How do the procedural safeguards for euthanasia and assisted suicide requests and assessments compare across jurisdictions? This research report, the second in a series of reports and briefs, compares the Canadian “medical assistance in dying” (MAiD) program to international jurisdictions in which some form of assisted dying is legal.

As discussed in more detail in part 1 of this series, “An International Comparison of Assisted Dying Regimes: Part 1—Eligibility Criteria,” assisted dying refers to euthanasia and/or assisted suicide. “Medical assistance in dying,” or MAiD, is the specific term used for both practices in Canada. The first paper also summarized the difference between euthanasia (clinician-administered death 1 1 Different jurisdictions have different rules surrounding which medical professionals can assess and/or administer assisted death. Canada, for instance, allows physicians or nurse practitioners to serve as assessors and providers of assisted deaths. Other jurisdictions may require assessors to be physicians—as we outline in this report—whereas providers could be nurse practitioners or nurses (we will explore restrictions surrounding which clinicians can administer assisted death in our third paper in this series). ) and assisted suicide (self-administered death), and the legal status of both practices across international jurisdictions, specifying which jurisdictions are and are not included in our comparison. 2 2 Vachon and Beauregard, “An International Comparison of Assisted Dying Regimes: Part 1—Eligibility Criteria.” Complete citations are provided for all sources at the end of this report. We have added in this second paper the US states of New York and Illinois, whose laws legalizing assisted suicide came into effect on August 5 and September 16, 2026, respectively.

Whereas part 1 of the series compared eligibility criteria, this second paper examines the procedural safeguards surrounding requests and assessments for assisted dying. We examine the nature of the safeguards in the following areas:

• initiating conversations about assisted dying with patients
• requesting assisted dying, including:
  • requirements for the request process
  • requirements for witnesses
• assessment of eligibility, including:
  • requirements for the number of assessors
  • requirements concerning who can serve as an assessor
  • requirements for residency
  • requirements for consultation with past/current health care providers and families

As in the first paper, this comparison is presented through a series of tables, accompanied by discussion. Government and scholarly sources were used to identify the legal parameters for each jurisdiction. For more information on the sources consulted and the methodology used, please see part 1 in the series.

Because international legislation varies in the terminology used for those medical professionals authorized to assess assisted dying requests, here we use:

• “physician” to refer to those licensed to practice medicine (also referred to in various legislation as doctors, medical practitioners, health practitioners, etc.)
• “clinician” to refer to those medical professionals who are allowed, in a given jurisdiction, to assess assisted dying requests (i.e., in Canada, this would refer to both physicians and nurse practitioners)
• “assessor” to refer to those clinicians who actually conduct assisted dying assessments
• “registered healthcare professionals” to refer to a broader category of professions regulated under the given jurisdiction’s healthcare professions act (nurses, midwives, physical therapists, etc., as well as physicians)

We find that, for the safeguards examined in this report, Canada’s approach lies somewhere between that of Australia, New Zealand, and US states on the one hand (more restrictive), and that of Europe on the other (more permissive). For the province of Alberta specifically, recent legislation aligns more closely with that of Australia, New Zealand, and the US.

Safeguards should be also understood in the context of eligibility criteria, discussed in part 1 of the series.

In some jurisdictions, patients must be the ones to initiate a discussion about assisted dying, and clinicians and sometimes other healthcare professionals or workers are prohibited from raising the issue unsolicited. The government of South Australia, for instance, states that this safeguard exists to “ensure that the request is completely voluntary and made without coercion.” 3 3 Government of South Australia, SA Health, “Voluntary Assisted Dying in South Australia Explained.” While some critics argue that this safeguard serves as a barrier to an informed decision for patients who may be unaware of assisted dying as an option, other voices argue that the safeguard acknowledges the power dynamic in the relationship between medical professionals and their patients, and how the presentation of assisted dying as an option may encourage patients—even inadvertently—to choose a premature end to their lives. 4 4 For critics, see, for example, Willmott et al., “Restricting Conversations,” and McDougall and Pratt, “Too Much Safety?” For supporting voices, see, for example, Grant, “Legislated Ableism,” 310–11; Jones, “Slippery Slopes Down Under,” 93; Pullman, “Slowing the Slide,” 69.

