Appendix 4 – Supplement for US Citizens

by Laura Carroll

Like the UK, the U.S. does not make it easy for its citizens to have end-of-life choices. While suicide is not considered a crime in the U.S., in some states attempted suicide is a crime. Similar to what John Watson elaborates for the UK, the various ways to attempt it oneself in the U.S. come with legal and medical risks if it fails. 

Helping someone commit suicide is a crime in all U.S. states, with the exception of laws permitting physician-assisted suicide, which vary by state. This is also often called medical aid in dying (MAID). Many prefer the use of MAID to emphasize that people are not actively choosing suicide, but rather to end their suffering and have control over the end of their lives. As of this writing, thirteen states and Washington D.C. have authorized MAID in their jurisdictions. They all have the requirement of a terminal illness and six or fewer months to live. Except for Oregon and Vermont who allow qualified non-residents to access MAID in their state, most states with MAID laws have historically required residency. Canada also has assisted dying laws, but they are not available to non-residents.

To learn more about the states where MAID is already legal, together with its history in the United States, see An Investigative Analysis of Implementation Barriers Across U.S. Jurisdictions Where Medical Aid in Dying is Legal,” conducted by Sarah J Kiskadden-Bechtel, bioethicist and Executive Director of the Academy of Aid-in-Dying medicine.  The report discusses MAID’s history and results of a qualitative analysis of barriers to and best practices of MAID in ten states and the District of Columbia, where the practice was legal as of December 2025.

Those who do not meet the terminal illness requirements in any of the U.S. jurisdictions can pursue a self-determined end-of-life in other ways. One is Voluntarily Stop Eating and Drinking, or VSED. If people do not qualify for a hospice which allows for pain killing medications to keep them comfortable as their bodies shut down, VSED can be a particularly challenging way to go.

However, in recent years, there have been more organizations that provide consultation and services to assist with this option, (as well as other end-of-life services), such as Empowered Endings. A second option is voluntary assisted death at an end-of-life organization in Switzerland. Its voluntary assisted death services do not have the terminal illness and six month or less restrictions that U.S. MAID laws do. Also, unlike most U.S. states with MAID and Canada, Switzerland allows non-Swiss citizens to receive medical support for voluntary assistance in dying. In the U.S., there has been a growing interest in this option.

Services Expected in the United States

Final-stage-of-life services in the U.S. include in-home care, assisted living facilities, nursing homes, memory care facilities, palliative care and hospice care that all provide care when people are in their final months or weeks of life. However, they are not designed to support a self-determined death. With the exception of hospice care when curative treatments are no longer pursued, these services focus on keeping people alive as comfortably as possible. 

U.S. Law

If you are a U.S. citizen, here are things to know regarding U.S. criminal law and civil law and any potential implications when considering the Switzerland alternative.

First, when in Switzerland to pursue medical aid in dying, U.S. citizens are subject to Swiss law, not U.S. law. So once in Switzerland, the U.S. Medical Aid in Dying (MAID) laws do not apply. 

While assisted suicide is considered a crime in every U.S. state, there is not a U.S. law that specifically states it is illegal to accompany someone out of the country for voluntary assisted death. However, according to Thaddeus Pope, a leading attorney for the right-to-die movement in the U.S., there is “not a systematic or comprehensive answer to the legality of accompanying a U.S. citizen to one of the Swiss medical aid in dying clinics.” 

Pope indicates that “state prosecutors (especially in Minnesota and Massachusetts) have regularly enforced [assisted suicide] statutes over the past few years,” though not for accompanying someone to Switzerland. For the Switzerland alternative, a physical action made in the U.S. by the accompanying person, such as buying the person’s ticket, going to the airport, getting on the plane “probably constitutes ‘assistance’ within the meaning of assisted suicide statutes.” According to Pope, accompanying someone to Switzerland “might technically violate assisted suicide statutes.” 

Over the past 20 years however, Pope can’t identify a single U.S. case where the accompanying person was investigated or prosecuted. An investigation or prosecution is conceivable, but as of this writing, it has never happened. 

Even so, when U.S. citizens go to Switzerland to a medical aid in dying clinic, it can be a good idea to consider taking steps beforehand to ensure it’s very clear that their end-of-life decision has clearly been made of their own free will, and the accompanying person is doing just that – simply going with them as the clinics require or strongly encourage. 

Here are two suggestions in this regard. 

Establish a pattern of desire 

If possible, the person who has chosen to go to Switzerland documents the timeline of desire from the first date of consideration to the day the decision is made, including reason(s) for the accompanying person, and that person’s specific actions prior to leaving the country. The accompanying person can do the same. Have as much evidence as possible beforehand that the person’s desire is his/her own and was not made in haste.

Inform a selection of others

Tangibly tell loved ones and anyone the person feels should know. This can be done through a letter or video by recorded by the person embarking on travel to Switzerland. If the accompanying person will receive an inheritance, through letter or video do the same for beneficiaries in the person’s Will.

