same period, several brand-new Societies emerged with the goal of redirecting the movement back to its roots: promoting the legalization of assisted dying. These new Societies included the Hemlock Society (later renamed End-of-Life Choices), Caring Friends, Americans for Death with Dignity, Death with Dignity National Center, Compassion in Dying (later merged with End-of-Life Choices to form Compassion & Choices), and Final Exit Network. Many of these Societies operated at the grassroots level and focused on providing direct assistance, e.g., training “helpers,” developing guidelines on life-ending decisions for physicians and patients, educating the public, conducting research to create model legislation, and collecting signatures in support of the legalization of assisted dying.
The movement may be largely concentrated in the U.S. and the U.K., but right-to-die societies also exist in other countries. To bring together dozens of Societies from all over the world, the World Federation of Right to Die Societies (WFRtDS) was established in 1980. This international federation aims to create a world where all individuals (a) have the right to die with dignity, peacefully, and without suffering; (b) can make their own end-of-life decisions while considering the interests of others; and (c) can do so in a supportive legal environment.
Currently, there are over 80 right-to-die societies worldwide, with 61 of them—one from Africa, five from Asia, 29 from Europe, 15 from North America, two from South America, and nine from Oceania—being members of the WFRtDS. To support Member Societies in achieving the aforementioned goals, the WFRtDS has implemented an array of strategies, which include disseminating information and educational materials on self-determined end-of-suffering and end-of-life issues, facilitating international conferences to promote cooperation between right-to-die societies, establishing new Societies in countries without existing ones, supporting publicity-seeking activities, and connecting legal experts to assist in policy formulation and regulatory amendment.
The controversial legacies
Given the sensitivity of the cause, the right-to-die movement naturally encounters numerous challenges. In terms of political opportunity structure, there is an absence of laws regulating dying people’s right to seek assistance to end their suffering, as well as limited protection for the physicians involved. In terms of cultural context and dominant discourses in the public sphere, assisted dying is often portrayed in a negative light due to the influence of societal values. In terms of transnational opportunities, there is a strong objection based on ethical considerations from international medical associations. Despite these obstacles, the right-to-die movement still managed to leave lasting legacies.
Initially, the notion of someone having the freedom to opt for death as a means of escaping misery was frowned upon by society, primarily due to religious teachings emphasizing the sanctity of life—all life is considered sacred, and thus should be preserved at all costs, regardless of its quality. Based on this belief, assisted dying was seen as an affront to the inherent dignity and value of life, as it was believed that no one has the right to interfere with the natural cycle of life and death. With the rise of the right-to-die movement, society began to accept the idea that everyone has ownership over their own life, including the option to end it. In the medical context, it means that patients have the right to refuse life-sustaining treatments or request assistance in ending their irremediable suffering.
There is a shift in the dominant narrative, as evidenced by the increasing public acceptance of assisted dying in several recent surveys. In 2020, 52% of the Irish supported allowing people to receive medical assistance to end their lives; the percentages are even higher in the U.S., with 74% supporting euthanasia and 61% supporting PAS. In 2021, 87% of Spaniards agreed that “people with incurable diseases should have the right to access medically assisted dying.” In 2022, 94% of the French supported the legalization of assisted dying, with 84% in favor of PAS; 78% of Australians also supported legalizing assisted dying for those experiencing unrelievable suffering. As of early 2024, 75% of Britons were in favor of a policy change to allow assisted dying for terminally ill, mentally competent adults.
In Western countries, where the concept of the “right to die” has gained widespread acceptance, public discourse has expanded to encompass the permissible methods (is it limited to PAS or also include voluntary euthanasia?) and the eligibility criteria (such as age restrictions, type of condition, severity of the condition, involvement of physicians, and residency status). In contrast, there is very little clamor for assisted dying in Asian societies due to extremely different societal values and views on autonomy—which is perceived as relational. Similarly, there remains widespread opposition to assisted dying in African societies, largely due to the glorification of the duty of care and preservation of life as the hallmark of medical practice.
A tangible manifestation of the changing perspective on assisted dying is the existence of relevant legislation. As of mid-2024, 15 countries have legalized assisted dying. Ten of these countries allow both active voluntary euthanasia and PAS: Colombia (since 1997), the Netherlands (since 2001), Belgium (since 2002), Luxembourg (since 2009), Canada (since 2016), New Zealand (since 2019), Spain (since 2021), Portugal (since 2023), Ecuador (since 2024), and six states of Australia—Victoria (since 2017), Western Australia (since 2019), Tasmania (since 2021), South Australia (since 2021), Queensland (since 2021), and New South Wales (since 2022). The remaining five countries have only legalized PAS: Switzerland (since 1942), Italy (since 2019), Germany (since 2020), Austria (since 2021), and 11 states of the U.S.—Oregon (since 1997), Washington (since 2008), Montana (since 2009), Vermont (since 2013), California (since 2015), Colorado (since 2016), District of Columbia (since 2016), Hawaii (since 2019), Maine (since 2019), New Jersey (since 2019), and New Mexico (since 2021). This number will likely increase, seeing that more countries are giving serious consideration to the issue of assisted dying and some are even already in the process of formulating related laws.