This safeguard was adopted in Australia by the state of Victoria and then by the state of South Australia and by New Zealand. A much looser version of the safeguard was adopted in the Australian states of New South Wales, Queensland, Tasmania, and Western Australia (table 1). The Australian Capital Territory adopted slightly different wording in its law, but the safeguard appears to be similar in practice.

Although Victoria was the first to establish this safeguard, a 2025 bill amended the original law and will allow, as of April 2027, discussion about assisted dying to be initiated “in the course of discussion about end of life care,” so long as “reasonable steps” are taken to inform the patient of treatment options and palliative care. 5 5 Victoria State Government, Voluntary Assisted Dying Amendment Act 2025, at §7. This diluted safeguard is about as strong as what exists in most other jurisdictions that require alternatives and palliative care to be raised/considered as part of informed consent. It may still provide residual protective elements, however, since it requires that treatments and palliative care be specifically discussed when raising MAiD, rather than merely at some point during the assessment and approval process.

Canada does not have this safeguard. Government guidance instead encourages clinicians to raise MAiD in some cases. Specifically, Health Canada’s Model Practice Standard recommends that physicians raise MAiD as an option to patients who may be eligible, if the clinician considers MAiD to be “consistent with the person’s values and goals of care.” Health Canada’s “Advice to the Profession” advises the same. Both were developed as documents “for use by regulatory bodies, public authorities, and health professional organisations and [are] intended to support a consistent approach to MAID practice across Canada.” They do not constitute binding law and are not applied consistently across the country. 6 6 Health Canada, “Model Practice Standard,” 2, 6–7; Health Canada, “Advice to the Profession,” 13–14; Close et al., “Medical Assistance in Dying in Canada.” As explored in a previous Cardus report, survey results indicate that a significant proportion of the Canadian population is concerned that Canadian clinicians raising MAiD unsolicited may create pressure on patients to choose MAiD. 7 7 Vachon, “Disability and MAiD,” 23–24.

The province of Alberta recently legislated this safeguard, among others, and will prohibit all regulated health professionals from providing unsolicited information about MAiD during their provision of health services. The province’s legislation also took the step of prohibiting information on MAiD from being displayed “in a public manner within a health care facility.” 8 8 “Regulated health professionals,” according to Alberta’s legislation, are all those regulated under the Health Professions Act and therefore a broader category than physicians and nurses only. Government of Alberta, Bill 18, Safeguards for Last Resort Termination of Life Act, at §1 (1)(p). Regarding the display of MAiD information, see Government of Alberta, Bill 18, Safeguards for Last Resort Termination of Life Act, at §10.

The request process varies in formality across jurisdictions. Australian states, most US states, and New Zealand provide more specificity in their laws as to the conditions surrounding requests for assisted dying. The Australian and US models typically have a three-request process. Researcher Russell Tolentino notes that requiring more requests can provide “additional avenues for reflection” for patients as well as greater scope for medical assessments, particularly when there are specific waiting periods between requests. 9 9 Tolentino, “Strengthening Safeguards,” 3. For example, California requires a two-day waiting period between the first and the second oral requests, while the District of Columbia and Delaware require at least fifteen days.

In most US states in which assisted dying is legal, the first two requests are oral, with a waiting period between the two, and the third request must be written. In Australia, the three-request model in most states is as follows:

1. The patient makes an oral or written request, or otherwise communicates it, to a medical practitioner. The request triggers an assessment process to determine the patient’s eligibility (see next section of this report).
2. If found eligible, the patient makes a second, written request in the presence of two witnesses.
3. The patient makes a final oral or written request or otherwise communicates it. 10 10 In Tasmania, the second request (in writing) occurs after the primary assessor finds the patient eligible (first assessment), which then triggers the referral to a second assessor (second assessment). Following this, the third request must also be made in writing. Tasmanian Government, End-of-Life Choices (Voluntary Assisted Dying) Act 2021, at §53.

Jurisdictions that require a written request also typically specify that if a patient cannot sign their written request for some reason, a third party may do so on their behalf. The third party is typically required to be an adult, not receive a benefit from the patient’s death, and sign in the presence of the patient and sometimes also the assessor.