The laws in the right-to-die area are evolving, so it is best to follow any changes in one’s state and in the U.S. that may legally impact the Switzerland alternative.

Life Insurance Policy Considerations

If a life insurance policy payout will be involved upon the death of someone choosing Voluntary Assisted Dying in Switzerland, contacting the insurer well before travel is recommended to get clear on the requirements for death benefit payouts beforehand. It is also advised to contact one’s state insurance regulator agency to confirm the regulatory obligations of the life insurance company and the regulatory agency’s beneficiary advocacy services if any issues arise.

One issue may involve Switzerland’s strong medical confidentiality laws. Article 321 of the Swiss Criminal Code requires that the cause of a person’s death in Switzerland not be released. The Consular Report of Death Abroad (CRDA), the official document issued by the U.S. embassy or consulate that confirms the death of U.S. citizen overseas states that the cause of death is “not provided by local authorities due to Swiss Medical Confidentiality Act.”

All U.S. states and Washington DC have insurance regulatory agencies, but the laws and regulations are not all the same. While the CRDA and Swiss International Death Certificate do not state the cause of death, state regulatory laws and rules may not require this to meet its payout obligations. For example, in California, the submission of the CRDA, the International Death Certificate along with Certified Translation, as well as completion of claim forms simply stating the cause of death as ‘Voluntary Assisted Death’ have met the requirements for efficient payout. 

If the regulatory law and rules in one’s state permit the insurer to refuse to pay benefits without cause of death on Swiss documents these two options can be considered well before travel to Switzerland. Neither are guaranteed, but are worth pursuing when life insurance collection is of importance.

*Contact the Public Prosecutor in the canton of  the end-of-life organization of choice, and inquire if it will provide a statement of the cause of death for U.S. insurance purposes. If it will, get this is writing before travel to Switzerland, and obtain this statement upon the death. The U.S. Embassy in Berlin, Switzerland has indicated that this has resolved the life insurance issue for U.S. families in the past. 

*Inquire with the organization of choice. Under Swiss law, every voluntary assisted dying has to be done in the presence of at least two people. For a non-Swiss citizen, this means two independent witnesses who have nothing to do with the patient or the family. Find out if on request, the organization will offer the service of witnesses signing a sworn document stating the insured who died by voluntary assisted dying and that they were present to witness the event. If one or both can be an option, before travel to Switzerland, find out and get in writing from the insurer it will accept this form of cause of death documentation. 

In handling the process in accordance with the state’s regulatory law and rules, it can be a good idea to purchase more than one Swiss Certified Death Certificate that is generated by the mortuary in the Canton where the death occurred. One hard copy is sent from the mortuary to the Embassy to generate the CRDA, and then forwarded to the designated person along with the deceased person’s original passport. Having additional copies saves much time and complication if by chance the one hard copy gets lost or is not returned by a U.S. organization or agency involved in the process.

Planning Your Visit

Swiss entry requirements for U.S. Citizens:

Currently, a valid U.S. passport with at least 6 months validity is required. No visa is required for 90 days or less.

As of this writing, The European Union has indicated that in the future U.S. citizens traveling to Switzerland will additionally need a European Travel Information and Authorization System (ETIAS) authorization. ETIAS is a travel authorization system for visa-exempt countries and is linked to a valid passport. Currently, the European Union has stated it will inform the public on the specific date of the start of ETIAS several months prior to its launch.

See the ETIAS site for updates and details on when ETIAS will be fully operational and the application process. To date, there will be a €20 (approximately $23 USD) fee for ages 18-70; above age 70 there is no fee. The site indicates that when operational, most applications will be processed within minutes, but in some cases up to four days. 

Air travel:

If using the Lifecircle, Pegasos or Athanasios, the closest airport is the Basel/Mulhouse. From the U.S., it will likely require a European connecting flight. Flying into Zurich can also be an option, as this can often provide more direct flights from the U.S. and each organization is no more than an hour to an hour and a half from Zurich by car. If using Dignitas, fly into Zurich airport.

Laura Carroll lives in California and is a former trial consultant, industrial psychology professional and nonfiction author. She is A Better Exit Board Member, a member of the Hemlock Society and Final Exit Network. She is not linked to any Assisted Dying Center in Switzerland. Laura offers this Supplement as a result of research for her own purposes of being informed of end-of-life options, so when the time comes, she can make the best decision for her. 

Disclaimer:

This Supplement reflects information gathered from right-to-die organizations and legal professionals in the United States, and online sources deemed reliable, the reality of which is not guaranteed.

It is believed to be correct at the time of publication and is for information purposes only and not intended to provide guidance or advice in any way. No liability will be accepted for any information that proves to be incorrect or legally interpreted differently than what is presented here. No part of this Supplement shall be regarded as advocacy of this action in any form. It is up to readers to seek their own professional consult and advice related to their situation.