1
This is he p e-p in e sion o he ollowing a icle:
Espe icue a, Luis. (2025). Ad ance Reques s o Medical Assis ance
in Dying in he In e na ional Con ex : Some Legal Issues o he
Canadian Case. Heal hca e Policy,20(2), P e- elease.
h ps://doi.o g/10.12927/hcpol.2024.27478, which has been
published in inal o m a
h ps://www.longwoods.com/con en /27478/heal hca e-
policy/ad ance- eques s- o -medical-assis ance-in-dying-in- he-
in e na ional-con ex -some-legal-issues- o . This a icle may be
used o non-comme cial pu poses in acco dance wi h Longwoods
Te ms and Condi ions o Use o Sel -A chi ed Ve sions.
Ad ance Reques s o Medical Assis ance in Dying in he In e na ional Con ex :
Some Legal Issues o he Canadian Case
Luis Espe icue a
Au ho in o ma ion: Depa men o Philosophy I, Uni e si y o G anada, Spain.
(INEDyTO II P ojec ); Red de É ica Salub is a pa a la Acción, Cuidados y Obse ación
Social (ESPACyOS), Spain.
Con ac in o ma ion: Depa men o Philosophy I, Uni e si y o G anada, A da. del
Hospicio, s/n G anada 18071, Spain. espe icue a@ug .es
Abs ac
An ad ance eques o medical assis ance in dying (ARM) is a documen ha allows
indi iduals o eques eu hanasia i hey lose hei decision-making capaci y. Cu en ly, i
is a ailable in all coun ies whe e medical assis ance in dying is pe mi ed o indi iduals
su e ing om a se ious and incu able illness whose na u al dea h is no easonably
o eseeable, excep in Canada. In his coun y, a ious ci izen and pa liamen a y
ini ia i es a e conside ing he inclusion o his documen in na ional legisla ion. This
a icle p esen s o he i s ime a compila ion o all ARM egula ions wo ldwide.
Analysis o he in e na ional amewo k sugges s ha he equi emen s o d a ing an
ARM could in luence he e ec i e implemen a ion o pa ien s' wishes.
Sho anno a ion: An ad ance eques o medical assis ance in dying (ARM) is a
documen ha allows indi iduals o eques eu hanasia i hey lose hei decision-making
capaci y. This a icle p esen s o he i s ime a compila ion o all ARM egula ions
wo ldwide.
2
Keywo ds: Ad ance Reques s; Ad ance Di ec i es; Ad ance Decision-Making; Medical
Assis ance in Dying; Eu hanasia; Assis ed Suicide; Demen ia
*E hics commi ee app o al is no equi ed.
In oduc ion
Medical assis ance in dying (MAiD) has been legally allowed in Canada since 2016. O e
he pas eigh yea s, his medical p ac ice has unde gone con inuous modi ica ions
h ough cou ulings and legisla i e amendmen s (Downie 2022). Ini ially, i was
a ailable only o indi iduals whose dea h was easonably o eseeable, bu i has since
been ex ended o hose no acing imminen dea h bu expe iencing se e e su e ing.
In his con ex , one o he mos deba ed changes was he amendmen allowing pe sons
su e ing solely om a men al diso de o be eligible o MAiD (MAiD MD-SUMC),
al hough i s implemen a ion has been pos poned o 2027. Ne e heless, his ecen
expansion o c i e ia o MAiD con as s wi h he legal impossibili y o using ad ance
eques s o i s applica ion. This disc epancy is pa icula ly no able when we conside
ha some may iew he use o Ad ance Reques s o MAiD (ARM) as less con o e sial.
Fo example, a 2021 su ey o Canadians ound ha 17% o esponden s opposed he use
o ARM, while 35% we e agains he implemen a ion o MAiD MD-SUMC, nea ly
double (IPSOS 2022). Suppo o ARM was also e lec ed in a 2015 su ey, in which
62% o a ep esen a i e sample o Canadians ag eed, and 22% disag eed, ha hey should
ha e access o MAiD i hey su e om ad anced demen ia and ha e an ARM ou lining
hei desi e o assis ed dea h a ha s age o he illness (EPOLRCC 2015).