In other jurisdictions, such as Belgium, Luxembourg, and the Netherlands, the law does not specify the request process but merely requires the clinician to be, as articulated in the Netherlands’ law, “satisfied that the patient’s request is voluntary and well considered.” 11 11 Government of the Netherlands, Wet toetsing levensbeëindiging op verzoek en hulp bij zelfdoding, at §2(a). Similar wording is found in the Belgian and Luxembourg laws; these two countries both require a request to be made in writing. 12 12 Government of Belgium, Loi relative à l’euthanasie, 2002, at §1, 4; Government of the Grand Duchy of Luxembourg. Loi du 16 mars 2009 at §Art. 2, 1(2)(4). In the Netherlands, uniquely, a written request is not required, but clinicians “must be satisfied that the request is unequivocal and consistent” prior to administering euthanasia. 13 13 Regional Euthanasia Review Committees, Government of the Netherlands, Euthanasia Code, 12–13.

Canada’s approach is close to that of Belgium and Luxembourg, requiring a written request after a finding of eligibility (resulting in, functionally, a two-request process—one that initiates the assessment processes, and one that constitutes the formal written request), 14 14 Health Canada, “Model Practice Standard,” 13–14. but does not delineate in law a highly specific series and sequence of requests as in Australia.

Some jurisdictions that require a written request also require that the request be witnessed by one or two persons. This requirement is understood to “bolster the integrity of the process” by helping to ensure that the request is voluntary. 15 15 Tolentino, “Strengthening Safeguards,” 3. The Australian state of Victoria, for instance, specifies that the witnesses must certify that the patient appears to “freely and voluntarily sign the declaration,” “have decision-making capacity,” and “understand the nature and effect of making the declaration.” 16 16 Victoria State Government, Voluntary Assisted Dying Act 2017, at §36(1).

The Australian and US states require two witnesses to the written request. In Australia, witnesses must be adults and cannot be the assessors for the patient’s request. In the US, the primary assessor is barred from being a witness; some US states also block the second (consulting) assessor from being a witness. In all Australian and US states but two, one or both of the witnesses cannot receive a benefit from the patient’s death. That is, some states require that neither witness be a beneficiary of the patient’s estate or receive other financial or material benefit from the death, and other states require that at least one of the two witnesses not be a beneficiary.

Of the other jurisdictions that require a written request (Belgium, Luxembourg, New Zealand, Spain, and Uruguay), no witnesses are required. Austria does not specifically require a written request but does require the request to be registered by an official public notary or legally qualified member of the Patientenvertretung (body of patient representatives). 17 17 Khakzadeh, “Assisted Suicide in Austria,” 141.

Canadian law was initially more aligned with that of the Australian and US states on requirements for witnesses. It required two independent witnesses for the written request and had similar restrictions on who these witnesses could be. This safeguard was loosened significantly in 2021 to require only one witness, and now allows paid professional caregivers or healthcare workers to serve as witnesses (previously, this was prohibited). 18 18 Bill C-14 at §3(c), 5; Bill C-7 at §(4), (8); Nicol and Tiedemann, “Legislative Summary of Bill C-7,” 12. Canadian law has never prohibited family members from serving as witnesses.

In Quebec, the requirement for an independent witness is not specifically mentioned in legislation but is mentioned on the government website and on the form used for the written request. Thus Quebec’s practice appears to align with the federal law. The provincial law does specify witness requirements for advance requests. 19 19 For more on advance requests, see Vachon, “The Risks of Advance Requests.”

The assessment process requires patients to be found eligible by two assessors, or sometimes three. 20 20 Belgian law requires a third assessor (or a “second consulted physician”) in cases where the requester is not expected to die reasonably soon; in such cases, this consulted physician must be either a psychiatrist or have expertise in the patient’s condition. A third assessor—specifically a child or adolescent psychiatrist or psychologist—is also required for evaluating requests from non-emancipated minors. Raus et al. “Euthanasia in Belgium,” 90–91. For more information about euthanasia for minors, see also Vachon and Beauregard, “An International Comparison of Assisted Dying Regimes: Part 1—Eligibility Criteria.” In cases where eligibility or competence may be in question, additional consultation may be required, as discussed below.

Along with the two assessors required, Spain has a Regional Guarantee and Evaluation Commission, which appoints two of its members—a physician and a jurist—to verify the requirements and conditions for each approved request before the patient receives an assisted death. In this verification, these two members review documentation and the patient’s medical history and, if they deem it necessary, interview the physician, health team, and/or patient. 21 21 Martínez-León et al., “Medico Legal Study,” 168; Velasco Sanz et al., “Spanish Regulation of Euthanasia,” 2.

