Chapter 11:Deliberate Termination of Life and Physician Assisted Suicide: Aid in Dying

Section 6. Additional Resources.

http://en.wikipedia.org/wiki/Euthanasia - Euthanasia

For the pro life presentation on this issue see http://www.all.org/issues/index.htm

http://www.webmd.com/content/article/21/1728_55200.htm - Deadly Business: MDs Report Experience With Assisted Suicide

http://www.webmd.com/content/article/21/1689_52815.htm - Who Chooses Physician-Assisted Suicide?

http://www.iaetf.org/ - International Task Force on Euthanasia and Assisted Suicide

http://www.newadvent.org/cathen/05630a.htm - Euthanasia

http://www.cwru.edu/affil/sce/Sovereignty.htm - Sovereignty and the Right to Death

http://www.growthhouse.org/dignity.html - Death with Dignity

http://www.deathwithdignityvermont.org/ - Death with Dignity Vermont

Before I Die
Includes "real-life stories" and provides key facts and in-depth information on end-of-life topics. This is the companion website to a PBS special that dealt with the medical, ethical, and social issues surrounding end-of-life care.
Growth House: Guide To Death, Dying, Grief, Bereavement, and End Of Life Resources
Excellent source. This site includes resources for life-threatening illness and end of life issues, including hospice care, home care, palliative care, pain management, death with dignity, bereavement, and related end of life topics.
Choices in Dying
This site includes detailed information about advance directives, State-specific downloadable advance directives, a summary of Right-to-Die Issues and facts about end-of-life care.

Doctor-Assisted Suicide - A guide to Websites and the literature

Developed by the Longwood College Library, this site includes all relevant legal cases and listings of journal, TV, audio, and web-based references. Copies of the Oregon Death with Dignity Act and statutes are included.

from:  Library & Information Services, Kennedy Institute of Ethics, Georgetown University

Recent Journal Issues Focusing on Assisted Suicide

Annals of Internal Medicine2000 132(6): Finding Common Ground: Consensus Papers from the Assisted Suicide Panel (University of Pennsylvania Center for Bioethics)

Cambridge Quarterly of Healthcare Ethics 1998 7(4): Special Section - Euthanasia and Public Policy

Christian Bioethics 1998 4(2): Physician-Assisted Suicide and Euthanasia: At the Front in the Culture Wars

Ethics: An International Journal of Social, Political and Legal Philosophy 1999 109(3): Symposium on Physician-Assisted Suicide

Supreme Court Bench Opinions

Vacco v. Quill

Washington v. Glucksberg

OREGON Death With Dignity Act:  http://www.ohd.hr.state.or.us/chs/pas/pas.htm

 

Selected Bibliography

The following bibliography has been prepared by the staff of the National Reference Center for Bioethics Literature (NRCBL) from BIOETHICSLINE, a National Library of Medicine online bibliographic database, the NRCBL collection, and the Internet. It is arranged alphabetically by author. Further information is available from the Center.
A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | W | Z



A

Abramson, Neil; Stokes, Jason; Weinreb, Neal J.; and Clark, W. Scott. Euthanasia and Doctor-Assisted Suicide: Responses by Oncologists and Non-Oncologists. Southern Medical Journal 91(7): 637-642, July 1998.

Public interest concerning euthanasia and doctor-assisted suicide is creating ethical dilemmas in the health care profession. We surveyed the views of oncologists and non-oncologists in Florida. METHODS: Physicians responded to an attitudinal questionnaire. The data collected were compared with standard statistical methods. RESULTS: Both oncologists and non-oncologists had similar opposition to euthanasia on philosophic or general grounds, with more opposition on general grounds expressed by oncologists. Both groups preferred better pain control and improved quality of life rather than euthanasia, but more oncologists than non-oncologists favored this alternative. Both groups admitted to participation in passive euthanasia, with little support for active euthanasia and doctor-assisted suicide. However, should the acts of euthanasia and doctor-assisted suicide become legalized, more non-oncologists than oncologists would agree to participate. CONCLUSION: In Florida, more opposition to aspects of the termination of life was expressed by oncologists than by non-oncologists. [Author abstract]

Alpers, Ann, and Lo, Bernard. Does It Make Clinical Sense to Equate Terminally Ill Patients Who Require Life-Sustaining Interventions With Those Who Do Not? JAMA 277(21): 1705-1708, 4 June 1997.

This article reviews the assertion of the two U.S. Circuit Court decisions on assisted suicide that competent, terminally ill patients being kept alive on life support are equivalent to competent, terminally ill patients who do not require such support. Because the former are permitted to end their lives by refusing treatment, the appellate courts found that the latter also have a right to determine the time and manner of their death through prescriptions for lethal doses of medication. The authors analyze the flaws in this reasoning and discuss the implications of this logic for undermining the care of terminally ill patients. [KIE annotation]

Alpers, Ann, and Lo, Bernard. The Supreme Court Addresses Physician-Assisted Suicide. Archives of Family Medicine 8(3): 200-205, May/June 1999.

