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Samuel Rodríguez would love to host a grand farewell party with his friends and family; he wants to say goodbye to everyone because he has chosen the moment of his death. But the law doesn't allow it. Mexican legislation prohibits euthanasia, pushing both him and the supporting doctors into secrecy.

Rodríguez, who is over 80 years old (and whose real name has been withheld for confidentiality), has cancer. He underwent surgery to remove a tumor but opted against chemotherapy or radiation. At his age, he doesn't mind if the cancer returns in a couple of years.

He has also decided that he doesn't want to live if the illness denies him a dignified existence. He didn't hesitate to ask his doctor friends if they could help him die. He believes medically assisted death shouldn't be a taboo.

"I know many notable doctors," Rodríguez said. "Whenever I have a health need, they're always willing to correct or alleviate it. Most agreed with my decision to die when necessary. The problem is it's not legal, and we have to do it clandestinely, taking all necessary precautions to protect everyone's legal integrity." 

Rodríguez gave clear instructions to his doctors about the perfect moment to die: when he can no longer care for himself, when he suffers unbearable pain, and when he starts losing consciousness and loses control over his thoughts.

"But I'm afraid that if I wait too long and can't clearly ask for what I want, they might fear helping me die. So, I'm thinking of being proactive and making the decision earlier. In fact, if at any point they're not willing to help, I would do it alone, which is very sad because I insist it should be a celebration. We should be able to do it with family and not be forced to do it clandestinely."

Asunción Álvarez, PhD, researcher in psychiatry and mental health at the National Autonomous University of Mexico (UNAM) in Mexico City, emphasized the importance of highlighting that euthanasia is practiced secretly by doctors who have a close relationship with the patient who requests it. She added that they also assist each other in dying, having access to other clinicians and knowledge of procedures, thus rendering a law unnecessary.

As a patient, Rodríguez is aware of his privilege. "I'm very fortunate to have this large number of doctors. Otherwise, I would struggle to find help. I know access to so many doctors is an extraordinary situation, and I want to make the most of it, but many people don't have these resources, don't know who to turn to, or what to do."

Law and Human Rights 

In Mexico, euthanasia and assisted suicide are punishable by imprisonment. In the law, they are referred to as mercy killing, and Article 312 of the Federal Penal Code states, "Anyone who aids or induces another to commit suicide shall be punished with a penalty of one to five years in prison; if they provide assistance to the point of executing the death themselves, the imprisonment will be from four to twelve years."

The problem with this legislation is that it penalizes doctors who help people die, thus fundamentally obstructing human rights, explained Juan Antonio Cruz Parcero, PhD, a specialist in law and philosophy, researcher at UNAM, and member of the College of Bioethics.

"…[W]e all have the right to a dignified life, but there are terminal illnesses that impoverish the quality of life and limit autonomy to a point where they may be incompatible with a dignified existence. In these cases, the right to live with dignity includes the right to die with dignity," he said.

Organizations supporting the right to die with dignity establish that to guarantee this right, people must have the option to refuse treatments; receive palliative care; officially declare their advanced directives; and request medically assisted death, including assisted suicide and euthanasia. 

Supporting Patients 

In Mexico, by law, patients have the right to receive palliative care. In 14 states of the republic, they have the option to create their advance care directive. The entities allowing this are Mexico City, Coahuila, Aguascalientes, San Luis Potosí, Michoacán, Hidalgo, Guanajuato, Guerrero, Nayarit, State of Mexico, Colima, Oaxaca, Yucatán, and Tlaxcala. In the rest of the country, such a document is not legal.

Regarding assisted death, Mexico has seen several attempts to decriminalize and regulate the procedure. The most recent was published on March 22, 2023, in the Chamber of Deputies.

This proposed law suggests allowing a dignified and painless death, defining it as follows: "A free and informed decision by the patient in a critical or terminal situation to conclude their life through a medical procedure actively inducing death in advance to minimize pain, suffering, or the risk thereof."