The Netherlands sets a much lower bar than other jurisdictions do, in that agreement between two assessors is not needed. The primary assessor/provider need only seriously consider the consulting (or second) assessor’s position but, as expressed in the Euthanasia Code, “if there is a difference of opinion between the two, the physician can nevertheless decide to grant the patient’s request, but will have to be able to provide adequate grounds [to the Regional Euthanasia Review Committee] for this decision, reflecting explicitly on the views expressed by the independent physician.” 22 22 Regional Euthanasia Review Committees, Government of the Netherlands, Euthanasia Code, 20.

In other jurisdictions, a disagreement between two assessors requires that a third clinician provide an assessment. As the Canadian case shows, however, when patients have been found ineligible, they may continue applying until they receive two affirmative findings of eligibility. 23 23 Lyon, “Canada’s Medical Assistance in Dying System,” 83–85. Although we lack data on the prevalence of such “assessor shopping” in Canada, instances have come to light, such as that of Kiano Vafaeian, a twenty-six-year-old resident of Ontario. Vafaeian was repeatedly found ineligible for MAiD locally and subsequently travelled to BC and received MAiD on December 30, 2025, from well-known MAiD provider and advocate Ellen Wiebe. This prompted criticism from his family, who argue that he should not have received a MAiD death and that “the system failed him.” 24 24 Canadian Press, “One of Canada’s Most Prominent MAID Providers Reflects”; Prasad and Judd, “Ontario Family Calls for Changes.”

Investigative journalist Alexander Raikin has written about a similar case that was discussed during a Canadian Association of MAiD Assessors and Providers (CAMAP) seminar. In this case, a man who was found ineligible for MAiD subsequently connected with Wiebe through Dying with Dignity Canada. As described by Raikin, Wiebe “found him [the patient] eligible, and found a second assessor to agree,” subsequently picking up the patient from the airport and, as Wiebe put it, “brought him to my clinic and provided [euthanasia] for him.” Raikin also reports that law professor Jocelyn Downie has stated in CAMAP seminars that if a second assessor does not agree that a patient is eligible, “you can ask as many clinicians as you want or need,” and “disagreement doesn’t mean you must stop [asking for another assessment that concurs].” 25 25 Raikin, “No Other Options.”

In Tasmania, by contrast, if two consulting clinicians (i.e., a second and then a third assessor) decide that the patient is ineligible, the process ends and the patient would need to restart with a new first request. The former primary assessor cannot accept a new first request from that patient for twelve months. 26 26 Tasmanian Government, End-of-Life Choices (Voluntary Assisted Dying) Act 2021, at §48. In Uruguay, if there is a disagreement between the first and second assessors, a final opinion is elicited from a medical board at the healthcare facility where the procedure would occur. 27 27 This board would include a psychiatrist, a physician with specialization in the patient’s condition, and another physician (internist or palliative care specialist). Government of Uruguay, Reglamentacion de la ley 20.431, at §6.

Most jurisdictions require both assessors to be physicians. The exceptions are Canada, the Australian Capital Territory, and a few US states. Canada allows nurse practitioners to be one or both assessors. The Australian Capital Territory requires one of the assessors to be a physician, but the other can be a nurse practitioner. 28 28 Australian Capital Territory Government, Voluntary Assisted Dying Act 2024, at §97(3). Until recently, all US states with legalized assisted dying required the assessors to be physicians, but three states now allow nurse practitioners (“advanced practice registered nurses” in the language of the US laws) to assess and prescribe, and two other states allow nurse practitioners and physician assistants to be assessors and providers.

Assessor independence is also required. As in the Canadian law, assessors may not be connected to each other as a mentor/mentee or supervisor/supervisee, nor be connected to the patient by benefiting in a material or financial way from their death—“other than standard compensation for their services relating to the request”—nor be connected to the clinician or patient “in any other way that would affect their objectivity.” 29 29 Government of Canada, Consolidated Federal Laws of Canada, Criminal Code, at §241.2(6).