In June 1997, the US Supreme Court unanimously decided that competent, terminally ill patients have no general constitutional right to commit suicide or to obtain assistance in committing suicide. Thus, the broad prohibitions against any kind of suicide assistance that almost every state has enacted do not violate the constitution. While many of the rulings and the bulk of the reaction to them focused on the Supreme Court's resolution of important legal controversies regarding physician-assisted suicide, this article focuses on the resulting potential for change in physicians' opinions on palliative care. The Court's reasoning may help physicians resolve substantial ethical dilemmas regarding the provision of narcotics given in high dosages, the care of incompetent patients, and the suffering caused by symptoms other than pain. For example, the Court concluded that a physician's intent can distinguish permissible acts of aggressive pain relief from impermissible acts of hastening death. This distinction has clinical uses and can help physicians develop ethical guidelines and practice standards to improve palliative care near the end of life. [Author abstract]

American Geriatrics Society. Brief to the United States Supreme Court [on Physician-Assisted Suicide] [See Also Lynn et al.]

American Medical Association. Council on Ethical and Judicial Affairs. Physician-Assisted Suicide [Report 59]. Code of Medical Ethics: Reports of the Council 5(2): 269-275, July 1994.

Revisiting their earlier report addressing assisted suicide Decisions Near the End of Life (JAMA 267(16): 2229-2233, 22/29 April 1992], the Council asserts that physician-assisted suicide (PAS) is "inconsistent with the physician's professional role," and observes that a request for PAS is "...a signal to the physician that the patient's needs are unmet..." [KIE annotation]

Amundsen, Darrel W. The Ninth Circuit Court's Treatment of the History of Suicide by Ancient Jews and Christians in Compassion in Dying v. State of Washington: Historical Naivete or Special Pleading? Issues in Law and Medicine 13(4): 365-423, Spring 1998.

In this article, Prof. Darrel Amundsen critiques Judge Reinhardt's comments regarding "Historical Attitudes Toward Suicide" in his Compassion in Dying opinion. Amundsen demonstrates that the court's characterization of ancient Jewish and Christian practices is inaccurate and misleading because it fails to acknowledge the complexities of the moral issue of suicide. Amundsen discusses martyrdom, suicide in general, suicide by the ill, and euthanasia in ancient Judaism. In contrast to the court's commentary, Amundsen demonstrates that regard for human life is a central feature of Jewish ethical monotheism. Furthermore, the author challenges the court's conclusions about early Christianity, and explains why its treatment of the issue of suicide in early Christianity is misleading and inaccurate. Amundsen's discussion of early Christianity includes suicide, martyrdom, and especially the Augustinian teaching on suicide. He concludes that the court's treatment of the issue of suicide in early Christianity is so historically and conceptually muddled as to be fundamentally inaccurate. [Author abstract]

Angell, Marcia. The Supreme Court and Physician-Assisted Suicide -- The Utimate Right. [Editorial]. New England Journal of Medicine 336(1): 50-53, 2 January 1997.

Paired with an editorial opposing physician-assisted suicide (PAS) [See Foley], Angell argues in favor of permitting PAS under certain circumstances. Calling objections to PAS "...too doctor-centered and not sufficiently patient-centered," the author bases her rebuttal of the arguments against PAS on respect for patient autonomy and on the recognition that in certain circumstances, despite the best of care, "...death is not fair and is often cruel." Ending the editorial with a description of her father's suicide after receiving a diagnosis of metastatic cancer, Angell concludes that PAS "...is simply a part of good medical care." [KIE annotation]

Annas, George J.; Glantz, Leonard H.; Mariner, Wendy K., et al. (Bioethics Professors Supporting Petitioners) Brief of Amicus Curiae: Vacco v. Quill, No. 95-1858, and Washington v. Glucksberg, No. 96-110. Filed in the Supreme Court of the United States, Washington, DC; 1996 Nov 12. 35 p.

Annas, George J. Physician-assisted Suicide -- Michigan's Temporary Solution. New England Journal of Medicine 328(21): 1573-1576, 27 May 1993.

Kevorkian says, in effect, that medicine cannot change and that society must therefore accept his methods as a reasonable alternative. The Michigan legislature has properly rejected his approach. But the real issues are related to medical practice, not the law, and the challenge Kevorkian presents to modern medicine is real. Physicians must respond by listening to their dying patients, comforting them, providing them with continuity of care and freedom from pain and suffering (even to the extent of prescribing drugs they might use to end their own lives), and bringing hospice care into mainstream medicine. If physicians fail to meet this challenge, society will ultimately embrace the solution that Kevorkian offers by medicalizing suicide the way we have already medicalized death. [Author abstract]

Arras, John D. Physician-Assisted Suicide: A Tragic View. In: Physician Assisted Suicide: Expanding the Debate. Margaret P. Battin; Rosamond Rhodes; and Anita Silvers (eds.) New York, NY: Routledge; 1998: 279-300.