An ARM is a documen “c ea ed in ad ance o a loss o decision-making capaci y,
in ended o be ac ed upon unde ci cums ances ou lined in he eques a e he pe son has
los decisional capaci y” (The Expe Panel Wo king G oup on Ad ance Reques s o
MAID 2018: 5). The use o his documen is especially impo an in cases o se e e
demen ia
1
and impai ed consciousness. Howe e , wi h he excep ion o Quebec
2
, i is no
pe mi ed in Canada, as he law equi es he pa ien o explici ly con i m hei consen
1
Demen ia gene ally p og esses h ough h ee main s ages: mild, mode a e, and se e e. In he se e e s age,
indi iduals expe ience signi ican cogni i e decline, ma ked unc ional limi a ions, and no iceable
beha iou al changes. Addi ionally, ad anced demen ia o en esul s in di icul ies wi h ea ing and
swallowing, equi es assis ance wi h walking, and demands con inuous suppo o pe sonal ca e. I also
inc eases he suscep ibili y o in ec ions. (Cli o d e al. 2024)
2
In June 2023, he Na ional Assembly o Quebec amended he law egula ing MAiD o allow indi iduals
o make an ARM unde ce ain condi ions. This new p o ision will ake e ec on 30 Oc obe 2024.
3
immedia ely be o e ecei ing medical assis ance in dying. Only when a pe son is a isk
o losing capaci y and hei na u al dea h is easonably o eseeable does he law allow
hem o wai e inal consen h ough a w i en ag eemen wi h hei heal hca e p o ide
(Pa liamen o Canada 2021). I is no able ha o he six coun ies in he wo ld whe e
eu hanasia is cu en ly p ac iced wi hou he equi emen o e minal illness, only Canada
does no pe mi he use o ARM.
3
Al hough bioe hical and philosophical issues a e a ied (Wijsbek and Nys 2022), some
heal h p o essionals in Canada appea o suppo he legal use o ARM by pa ien s wi h
ad anced demen ia. Acco ding o a su ey conduc ed in Vancou e , mos demen ia ca e
specialis s a o allowing ARM o hese pa ien s, al hough hey exp ess e hical and
logis ical conce ns abou i s use (Nakanishi e al. 2021). The e is also poli ical in e es in
add essing he use o ARM sa ely. Sena o Chan al Pe i cle c’s ema ks du ing he second
eading o Bill C-7 a e illus a i e: “I equi es us o conside sa egua ds o wo
comple ely dis inc ac s ha may be many yea s apa — he making o he documen
se ing ou he wish o MAID and he p o ision o MAID o a pe son who can no longe
consen on he basis o he ea lie documen ” (Pe i cle c 2020). Fo his eason, i is use ul
o examine he p ocedu es ollowed in he six ju isdic ions (Ne he lands, Belgium,
Luxembou g, Colombia, Spain, and Quebec) whe e access o ARM is pe mi ed.
Who can d aw up an ARM in o he ju isdic ions?
Rega ding he p o ile o indi iduals, we ound ha wo o he six ju isdic ions s udied
allow mino s o make an ARM. Speci ically, he minimum age in he Ne he lands is 16
(Law Bank 2002), while in Colombia, i is 14. In Colombia, howe e , his is only
pe mi ed i he mino has a “diagnosis o e minal illness o li e- h ea ening condi ion”
(Minis e io de Salud y P o ección Social 2018). Once he indi idual eaches he age o
18, hey mus c ea e a new documen wi hou diagnos ic es ic ions. In bo h Colombia
and he Ne he lands, MAiD is a ailable o mino s. In Spain, by con as , he age o
majo i y is equi ed o comple e an ARM. In some au onomous communi ies,
emancipa ed mino s o hose aged 16 and o e can make ad ance eques s o si ua ions
3
In 2024, Ecuado judicially dec iminalized MAiD o indi iduals wi h e minal o se ious ch onic illnesses
(Espe icue a 2024). Soon, he Ecuado ian pa liamen will need o pass a law, a which poin we will know
whe he i will allow ARMs.