Due to its legalization in several countries, the number of documented and legally authorized cases of assisted dying has increased in the past few years, particularly in Canada, the Netherlands, Belgium, and Switzerland. In 2018, there were 4,480 cases in Canada, 6,126 cases in the Netherlands, 2,357 cases in Belgium, and 1,176 cases in Switzerland. By 2022, these numbers had risen to 13,241 cases in Canada, 8,720 cases in the Netherlands, 2,966 cases in Belgium, and 1,594 cases in Switzerland.
Regarding existing laws, different jurisdictions have their own distinct requirements. Nevertheless, there are several commonalities among these regulations. In terms of substance, all jurisdictions require (a) voluntary and repeated requests; (b) a grave and irremediable condition, with some even mandating a prognosis of imminent death; (c) unbearable and incurable physical or psychological suffering; and (d) a clear understanding of medical conditions and options. As for the procedure, all jurisdictions require (a) peer consultation between the treating physicians and independent physicians to confirm the applicant’s eligibility; (b) a waiting period between the request and the provision of assisted death; and (c) reporting of the case to the review committee and/or relevant authorities, either before or after the procedure is carried out.
When compared to the total jurisdictions worldwide, assisted dying is legal in only a small number of countries. As a result, dying people living in countries that still criminalize the practice or who do not meet the eligibility requirements are forced to seek the procedure in other countries, where the policies are more ‘flexible’—this phenomenon is known as “suicide tourism.” Switzerland is one of the most popular destinations for suicide tourism, as it allows non-resident foreigners to receive assistance in dying through membership of right-to-die organizations, such as Dignitas, Eternal SPIRIT, Exit International, Lifecircle, and Pegasos. The fact that “going to Switzerland” has become a euphemism for seeking assisted death is proof of Switzerland’s enormous popularity as a ‘good death’ haven.
For some, suicide tourism represents either a solution to an unresolved issue—the lack of regulations protecting individuals’ right to make rational and meaningful end-of-life choices—or an alternative for those who are looking for the best place to die. For others, suicide tourism is just another proof of how in its effort to preserve the sanctity of life, the State shows no compassion for those facing an agonizing death.
By failing (or rather refusing) to legalize assisted dying, the State allows dying people to suffer different forms of injustice, which are only made clearer by the existence of suicide tourism. First, the cost of obtaining an assisted death overseas is significantly higher than doing so domestically. As an example, Swiss residents can apply for an assisted death at Dignitas for CHF 9,000–10,500 (around $7,900–11,800), whereas Britons have to pay an average of £10,000 (around $12,700)—or even more—due to the additional travel and living expenses in Zürich. This cost is prohibitively expensive, making suicide tourism a ‘luxury’ that the majority of dying people cannot afford.
Secondly, obtaining an assisted death overseas is an arduous and taxing process. Dying people are already grappling with immense pain and distress, and yet they are still forced to travel great distances to make one last decision. At times, they may even have to face a lonely death in a foreign place to spare their loved ones from the risk of legal prosecution, as aiding in another person’s death could be deemed a criminal offense.
Thirdly, dying people must meet certain health requirements in order to travel to the destination country, leaving them with a tough decision of whether to undertake the journey sooner than they might otherwise choose to—that is, before they become too sick to travel at all. This harsh trade-off deprives dying people of the autonomy to determine the terms of their own death—a decision that ideally should only be made when they are fully prepared.
Finally, when seeking assisted death abroad, dying people may encounter uncertainty about the level of cooperation they will receive from healthcare providers. If they were to become victims of mistreatment or coercion in another country, it would likely go unnoticed by authorities, as there are no established legal mechanisms to prompt an immediate investigation. In other words, dying people would be left in an extremely vulnerable position.
Conclusion
The right-to-die movement is a reformative movement closely tied to biopolitics, revolving around the struggle for rights and autonomy in dying and death. Its emergence stems from State intervention in end-of-life choices. Contrary to popular belief, this movement does not necessarily endorse premature death but rather advocates for individuals’ right to choose survival while also providing legal options for a quick, painless, and dignified death when suffering becomes unbearable. This movement employs strategies such as legislative efforts, information dissemination, provision of direct assistance, and the establishment of an international solidarity network to promote widespread acceptance of the “right to die.” Over decades, these efforts have fostered growing public acceptance of assisted dying, leading to its legalization in 15 countries (and still counting). Additionally, the phenomenon of suicide tourism has emerged, which, depending on how one looks at it, may offer a solution or complicate the status quo of assisted dying.