Noting that "...PAS poses a 'tragic choice' for society in the sense that whichever policy we embrace, there are bound to be victims," Arras examines two slippery slope arguments used against PAS and suggests that the alleviation of social amd medical deficiencies would circumvent most PAS requests. [KIE annotation]


B

Bachman, Jerald G.; Alcser, Kirsten H.; Doukas, David J.; Lichtenstein, Richard L.; Corning, Amy D.;and Brody, Howard. Attitudes of Michigan Physicians and the Public toward Legalizing Physician-Assisted Suicide and Voluntary Euthanasia. New England Journal of Medicine 334(5): 303-309, 1 February 1996.

Background: There has been a continuing public debate about assisted suicide and the proper role, if any, of physicians in this practice. Legislative bans and various forms of legalization have been proposed. Methods: We mailed questionnaires to three stratified random samples of Michigan physicians in specialties likely to involve the care of terminally ill patients: 500 in the spring of 1994, 500 in the summer of 1994, and 600 in the spring of 1995. Similar questionnaires were mailed to stratified random samples of Michigan adults: 449 in the spring of 1994 and 899 in the summer of 1994. Several different questionnaire forms were used, all of which included questions about whether physician-assisted suicide should be banned in Michigan or legalized under certain conditions. : Usable questionnaires were returned by 1119 of 1518 physicians eligible for the study (74 percent), and 998 of 1307 eligible adults in the sample of the general public (76 percent). Asked to choose between legalization of physician-assisted suicide and an explicit ban, 56 percent of physicians and 66 percent of the public supported legalization, 37 percent of physicians and 26 percent of the public preferred a ban, and 8 percent of each group were uncertain. When the physicians were given a wider range of choices, 40 percent preferred legalization, 37 percent preferred "no law" (i.e., no government regulation), 17 percent favored prohibition, and 5 percent were uncertain. If physician-assisted suicide were legal, 35 percent of physicians said they might participate if requested -- 22 percent would participate in either assisted suicide or voluntary euthanasia, and 13 percent would participate only in assisted suicide. Support for physician-assisted suicide was lowest among the strongly religious. Conclusions: Most Michigan physicians prefer either the legalization of physician-assisted suicide or no law at all; fewer than one fifth prefer a complete ban on the practice. Given a choice between legalization and a ban, two thirds of the Michigan public prefer legalization and one quarter prefer a ban. [Author abstract]

Back, Anthony; Baker, Robert; Battin, Margaret P., et al. (Bioethicists Supporting Respondents) Brief of Amicus Curiae: Vacco v. Quill, No. 95-1858, and Washington v. Glucksberg, No. 96-110. Filed in the Supreme Court of the United States, Washington, DC; 1996 Dec 10. 27 p.

Badham, Paul. A Theological Examination of the Case for Euthanasia. In his: Facing Death: An Interdisciplinary Approach. with Paul Ballard,ed. Cardiff: University of Wales Press, 1996: 101-116.

The author believes that in some cases voluntary assisted suicide could be considered an opportunity for a prayerful death within the Christian tradition, citing passages from the Bible as spiritual guidance for this view. [KIE annotation]

Baron, Charles H.; Gostin, Lawrence, et al. (Law Professors in Support of Respondents) Brief of Amicus Curiae: Vacco v. Quill, No. 95-1858, and Washington v. Glucksberg, No. 96-110. Filed in the Supreme Court of the United States, Washington, DC; 1996 Dec 10. 27 p.

Battin, Margaret P. Going Early, Going Late: The Rationality of Decisions About Suicide in AIDS. Journal of Medicine and Philosophy 19(6): 571-594, December 1994 .

Where assistance in suicide is readily available to those dying of AIDS, as in the West Coast gay communities of the United States and in the Netherlands, we must examine the different roles of physicians and friends (including lovers, spouses, family members, religious advisors, members of support groups, and intimate others) in helping a person with AIDS decide about and carry out suicide. This paper makes a central assumption: that where assistance in suicide is available, it is the moral obligation of others to protect and enhance as much as possible the rationality of that choice. Four components are identified in a rational choice about suicide in AIDS -- whether it is a choice for or against suicide. Phrased as questions a person with AIDS might ask him- or herself, they are: (1) "Is suicide an option I want to consider?" (2) "Shall I hold out for the chance of a cure?" (3) "How shall I time my suicide?" (4) "What weight shall I give to the welfare and interests of others?" Although physicians often make assertions relevant to (1), they are appropriately involved only in (3); and although friends or intimate partners often provide the patient with anecdotal information relevant to (3), they should be involved primarily in (1). In short, both physicians and friends often intervene in the wrong parts of choices made by a person with AIDS about suicide. [Author abstract]

Battin, Margaret. On the Structure of the Euthanasia Debate: Observations Provoked by a Near-Perfect For-and-Against Book. [Review of Euthanasia and Physician-Assisted Suicide: For and Against by Gerald Dworkin, R. G. Frey, and Sissela Bok.] Journal of Health Politics, Policy and Law 25(2): 415-430, April 2000.