4
ou side o MAiD (BOE 2002). Ne e heless, MAiD is p ohibi ed o mino s h oughou
he coun y wi hou excep ion (BOE 2021).
A di e en si ua ion exis s in Belgium, whe e an emancipa ed mino can make an ARM
(Moni eu Belge 2002). Howe e , ega dless o age, an ARM applies only i he pa ien ,
in addi ion o su e ing om a se ious and incu able illness o inju y, is in a s a e o
i e e sible unconsciousness acco ding o cu en scien i ic knowledge. As a esul , while
Belgian law does no explici ly add ess he case o demen ia, i indi ec ly excludes i . A
simila si ua ion occu s in Luxembou g, whe e an ARM can only be used when he pa ien
has i e e sibly los consciousness (Minis e de la San é e de la Sécu i é Sociale 2009).
In Luxembou g, only adul s, no emancipa ed mino s, can comple e his documen . Wi h
espec o he p o ince o Quebec, only indi iduals o legal age a e allowed o make an
ARM (Assemblée Na ional du Québec 2023).
Rega ding he heal h s a us o he pe son, i is impo an o no e ha , wi h he excep ion
o Quebec, no ju isdic ion explici ly equi es a p io diagnosis. This means ha an ARM
can be made by an indi idual who is no ill and can co e any scena io in which hey wish
o exp ess hei will. In con as , Quebec law s ipula es ha , in o de o comple e an ARM,
a pe son mus su e “ om a se ious and incu able illness leading o incapaci y o gi e
consen o ca e” (Assemblée Na ional du Québec 2023).
In addi ion, al hough he documen mus be in w i ing in all coun ies, he con ex in
which i mus be p epa ed a ies. In he Ne he lands, o example, i mus be d awn up
wi h he assis ance o a medical p o essional (Sup eme Cou o he Ne he lands 2020).
In con as , bo h Spain and Colombia o e h ee op ions: o o malise he documen in
he p esence o a no a y, medical pe sonnel, o wi nesses (in Spain, wo o h ee
depending on he egion; in Colombia, wo). Bo h coun ies ha e di e en c i e ia o
wi nesses conce ning hei ela ionship o he pe son signing he ARM. In Spain,
wi nesses canno be ela ed up o he second deg ee o kinship o a ini y, no can hey
ha e any economic ela ionship wi h he pe son. In Colombia, anyone can be a wi ness
unless hey ha e been disquali ied by a cou decision o ha e an economic o
employmen ela ionship wi h he pe son. In Belgium and Luxembou g, howe e , an
ARM mus be signed in he p esence o wo wi nesses o legal age. In Belgium, “a leas
one o hem will ha e no ma e ial in e es in he dea h o he decla an ” (Moni eu Belge
2002).
5
In Quebec, on he o he hand, he law equi es ha a pa ien making an ARM be assis ed
by a compe en p o essional du ing he d a ing p ocess. The ARM mus hen be
o malised in he p esence o ei he a no a y o wo wi nesses. The wi nesses mus be o
legal age and capable o gi ing in o med consen .
How long is an ARM alid in o he ju isdic ions?
The alidi y o an ARM is unlimi ed in he Ne he lands, Colombia, Spain, Belgium, and
Quebec. Ne e heless, i is impo an o no e ha , acco ding o he Regional Eu hanasia
Re iew Commi ees (2022: 38) in he Ne he lands, “ he olde he di ec i e, he mo e
doub he e may be as o whe he i s ill e lec s he pa ien ’s ac ual wishes”. Meanwhile,
in Colombia, as p e iously men ioned, an ARM made by indi iduals aged 14 o 18 mus
be eplaced once hey each he age o majo i y. In Belgium, an ARM had o be enewed
e e y i e yea s un il Ap il 2, 2020. Howe e , he Loi du 15 ma s 2020 isan à modi ie
la législa ion ela i e à l'eu hanasie (Moni eu Belge 2020) s ipula es ha ARMs issued
a e his da e a e alid inde ini ely. Luxembou g is he only coun y whe e ARMs mus
be enewed e e y i e yea s (Minis e de la San é e de la Sécu i é Sociale 2009).