The proposal considers the following three scenarios in which a patient can choose a dignified and painless death:

• If he or she has a terminal illness with a life prognosis of less than 6 months;
• If he or she suffers from a permanently and intensely painful illness or injury; or
• If the patient is in agony, with a life prognosis between two and three days.

Cruz pointed out that the new proposal has an advantage: it is brief and directly mentions euthanasia. The previous proposal avoided using that word. However, there are disadvantages in the new document. For example, it does not propose repealing Article 312. In other words, the General Health Law would allow euthanasia, while the Penal Code would punish it.

"That can be easily resolved in front of a judge because there is the principle of lex posterior, where the later law prevails over the earlier one. But similarly, the contradiction could generate a lot of confusion among healthcare professionals," said Cruz.

Another contradiction in the initiative arises in the case of people in agony, with a life prognosis of between two and three days. Arnoldo Kraus Weisman, MD, rheumatologist, bioethics specialist, and researcher at UNAM's Faculty of Medicine, noted that predicting a 2- to 3-day life prognosis is very difficult. In addition, the initiative states that a patient requesting euthanasia must maintain his or her decision for at least 15 days.

Cruz mentioned that this problem could be resolved by stating that the 15-day procedure does not apply to patients in agony. However, this approach involves revisiting the initiative. He explained that sometimes it's better to advance initiatives with errors because there is a risk that the issue remains unresolved for several more years.

María de Jesús Medina, PhD, bioethicist and researcher at UNAM's Institute of Legal Research, indicated that the legislative path to approve euthanasia is long, since the initiative has to be voted on, modified, and approved in the Chamber of Deputies and the Senate.

"In addition, if approved, a section in the General Health Law or an Official Mexican Standard detailing the correct procedures for providing medical assistance to die, who can perform the procedure, and where, would still be necessary," she added.

De Jesús Medina also pointed out that if the legalization of euthanasia is not accompanied by public policy, if the state does not allocate resources for all patients to access the procedure, dignified death will continue to be a matter of privilege.

Supporting Doctors 

A law allowing assisted euthanasia would benefit people seeking assistance in cases of illness and suffering. However, it is healthcare professionals who would carry out the procedure. How would legislation of this kind benefit doctors?

Álvarez and de Jesús Medina mentioned that if the proposed law is approved, doctors who already help with a peaceful death would not have to operate in the shadows; they would have legal support. As for doctors who oppose euthanasia, the experts noted that there doesn't seem to be much advantage unless they appreciate plurality and respect differences.

Álvarez emphasized that no doctor would be obliged to perform the procedure; they can always become conscientious objectors. So, even if doctors against euthanasia do not lose out, when weighing the issue, there is always more advantage.

In Mexico, conscientious objection is recognized in the General Health Law. Article 10 bis establishes that healthcare and nursing personnel affiliated with the National Health System may excuse themselves from performing a legally approved and legally enforceable euthanasia act if they consider it incompatible with their religious beliefs, moral principles, or ethical conscience.

This means that if euthanasia is legalized, a doctor has the constitutional right to refuse to assist a person in dying. However, for the protection of patients, the Supreme Court has issued criteria regulating conscientious objection.

"A doctor has the right not to participate in the procedure, but they are obliged to refer the patient to a doctor who does not object. They must ensure that the person is directed to a professional who provides care, counseling, and assistance. Additionally, the objecting doctor cannot misinform, obstruct, or influence the decision of the person," said Cruz, adding that a doctor failing to meet these conditions would be incurring professional responsibility. He or she would be obstructing the exercise of a right and could be sanctioned.

Perspectives on Euthanasia

Kraus was unequivocal in stating that the right to assisted death provides autonomy to patients, allowing them to be in control of their lives until the final decision. In an era where technology and aggressive therapeutic measures can unnecessarily prolong life, causing undue suffering, doctors and patients must contemplate, from a young age, the conditions in which they want to experience the end of life.

Kraus mentioned having heard from patients or family members who, after much suffering, claimed that the doctor, instead of extending life, prolonged death. He emphasized that discussing the end of life openly and honestly, with a doctor aiding a patient in dying, means that the patient is always accompanied and listened to, even in his or her last decision, and that is something to celebrate.