This review provides a concise outline of the structure of the assisted dying debate which Battin believes shows "some progress - indeed, real growth - toward a more mature phase of the debate." [KIE annotation]

Battin, Margaret. Voluntary Euthanasia and The Risk of Abuse: Can We Learn Anything From The Netherlands? Law, Medicine and Health Care 20(1-2): 133-143, Spring-Summer 1992.

In general, I think it is crucial to be as clear and forthright about the issue of abuse as possible, even if one supports, as I do, the legalization of aid-in-dying. In doing so, one must answer two central questions: 1) Will there be abuse, and if so, precisely what kind? 2) Can abuse of this sort be prevented? It is to the second of these questions that I will be particularly attentive here. In doing so, I shall consider only the possible effects of legalizing voluntary, active, physician-performed euthanasia and physician-assisted suicide, restricted to cases in which such help is requested by competent, terminally ill patients with less than 6 months to live -- that is, I shall be considering only what Initiative 119 would have legalized -- but some of the arguments will clearly apply to a wider range of possible legislation as well.... [Author abstract]

Brahams, Diana. The Right to Be Allowed to Die. Lancet 1(8372): 351-352, 11 February 1984.

Commenting on the California case of Elizabeth Bouvia, a quadreplegic who requested hospital assistance to alleviate suffering while she starved herself to death, Brahams expresses the hope that no patient in the United Kingdom will ever be forcibly fed against his or her wishes. Since passage of Britain's Suicide Act of 1961, taking one's own life is not a crime, although aiding a suicide is illegal. In a court case involving a book published by the Voluntary Euthanasia Society, Mr. Justice Woolf ruled that giving the booklet to another person could amount to encouraging suicide. Brahams contends that provision of medical comfort does not constitute encouragement. She cites the British government's decision not to force feed IRA hunger strikers, the possibility that force feeding constitutes battery under British law, and a Florida court ruling that a patient had the right to decline life prolonging treatment. (KIE abstract)

Braun, Kathryn L. Do Hawaii Residents Support Physician-Assisted Death? A cCmparison of Five Ethnic Groups. Hawaii Medical Journal 57(6): 529-534, June 1998.

Surveyed were 250 adults in five ethnic groups -- Caucasian, Chinese, Filipino, Hawaiian, and Japanese -- on questions about physician-assisted death. When asked if there were any conditions under which physician-assisted death should be allowed, 52% said yes, 19% said perhaps, and 29% said no. Differences in response were seen, however, by ethnicity (with less support among Filipinos and Hawaiians), by religious affiliation (with less support among Catholics), and by educational attainment (with greater support among college graduates). Given the controversial nature of this topic, more public education and debate are needed. Meanwhile, physicians are urged to expand discussions with patients on their expectations about and options for end-of-life care. [Author abstract]

Brody, Howard. Causing, Intending, and Assisting Death. Journal of Clinical Ethics 4(2): 112-117, Summer 1993.

Are there morally compelling differences among allowing a patient to die by forgoing treatment, physician-assisted suicide, and active euthanasia? And what follows for medical ethics and public policy if these differences do or do not exist? Recently, Edmund D. Pellegrino has forcefully restated an old argument in defense of a compelling difference: in active euthanasia or physician-assisted suicide, the physician causes the patient's death, while in forgoing treatment, the disease causes the patient's death. Similarly, Raymond J. Devettere has argued that what makes active euthanasia immoral is that the physician directly intends the patient's death, while in forgoing treatment, the physician does not intend the patient's death. I have two purposes in this article. The most obvious is to contend that these two arguments based on causation and intention fail to do the work we ask of them, but in the end, that failure does little to illuminate what public policy ought to be on physician-assisted suicide or active euthanasia. The less obvious purpose is to try to illustrate and develop a key concept in the rediscovery of casuistry as a methodology in medical ethics. [Author abstract]

Brody, Howard. Assisted Death -- A Compassionate Response to a Medical Failure. New England Journal of Medicine 327(19):1384-1388, 5 November 1992.

I argue here that an adjudication of assisted death might follow from viewing it as a compassionate response to one sort of medical failure, rather than as something to be prohibited outright or as something to be established as a standard policy. This would seem to translate, in law, into allowing compassionate and competent medical practice to serve as a defense against a charge of homicide or of assisting a suicide. By assisted death I mean either voluntary, active euthanasia, as now commonly practiced in the Netherlands and as proposed in an unsuccessful referendum in Washington State in 1991, or assisted suicide, in which the patient is provided at his or her request with sufficient medication or other means to end life, with the knowledge that the patient intends to use the medication for that purpose. [Author abstract]


C

Callahan, Daniel. When Self-Determination Runs Amok. Hastings Center Report 22(2): 52-55, March-April 1992.