Who can in oke an ARM in o he coun ies?
Once he pe son is in he si ua ion desc ibed in he documen , he p ocedu e can a y
signi ican ly om coun y o coun y. In Spain and Colombia, he e is no comple e
ce ain y abou he e ec i e implemen a ion o an ARM. Indeed, depending on how he
documen is signed, he e may be un o eseen complica ions i he pa ien is unable o
indica e he exis ence o an ARM. Fo example, a documen o malised in on o
wi nesses would ely on one o hem deli e ing i o a physician in ime. Simila ly, i i
we e no a ised, i would be essen ial o he pa ien o ha e in o med someone o i s
exis ence so ha i could be e ie ed and p esen ed in a imely manne . The e o e, since
i is no manda o y o egis e he ARM o include i in he pa ien 's medical eco d, he
p ope ul ilmen o he pa ien 's wishes would depend on a ious ci cums ances. As a
esul , he egula ions in hese coun ies do no p o ide su icien ce ain y ega ding who
can in oke he exis ence o an ARM.
In Belgium and Luxembou g, an ARM mus be comple ed in he p esence o wo
wi nesses. The laws emphasize ha one o mo e “ us ed pe sons” can be designa ed when
d a ing he documen o communica e he pa ien 's wishes o he a ending physician.
Belgian law also sugges s ha i is p e e able o designa e se e al pe sons and ank hem
6
in o de o p e e ence. In his way, “each us ed pe son eplaces he one who p ecedes
hem in he decla a ion in he e en o e usal, incapaci y, disabili y, o dea h” (Moni eu
Belge 2002). I should also be no ed ha Belgium explici ly p ohibi s doc o s amilia
wi h he pa ien 's case om being designa ed as a “ us ed pe son.” Only in Luxembou g
does he law equi e ha an ARM be egis e ed wi h he Commission Na ionale de
Con ôle e d'É alua ion. Any doc o ea ing a pa ien in a medical si ua ion eligible o
MAiD unde he law mus consul his egis e .
In he Ne he lands, since he ARM mus be p epa ed wi h he a ending physician, i is
unde s ood ha his documen will be included in he pa ien 's medical eco d. This helps
a oid unnecessa y delays and in e media ies ha could comp omise he e ec i eness o
he ARM. Addi ionally, i is ecommended ha he documen be p epa ed wi h he
in ol emen o someone close o he pa ien and ha he pa ien communica es hei
wishes o hei amily (KNMG 2021). This sa egua d ensu es ha he pa ien 's us ed
pe sons can e i y ha he medical s a app op ia ely ca ies ou he pa ien 's wishes in
a imely manne .
In Quebec, he law equi es ha all ARMs be eco ded by he p o essional assis ing he
pa ien o by he no a y in a egis e es ablished by he Minis y o Heal h (Assemblée
Na ional du Québec 2023). Addi ionally, he law ecognises he ole o us ed pe sons,
who a e no pe mi ed o se e as wi nesses a he same ime. These p o isions se e as
sa egua ds, allowing bo h p o essionals and indi iduals close o he pa ien o in oke an
ARM in a imely manne .
Wha e en s igge an ARM in o he ju isdic ions?
Finally, conce ning he elemen s jus i ying he ac i a ion o an ARM, in Belgium and
Luxembou g, i is he i e e sible loss o consciousness. In he Ne he lands and
Colombia, i is he inding o unbea able su e ing in he pa ien – which may exclude
cases whe e he pe son wi h demen ia appea s happy – (Assche and an de Va ho s
2020). Whe eas in Spain, i mus be p o en ha he pa ien has limi a ions in his physical
au onomy and abili y o ela e o o he s, as well as cons an physical o psychological
su e ing (BOE 2021). In Quebec, on he o he hand, he law speci ies ha he pa ien
mus be incapable o gi ing consen o ca e due o a se ious and incu able illness.