Requirements relating to assessor expertise and experience vary by jurisdiction (table 4). Tolentino discusses the importance of such requirements, noting that “medical practitioners without specialised training in end-of-life care, mental health, or complex capacity assessments may not possess the requisite expertise needed to navigate the nuanced clinical, psychological, and ethical dimensions of decisions surrounding assisted dying.” He also describes how requiring psychological assessments may be beneficial to ascertain the full voluntariness of the request, since “coercion, whether overt or subtle, can prove difficult to detect without comprehensive psychological and social assessments.” 30 30 Tolentino, “Strengthening Safeguards,” 2, 3.

Some jurisdictions require one or both assessors to have expertise or experience in treating the patient’s condition, whereas others require a consultation or referral to a specialist only if eligibility is undetermined or if decision-making incapacity or mental illness is suspected. Hawaii requires a higher standard for mental-health screening: Requesters must receive counselling from a licensed mental-health professional prior to a request being approved. This assessment is for the purpose of determining “that the patient is capable, and does not appear to be suffering from undertreatment or nontreatment of depression or other conditions which may interfere with the patient’s ability to make an informed decision.” 31 31 Hawaii Revised Statutes, Our Care, Our Choice Act, at §6.

Health Canada’s Model Practice Standard indicates that, “Where appropriate, assessors and providers should consult with clinicians with expertise in the assessment of decision-making capacity,” 32 32 Health Canada, “Model Practice Standard,” 10. but expertise or referrals to those with expertise in psychiatry or mental health are not specifically required in Canadian law, although some provincial regulators do require a psychiatric referral if capacity is in question. 33 33 Close et al., “Medical Assistance in Dying in Canada,” 15. As such, the determination that any such consultation is needed would be left up to assessors’ discretion.

In jurisdictions where eligibility is not limited solely to those with terminal illness, 34 34 For more information, see Vachon and Beauregard, “An International Comparison of Assisted Dying Regimes: Part 1—Eligibility Criteria.” the importance of an assessor having expertise or referring the patient to a specialist with expertise in the patient’s condition is heightened. Belgium, for instance, requires that the second assessor be “competent” to evaluate the patient’s condition, and if the patient’s natural death is not expected in the near future, a third assessor must be a psychiatrist or a specialist in the patient’s condition. 35 35 Government of Belgium, Loi relative à l’euthanasie, at §§2(3) and 3(1). As explained by bioethicists Raus et al., however, Belgium’s Federal Control and Evaluation Commission for Euthanasia considers general practitioners as specialists in cases of polypathology, which comprise nearly half of non-terminal euthanasia cases, a latitude that could significantly limit the efficacy of this safeguard. Raus et al., “Euthanasia in Belgium,” 90–91.

Canadian law does not require assessments to involve specialists in the patient’s condition. For cases of Track 2 MAiD, in which death is not “reasonably foreseeable,” one of the assessors must have expertise in the condition causing the suffering, or if neither assessor has this expertise, another clinician with such expertise must be consulted. “Expertise” is not defined, however, and thus may result in significant variations in interpretation. As Close et al. have noted, some regulators have “clarified that this ‘expertise’ can be gained through experience, training, or education,” 36 36 Close et al., “Medical Assistance in Dying in Canada,” 15–16. The authors also note that the College of Physicians and Surgeons of Newfoundland and Labrador require referral if both assessors lack expertise for those whose death is not reasonably foreseeable. and thus the practitioner does not need to have a regulated specialty to qualify as having the requisite “expertise.” 37 37 Lyon, “Canada’s Medical Assistance in Dying System,” 68, 89.

Some, but not all, jurisdictions require a residency determination during the assessment process. Requiring that the patient be a resident of the jurisdiction can serve multiple purposes. Practically speaking, many healthcare systems are already strained, and policymakers may wish to avoid a situation whereby an “influx [of non-residents requesting assisted dying] may overwhelm the healthcare system and divert resources from domestic patients.” 38 38 Tolentino, “Strengthening Safeguards,” 3. Additionally, it may be legally, ethically, and practically difficult to accommodate non-resident requests if the requester’s medical records, medical team, and family are not easily accessible for consultation.