The euthanasia debate is not just another moral debate, one in a long list of arguments in our pluralistic society. It is profoundly emblematic of three important turning points in Western thought. The first is that of the legitimate conditions under which one person can kill another....The second turning point lies in the meaning and limits of self-determination....The third turning point is to be found in the claim being made upon medicine: it should be prepared to make its skills available to individuals to help them achieve their private vision of the good life....I believe that, at each of these three turning points, proponents of euthanasia push us in the wrong direction. Arguments in favor of euthanasia fall into four general categories, which I will take up in turn: (1) the moral claim of individual self-determination and well-being; (2) the moral irrelevance of the difference between killing and allowing to die; (3) the supposed paucity of evidence to show likely harmful consequences of legalized euthanasia; and (4) the compatibility of euthanasia and medical practice. [Author abstract]

Campbell, Courtney S.; Hare, Jan; and Matthews, Pam. Conflicts of Conscience: Hospice and Assisted Suicide. Hastings Center Report 25(3): 36-43, May-June 1995.

Proposals to legalize assisted suicide challenge hospice's identity and integrity. In the wake of Measure 16, Oregon hospice programs must develop practical policies to balance traditional commitments not to hasten death and not to abandon patients with dying patients' legal right to request lethal prescriptions....The moral fallout of Measure 16 involved a collapse of the shared value framework that has guided hospice for the last two decades. [Author abstract]

Caplan, Arthur L.; Snyder, Lois; and Faber-Langendoen, Kathy. [University of Pennsylvania. Center for Bioethics. Assisted Suicide Consensus Panel] The Role of Guidelines in the Practice of Physician-Assisted Suicide. Annals of Internal Medicine 132(6): 476-481, 21 March 2000.

Capron, Alexander Morgan. Even in Defeat, Proposition 161 Sounds a Warning. Hastings Center Report 23(1): 32-33, January-February 1993 .

Occasionally law that isn't made may be as significant as law that is. One such instance was the rejection on 3 November of Proposition 161 by a 54-46 majority of California voters. Had this initiative passed, the state would have been the first in the world since the Nazi era formally to permit physicians to perform active euthanasia. Even though defeated, the strong showing for this ballot measure -- and the even stronger support it enjoyed outside the voting booth -- sounds a loud alarm for health care professionals not just in California but across the country. [Author abstract]

Cassel, Christine K., and Foley, Kathleen M. Priniciples for Care of Patients at the End of Life: An Emerging Consensus Among the Specialties of Medicine. New York, NY: Millbank Memorial Fund, December 1999.

Cassel, Christine K., and Meier, Diane E. Morals and Moralism in the Debate over Euthanasia and Assisted Suicide. New England Journal of Medicine 323(11): 750-752, 13 September 1990.

In this Sounding Board essay, Cassel and Meier criticize the reaction of the medical profession to a recent, highly-publicized case involving the physician-assisted suicide of a patient said to be suffering from the early stages of Alzheimer's disease. While acknowledging the disturbing aspects of Janet Adkins' suicide with the help of Dr. Jack Kevorkian, Cassel and Meier maintain that the uniform response by doctors condemning physician-assisted suicide ignores the complexity of the issue. They argue that the medical profession's strict prohibition against aiding death fails to take into account the needs and values of patients or to acknowledge the limits of medicine and the inevitability of death. They call for a broadening of the debate over assisted suicide and euthanasia and a more thorough and thoughtful analysis of the issues. (KIE abstract)

Cavanaugh, Thomas A. The Nazi! Accusation and Current US Proposals. Bioethics 11(3-4): 291-297, Jul-Oct 1997.

In contemporary ethical discourse generally, and in discussions concerning the legalization of physician-assisted suicide (PAS) and voluntary active euthanasia (VAE) specifically, recourse is sometimes had to the Nazi! accusation. Some disputants charge that such practices are or will become equivalent to the Nazi 'euthanasia' program in which over 73,000 handicapped children and adults were killed without consent. This paper reflects on the circumstances that lead to the use of this charge and offers reasons for putting the Nazi! charge aside in contemporary discussions of PAS and VAE. A number of the philosophical presuppositions common to both the Nazi 'euthanasia' program and the currently proposed practices of PAS and VAE are examined. Noting that racist ideology and violent coercion characterized the Nazi program, the paper concludes with a cautionary consideration of the current circumstances that would specify PAS and VAE in the US. [Author abstract]

CeloCruz, Maria T. Aid-in-Dying: Should We Decriminalize Physician-Assisted Suicide and Physician-Committed Euthanasia? [Note]. American Journal of Law and Medicine 18(4): 369-394, 1992.