However, for other doctors, euthanasia is an act contrary to a doctor's function, which is to save lives. In fact, the American Medical Association strongly opposes euthanasia and suicide with medical assistance.

In Mexico, a group of researchers interviewed 1319 medical students from three out of four medical schools in Nuevo León in 2020. The results showed that 44.4% favored euthanasia, and 52.1% agreed to discontinue therapy at the patient's request, even if it led to death.

In a 2008 study, 2097 doctors from various public hospitals in the country were asked about their stance on euthanasia. Only 47.3% agreed to respond to the survey. The results revealed that 40% agreed that doctors should help terminally ill patients die if requested, 44% disagreed, and the rest were undecided.

In both studies, the main reason for supporting euthanasia was respect for the patient's autonomy and the desire to avoid suffering. The primary reasons for opposing euthanasia were religion and the significance of religion or spirituality in daily life.

It is noteworthy that medical students often cited the illegality of the procedure as a significant argument against euthanasia. The study indicated that if the legal landscape changed, some students would support assisted death.

Palliative Care 

Kraus and Álvarez held that religion is a crucial factor for doctors who oppose assisted death. They also highlighted medical education — the idea that the goal of doctors is to cure, regardless of the means or the patient's wishes.

With the emergence of palliative care, the focus has shifted to teaching that providing support and relieving symptoms during illness are equally important, even when there is no chance of a cure. This approach improves the quality of life for patients suffering from severe conditions. However, some people believe that palliative care has its limits.

"In my case, pain is not the only issue. It is crucial to be able to fend for myself," said Rodríguez, explaining why he wishes to access assisted death despite having palliative care.

Álvarez noted that the belief that quality palliative care would eliminate the desire for medical assistance in dying is a common argument among opponents. She emphasized that this belief is false. Although every patient should have access to palliative care before considering assisted death, there are medical conditions that cannot be alleviated.

"Assisted death is related to what patients consider an undignified life. Palliative care cannot say, 'You should be content with your life. Look at everything we've done for you.' Doctors must respect that each individual decides the dignity of his or her own life."

Álvarez, who is also the president of the World Federation of Right to Die Societies, mentioned that assisted death becomes a taboo among palliative care practitioners, even those in favor of the right to assisted death who hesitate to openly express their stance.

Is Mexico Ready?

Mexico is a predominantly Catholic country, with 77.7% of its population identifying with this religion. One might assume that legalizing assisted death would face significant opposition among Mexicans. However, the National Survey for the Right to Die with Dignity, Mexico 2022, tells a different story.

When asked, 72.7% of Mexicans believe that laws should be changed to allow the sick to receive help in ending their lives if they so decide. The survey, representative of the Mexican population, pleasantly surprised Álvarez. She commented that in all countries where surveys are conducted, approval of assisted death ranges between 60% and 90%, suggesting that the population is ready to accept euthanasia legislation.

"It's more the doctors and politicians who shy away from the issue because the population is well aware of what happens elsewhere, has experiences of bad endings to life. So, people wonder why it's not legalized, why we shouldn't have the right to die with dignity," she said.

As someone seeking medical assistance to die, Rodríguez is aware that there is a proposal to regulate assisted death in Mexico.

"In Mexico, initiatives have been made in this regard, but they are shelved, dormant; no one pays attention to them because they don't want to get into dilemmas. They prefer to avoid serious confrontations," he said.

Cruz commented that the initiative is an opportunity for a much-needed reform, considering that public opinion has changed and there is significant public support for euthanasia. In a secular and pluralistic state, no religious opinion should override how we conceive our human rights.

Until the state provides conditions for people to have a dignified end of life, including the possibility of seeking medical assistance to die, dying with dignity will continue to be a privilege of the few.

Álvarez, Cruz, Kraus, and de Jesús Medina have declared no relevant financial conflicts of interest.

This article was translated from the Medscape Spanish edition.