Another factor is “jurisdiction shopping,” whereby requesters from jurisdictions where assisted dying is not legal, or legal but more difficult to access or to be found eligible, may travel to a more permissive jurisdiction to receive an assisted death. Switzerland is well known as one such jurisdiction. As discussed in the first brief in this series, assisted suicide there is decriminalized and not subject to residency requirements, resulting in “suicide tourism,” with the country becoming “a destination for people internationally who wish to die by suicide.” 39 39 Bartsch et al., “Assisted Suicide in Switzerland,” 545; Gauthier et al., “Suicide Tourism.” A Swiss study examining death records from 1985 to 2014 found that 54 percent of those who died by assisted suicide were Swiss residents, and the remaining 46 percent were non-residents who travelled there for the purpose. 40 40 Bartsch et al., “Assisted Suicide in Switzerland,” 547.

A lack of residency requirements may encourage “jurisdiction shopping,” thus “undermining the integrity of both domestic and international regulations” on assisted dying and allowing those with the means and finances to travel to receive an assisted death that would not otherwise be allowed in their home jurisdiction. 41 41 Tolentino, “Strengthening Safeguards,” 3.

As summarized in table 5, most jurisdictions have residency requirements. The Benelux countries are the exception. The Dutch government notes, however, that providing euthanasia to non-residents “almost never happens,” because of the due-care criteria that clinicians apply, the time that assessments can take, and administrative issues. 42 42 Administrative issues include the fact that costs are not covered if a patient lacks Dutch health insurance, and that access to some services, such as the Dutch Euthanasia Expertise Centre, requires residency, Dutch health insurance, and registration with a physician in the Netherlands. Government of the Netherlands, “Is Euthanasia Legal in the Netherlands?”

In jurisdictions that require or formerly required residency, some erosion in this safeguard has occurred. For instance, all US states with legal assisted suicide had a residency requirement at one point, but both Oregon and Vermont removed this requirement in 2023 in response to legal challenges. 43 43 Oregon Health Authority, Oregon Death with Dignity Act: 2023 Data Summary, 4–5; Vermont General Assembly, An act relating to removing the residency requirement. See also Dresser, “Residency Requirements.” Efforts, both legislatively and in courts, have been ongoing in other states to achieve the same change. 44 44 Pope, “Top Ten New and Needed Expansions,” 89.

In Australia, states that have legalized assisted dying more recently have been less restrictive about residency. Requesters can apply for an exemption to residency requirements in the Australian Capital Territory, New South Wales, Queensland, and, starting in April 2027, Victoria. Exemptions may be granted based on a substantial connection to the state (living nearby, working in the state, receiving medical care in the state, etc.) and, in some jurisdictions, on compassionate grounds.

New South Wales, Queensland, and Tasmania are overall less restrictive on residency, in that they allow persons to request assisted dying if they can demonstrate residency in Australia for a minimum of three years continuously—creating a pathway for those who are neither Australian citizens nor permanent residents. 45 45 Jones, “Slippery Slopes Down Under,” 93; Okninski, “Voluntary Assisted Dying in Australia,” 14. The Australian Capital Territory, which is the most recent jurisdiction in Australia to legalize assisted dying, goes further, requiring the person to have lived in the jurisdiction only for the prior twelve months (or receive an exemption). 46 46 Australian Capital Territory Government, Voluntary Assisted Dying Act 2024, at §11(1)(f), 154.

Canada does not require residency specifically, but eligibility for MAiD is contingent on eligibility for funded health services. 47 47 Government of Canada, Consolidated Federal Laws of Canada, Criminal Code, at §242.2(1)(a). In other words, the law does not require MAiD recipients to be Canadian citizens or residents so long as they qualify for funded health services, but practically speaking, this largely prevents international assisted death “tourism.” As discussed in the previous section, however, some patients who are found ineligible in their own province or locality do travel to other Canadian provinces to receive MAiD from more permissive providers, leading to similar problems of circumventing safeguards.

Jurisdictions differ in the degree to which assessors are obligated to consult with a patient’s current or past medical providers and/or with the patient’s family. Such consultations could provide important information about a patient’s medical history and state of mind, but this safeguard is usually not required.

In many jurisdictions, the law simply requires the assessor to encourage the patient to inform their other care provider(s) of their assisted dying request. Belgium, New Zealand, and Spain are the exception here, requiring assessors to have contact with the previous or regular healthcare teams. In New Zealand, the consultation appears to be related more to ensuring that the request is free from external pressure than to gathering information about the patient’s medical history per se. 48 48 Government of New Zealand, End of Life Choice Act 2019, at §11(2)(h).