Recent news stories, medical journal articles, and two state voter referenda have publicized physicians' providing their patients with aid-in-dying. This Note distinguishes two components of aid-in-dying: physician-assisted suicide and physician-committed voluntary active euthanasia. The Note traces these components' distinct historical and legal treatments and critically examines arguments for and against both types of action. This Note concludes that aid-in-dying measures should limit legalization initiatives to physician-assisted suicide and should not embrace physician-committed voluntary active euthanasia. [Author abstract]

Childs, Brian H. The Last Chapter of the Book: Who is the Author? Christian Reflections on Assisted Suicide. Journal of Medical Humanities 18(1): 21-28, Spring 1997.

In this paper the author argues that a narrative approach to understanding assisted suicide has been compromised by the notion that all narratives must be both coherent and unified. He asks what we are to do with those narratives that cannot seem to cohere or be other than full of disunity? Is suicide the only way to make meaning out of suffering? He then proposes that the narrative found in the Gospel of Mark leads Christians to a life in hope and compassion in spite of apparent incoherence and disunity and threats of abandonment and suffering.

Coulehan, Jack. The Man with Stars Inside. Annals of Internal Medicine 126(10): 799-802, 15 May 1997.

Public opinion polls show that a large percentage of persons in the United States currently favor the legalization of professionally assisted death. This support reflects widespread fear and confusion over the tortuously prolonged and painful process of dying countenanced by contemporary medicine. Physician-assisted suicide and euthanasia are complex moral issues. The current drive to translate them into debates about rights and public policy is curious: Does the energy directed toward palliation-by-death mean that our society is more compassionate now, or more just, than in the past? To the contrary, I believe that the movement toward assisted death reflects inadequate palliative care, poor patient-physician communication, great confusion about the right to refuse treatment, and profound inequity in U.S. health care. Legalization of assisted death diverts us from addressing these problems. Palliation-by-death will drive us farther apart, not closer together. [Author abstract]


D

Degnin, Francis Dominic. Levinas and the Hippocratic Oath: A Discussion of Physician-Assisted Suicide. Journal of Medicine and Philosophy 22(2): 99-123, April 1997.

At least from the standpoint of contemporary cultural and ethical resources, physicians have argued eloquently and exhaustively both for and against physician-assisted suicide. If one avoids the temptation to ruthlessly simplify either position to immorality or error, then a strange dilemma arises. How is it that well educated and intelligent physicians, committed strongly and compassionately to the care of their patients, argue adamantly for opposing positions? Thus rather than simply rehashing old arguments, this essay attempts to rethink the nature of human morality as both a source and a fracturing of human rationality- and with morality, the question of human nature in the context of violence, oppression, service, and obligation. This interpretation of moral life is laid out roughly along the lines of the Jewish philosopher Emmanuel Levinas, and further clarified through a discussion of the Hippocratic Oath. These resources are then brought to bear on the specific arguments and recommendations concerning physician-assisted suicide. [Author abstract]

Dellinger, Walter; Hunger, Frank W.; Waxman, Seth P., et al. (United States). Brief of Amicus Curiae for the United States Supporting Petitioners: Washington v. Glucksberg, No. 96-110. Filed in the United States Supreme Court, Washington, DC; 1996 Nov 12. 32 p.

Dellinger, Walter; Hunger, Frank W.; Waxman, Seth P., et al. (United States). Brief of Amicus Curiae for the United States Supporting Petitioners: Vacco v. Quill, No. 95-1858. Filed in the United States Supreme Court, Washington, DC; 1996 Nov 12. 21 p.

Drickamer, Margaret A.; Lee, Melinda A.; and Ganzini, Linda. Practical Issues in Physician-Assisted Suicide. Annals of Internal Medicine 126(2): 146-51, 15 January 1997.

Support for the participation of physicians in the suicides of terminally ill patients is increasing, and the concrete effects on physician practice of a policy change with regard to physician-assisted suicide must be carefully considered. If physician-assisted suicide is legalized, physicians will need to gain expertise in understanding patients' motivations for requesting physician-assisted suicide, assessing mental status, diagnosing and treating depression, maximizing palliative interventions, and evaluating the external pressures on the patient. They will be asked to prognosticate not only about life expectancy but also about the onset of functional and cognitive decline. They will need access to reliable information about effective medications and dosages. The physician's position on physician-assisted suicide must be open to discussion between practitioner and patient. Protection of the patient's right to confidentiality must be balanced against the need of health care professionals and institutions to know about the patient's choice. Insurance coverage and managed care options may be affected. All of these issues need to be further explored through research, education, decision making by individual practitioners, and ongoing societal debate. [Author abstract]

Dworkin, Gerald; Frey, R.G.; and Bok Sissela. Euthanasia and Physician-Assisted Suicide: For and Against. New York: Cambridge University Press, 1998. 139 p.