Addi ionally, he pa ien mus consis en ly exhibi he clinical mani es a ions ela ed o
hei illness desc ibed in he eques ; be in a s a e o ad anced, i e e sible decline in
7
capabili y; and expe ience, in he judgemen o he compe en p o essional, “endu ing and
unbea able physical o psychological su e ing ha canno be elie ed unde condi ions
conside ed ole able” (Assemblée Na ional du Québec 2023).
Wha ad ice can we d aw om in e na ional amewo k?
Since he ques ion o allowing MAiD o mino s is unde conside a ion in Canada
(Comi é mix e spécial su l’aide médicale à mou i 2023), i would be impo an o he
coun y o de e mine he minimum age equi ed o sign an ARM and o de elop
app op ia e sa egua ds i his igh is ex ended o his popula ion. Addi ionally, legisla o s
mus ca e ully conside whe he o equi e a speci ic heal h condi ion o d aw up an ARM,
as is he case in Quebec, which con as s wi h in e na ional p ac ices. In his con ex , he
possibili y o making an ARM wi hou a p io diagnosis is a con o e sial issue, as he e
a e conce ns abou an indi idual's abili y o accu a ely p ojec cu en p e e ences on o
u u e e en s o si ua ions ( an den Bosch e al. 2021).
Ano he essen ial poin will be speci ying he app op ia e way o signing an ARM and
he indi iduals in ol ed. The e a e a leas ou models o policymake s o conside : he
Hispanic-Ame ican model, which we conside o be less p o ec i e; he Belgian-
Luxembou g model, which educes unce ain y by clea ly de ining he oles o he
wi nesses and us ed pe sons in ol ed in he e ec i e implemen a ion o he ARM
(Luxembou g, in pa icula , p o ides a key sa egua d by es ablishing a dedica ed ARM
egis e ); he Du ch model; o he Québécois model, which inco po a es se e al o he
sa egua ds o he o he models and is conside ed by us o be mo e p o ec i e. Indeed,
clea ly de ining who can ac i a e an ARM could signi ican ly in luence whe he key
logis ical and e hical issues, such as he iming— he p ecise momen o adminis e MAiD
(Melle e al. 2021)—can be e ec i ely add essed.
Finally, Canada should conside how o e i y he elemen s ha mus be me in o de o
access medical assis ance in dying h ough he ARM. In pa icula , i will need o add ess
how o apply he c i e ion o “physical o psychological su e ing ha is in ole able o
hem and ha canno be elie ed unde condi ions ha hey conside accep able” in he
cu en law (Pa liamen o Canada 2016). One op ion could be o ollow Quebec’s
app oach, conside ing bo h he pa ien 's pe sonal ci cums ances unde which hey wish o
ecei e MAiD and he medical judgmen o he compe en p o essional. The co ec
8
wo ding o he ARM and e ec i e communica ion be ween he pa ien , amily, and
heal hca e p o essionals will be c ucial in his ask.
Conclusions
Conside ing he a ious in e na ional models, he equi emen ha he ad ance eques
be d a ed wi h he assis ance o he compe en p o essional and us ed pe sons seems o
o e one o he bes sa egua ds. The mo e ho oughly and p ecisely he ARM is p epa ed,
he mo e eliable and e ec i e i s implemen a ion could be. The compe en p o essional,
he ca egi e s, and he pa ien s' us ed pe sons play a key ole in he d a ing and e en ual
in e p e a ion o he ARM. The e o e, i is also essen ial o eco d his documen in a
aceable and sea chable egis e . Finally, he inclusion o app op ia e sa egua ds will help
no only o ensu e ha he igh s and wishes o pa ien s a e espec ed in all ci cums ances,
bu could also s eng hen public us in he sys em.
Acknowledgmen
This s udy was unded by he Spanish Minis y o Science and Inno a ion,
MICIU/AEI/10.13039/501100011033 and ESF+; INEDyTO II p ojec : Bioe hics and
p ac ices ela ed o he end o li e (PID2020‐118729RBI00), "ayudas pa a con a os
p edoc o ales" (PRE2021‐098759), and A iadna p ojec PPJIB-2024-55 (Uni e si y o
G anada).
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