Most jurisdictions have no requirement to consult or even notify the patient’s family. Some jurisdictions, such as the Australian states, do indicate that providers should take “reasonable steps” to inform a patient’s family about clinical guidelines and processes for an assisted death, but only if the patient consents. Even this contact, however, is for the purpose of arranging the death, not for assessing eligibility. New Zealand has a slightly higher bar, in that the assessors must confer with family members “approved” by the patient. 49 49 Government of New Zealand, End of Life Choice Act 2019, at §11(2)(h).

Some jurisdictions note that family contact can be useful for collecting information, but this contact is optional rather than required. For example, in cases in the Netherlands in which the assessor cannot communicate with the patient (due to loss of verbal faculties), the Euthanasia Code indicates that the physician “must provide an assessment based on all other available and relevant facts and circumstances. It can be useful to obtain further information from the physician and any family members of the patient or other healthcare professionals involved in the patient’s care.” 50 50 Regional Euthanasia Review Committees, Government of the Netherlands, Euthanasia Code, 22, 28–31.

Canadian federal law is silent on consulting with previous healthcare providers or families. Health Canada guidance indicates, however, that “forming an opinion about MAID eligibility may require the provider or assessor to undertake certain actions,” including gathering “information known to the current or previous treating team and/or family members and/or significant contacts.” Such contact requires consent of the patient, and if consent is denied, “then the assessors and providers must explain that without such information, the assessment cannot be completed and therefore the person cannot be found to be eligible.” 51 51 Health Canada, “Model Practice Standard,” 16. However, given that the recommendation is not law, and given a general lack of comprehensive monitoring and compliance programs in Canada, we do not know the extent to which this recommendation is followed in practice.

Local Canadian authorities may introduce particular stipulations for their regions or institutions regarding collecting information on the patient’s history from previous care providers or families. 52 52 Thomas et al., “Medical Assistance in Dying.” This variation by locality can result in varied approaches to assessment. Likewise, individual assessors may have higher or lower standards for the information that they decide to collect and review. While some assessors may take a thorough approach, others may be less thorough, given that some MAiD provisions in Canada occur on the same day as or the day after the assessment. 53 53 Troubling cases that were found within the practice of same day / next day assessments and provisions are also detailed in Ministry of the Solicitor General, Office of the Chief Coroner of Ontario, MDRC Report 2024–4.

Quebec and Alberta have enshrined higher standards in law. Quebec requires the assessment of eligibility through, among other actions, “discussing the patient’s request with any members of the care team who are in regular contact with the patient.” 54 54 Government of Quebec, Act Respecting End-of-Life Care, at §29(1)(d)(e). Alberta’s recent legislation goes further, requiring the assessor to make reasonable efforts to review a patient’s medical history and personal information, including contacting each primary healthcare provider who treated the patient in the twelve-month period preceding the request. Alberta does not require that family members be contacted during assessments but does require that they be notified at some point before the death, due to the new requirement that a family member be a witness to the provision of MAiD (so long as there is a family member available and willing). 55 55 Government of Alberta, Bill 18, Safeguards for Last Resort Termination of Life Act, at §§5(2), 4(1), (2)(e), (3), (4).

In this second part of the “International Comparison of Assisted Dying Regimes” series, we compared the request and assessment processes for assisted dying across jurisdictions where it is legal.

Canada’s safeguards around requests and assessments place it somewhere between the approach of Australia, New Zealand, and the US states (more restrictive) and that of European jurisdictions (more permissive). Overall, coupled with the generally stricter eligibility criteria found in Australia, New Zealand, and the US (see the brief “An International Comparison of Assisted Dying Regimes: Part 1—Eligibility Criteria”), these jurisdictions provide examples of stricter safeguard criteria that Canada could learn from. Unfortunately, however, erosion has occurred over time in those jurisdictions. Some states in Australia and the US have enacted less strict legislation or amended legislation to loosen safeguards, a worrying trend. 56 56 Jones, “Slippery Slopes Down Under”; Jones, Wrong Side of the World.

The province of Alberta, by contrast, is a unique example of tightening, rather than loosening, safeguards. Its 2026 legislation prohibits MAiD from being raised unsolicited to patients or advertised in healthcare facilities, and specifically requires more in-depth medical reviews and consultations with patients’ past healthcare providers. Whether other Canadian provinces or international jurisdictions follow suit remains to be seen.