Part One, written by Dworkin and Frey (and presenting the `for' side of the book), theorizes on the the limits of medicine, distinctions in death, fear of the slippery slope and moral dilemmas in making assisted suicide public policy. Part Two by Sissela Bok looks at debates concerning individual control at the end of life, the three main categories of contemporary views in choosing death and taking life, freedom to choose death, the history and background for and against suicide and indicates that legalization of euthanasia and physician-assisted suicide entails grave risks, dealing inadequately with the needs of the dying, particularly if these patients have no health insurance. [KIE abstract]

Dworkin, Ronald; Nagel, Thomas; Nozick, Robert; Rawls, John; Scanlon, Thomas; Thomson, Judith Jarvis. Brief of Amicus Curiae in Support of Respondents: Washington v. Glucksberg, No. 96-110, and Vacco v. Quill, No. 95-1858. Filed in the United States Supreme Court, Washington, DC; 1996 Dec 10. 22 p.


E

Emanuel, Ezekiel J., and Daniels, Elisabeth. Oregon's Physician-Assisted Suicide Law: Provisions and Problems. Archives of Internal Medicine 156(8): 825-829, 22 April 1996.

The Oregon Death With Dignity Act constitutes a major change in social policy and the practices of medicine. Regardless of one's position on the ethics of legalizing euthanasia and assisted suicide, the law raises serious problems that must be addressed prior to implementation: (1) its safeguards fail to ensure that assistd suicide be offered appropriately as an option only after efforts to treat reversible conditions have been exhausted and (2) its monitoring system fails to ensure that the consequence of change in social policy will be adequately evaluated. [Author abstract]

Emanuel, Ezekiel J. What Is the Great Benefit of Legalizing Euthanasia or Physician-Assisted Suicide? Ethics 109(3): 629-642, April 1999.

Noting that the current debate on legalizing physician assisted suicide has centered on the care of individuals, the author proposes that the discussion be refocused around the question of what constitutes a good death. [KIE abstract]

Episcopal Diocese of Washington, D.C. Committee on Medical Ethics (Chair: Cynthia B. Cohen) Assisted Suicide and Euthanasia: Christian Moral Perspectives (The Washington Report). Harrisburg, PA: Morehouse Publishing, 1997. 92 p.


F

Foley, Kathleen M. Competent Care for the Dying Instead of Physician-Assisted Suicide. [Editorial]. New England Journal of Medicine 336(1): 54-58, 2 January 1997.

Paired with an editorial in favor of physician-assisted suicide (PAS),[See Angell] the author suggests that the debate over PAS provides a "...unique opportunity to engage the public, health care professionals, and the government in a national discussion of how American medicine and society should address the needs of dying patients and their families." Foley believes that "...[i]f legalized, physician-assisted suicide will be a substitute for rational therapeutic, psychological, and social interventions that might otherwise enhance the quality of life for patients who are dying." [KIE annotation]


G

Ganzini, Linda ; Nelson, Heidi D. ; Schmidt, Terri A. ; Kraemer, Dale F. ; Delorit, Molly A. ; and Lee, Melinda A. Physicians' Experiences with the Oregon Death with Dignity Act. New England Journal of Medicine 342(8): 557-563, 24 February 2000.

Physician-assisted suicide was legalized in Oregon in October 1997. There are data on patients who have received prescriptions for lethal medications and died after taking the medications. There is little information, however, on physicians' experiences with requests for assistance with suicide. METHODS: Between February and August 1999, we mailed a questionnaire to physicians who were eligible to prescribe lethal medications under the Oregon Death with Dignity Act. RESULTS: Of 4053 eligible physicians, 2649 (65 percent) returned the survey. Of the respondents, 144 (5 percent) had received a total of 221 requests for prescriptions for lethal medications since October 1997. We received information on the outcome in 165 patients (complete information for 143 patients and partial for on an additional 22). The mean age of the patients was 68 years; 76 percent had an estimated life expectancy of less than six months. Thirty-five percent requested a prescription from another physician. Twenty-nine patients (18 percent) received prescriptions, and 17 (10 percent) died from administering the prescribed medication. Twenty percent of the patients had symptoms of depression; none of these patients received a prescription for a lethal medication. In the case of 68 patients, including 11 who received prescriptions and 8 who died by taking the prescribed medication, the physician implemented at least one substantive palliative intervention, such as control of pain or other symptoms, referral to a hospice program, a consultation, or a trial of antidepressant medication. Forty-six percent of the patients for whom substantive interventions were made changed their minds about assisted suicide, as compared with 15 percent of those for whom no substantive interventions were made (P less than 0.001). CONCLUSIONS: Our data indicate that in Oregon, physicians grant about 1 in 6 requests for a prescription for a lethal medication and that 1 in 10 requests actually result in suicide. Substantive palliative interventions lead some -- but not all -- patients to change their minds about assisted suicide. [Author abstract]

Ganzini, Linda; Fenn, Darien S.; Lee, Melinda A.; Heintz, Ronald T.; and Bloom, Joseph D. Attitudes of Oregon Psychiatrists Toward Physician-Assisted Suicide. American Journal of Psychiatry 153(11): 1469-1475, November 1996.

OBJECTIVE: After passage, in November 1994, of Oregon's ballot measure legalizing physician-assisted suicide for terminally ill persons, the authors surveyed psychiatrists in Oregon to determine their attitudes toward assisted suicide, the factors influencing these attitudes, and how they might both respond to and follow up a request by a primary care physician to evaluate a terminally ill patient desiring assisted suicide. METHOD: An anonymous questionnaire was sent to all 418 Oregon psychiatrists. RESULTS: Seventy-seven percent of psychiatrists (N = 321) returned the questionnaire. Two-thirds endorsed the view that a physician should be permitted, under some circumstances, to write a prescription for a medication whose sole purpose would be to allow a patient to end his or her life. One-third endorsed the view that this practice should never be permitted. Over half favored Oregon's assisted suicide initiative becoming law. Psychiatrists' position on legalization of assisted suicide influenced the likelihood that they would agree to evaluate patients requesting assisted suicide and how they would follow up an evaluation of a competent patient desiring assisted suicide. Only 6% of psychiatrists were very confident that in a single evaluation they could adequately assess whether a psychiatric disorder was impairing the judgment of a patient requesting assisted suicide. CONCLUSIONS: Psychiatrists in Oregon are divided in their belief about the ethical permissibility of assisted suicide, and their moral beliefs influence how they might evaluate a patient requesting assisted suicide, should this practice be legalized. Psychiatrists' confidence in their ability to determine whether a psychiatric disorder such as depression was impairing the judgment of a patient requesting assisted suicide was low. [Author abstract]

Gevers, J.K.M. Physician-Assisted Suicide and the Dutch Courts. Cambridge Quarterly of Healthcare Ethics 5(1): 93-99, Winter 1996.

.Until recently, little attention was paid to PAS [physician-assisted suicide] as such. During the last years, however, several cases of PAS that do not resemble the usual euthanasia cases have been brought before the [Dutch] courts. Most of these new cases do not concern patients suffering from serious somatic disases, like terminal cancers, but psychiatric patients. They have raised several questions. Could PAS be justified when psychiatric patients are concerned? Could it be allowed when the person in question wants to commit suicide, not primarily because of an unbearable illness or disability that leaves no hope for the future, but rather because of intolerable life circumstances? This article discusses the recent court decisions in which these questions, at least to some extent, have been addressed. [Author abstract]

Gevers, Sjef. Physician Assisted Suicide: New Developments in the Netherlands. Bioethics 9(3/4): 309-312, July 1995.

Until recently, physician assisted suicide was dealt with on the same basis as active voluntary euthanasia in the Netherlands. Over the last years, several cases relating to assistance in suicide of mental patients did raise specific issues, not addressed so far in the debate on euthanasia. One of these cases resulted in a Supreme Court decision. The paper summarizes this decision and comments on it from a legal point of view. [Author abstract]

Glucksberg, Harold; Halperin, Abigail; Preston, Thomas A.; Shalit, Peter. Brief for Respondents: Washington v. Glucksberg, No. 96-110. Filed in the United States Supreme Court, Washington, DC; 1996 Dec 10. 48 p.

Gostin, Lawrence O. Drawing a Line Between Killing and Letting Die: The Law, and Law Reform, on Medically Assisted Dying. Journal of Law, Medicine and Ethics 21(1): 94-101, Spring 1993.

While much has been written about the professional ethics of physician assisted dying, little is known about where the law draws the line, whether the law is enforced in practice, and how the law should be reformed to reflect changing public opinion and ethical thought. This article addresses these questions and the need for clearer public policy [in the United States] on physician assisted dying. [Author abstract]

Gregoire, Christine O. (Washington). Brief for the Petitioners: Washington v. Glucksberg, No. 96-110. Filed in the United States Supreme Court, Washington, DC; 1996 Nov 12. 61 p.

Gregoire, Christine O. (Washington). Reply Brief for Petitioners: Washington v. Glucksberg, No. 96-110. Filed in the United States Supreme Court, Washington, DC; 1996 Dec 26. 20 p.

Groenewoud, Johanna H. ; van der Heide, Agnes ; Onwuteaka-Philipsen, Bregje D. ; Willems, Dick L. ; van der Maas, Paul J. ; and van der Wal, Gerrit. Clinical Problems with the Performance of Euthanasia and Physician-Assisted Suicide in the Netherlands. New England Journal of Medicine 342(8): 551-556, 24 February 2000.

The characteristics and frequency of clinical problems with the performance of euthanasia and physician-assisted suicide are uncertain. We analyzed data from two studies of euthanasia and physician-assisted suicide in The Netherlands (one conducted in 1990 and 1991 and the other in 1995 and 1996), with a total of 649 cases. We categorized clinical problems as technical problems, such as difficulty inserting an intravenous line; complications, such as myoclonus or vomiting; or problems with completion, such as a longer-than-expected interval between the administration of medications and death. RESULTS: In 114 cases, the physician's intention was to provide assistance with suicide, and in 535, the intention was to perform euthanasia. Problems of any type were more frequent in cases of assisted suicide than in cases of euthanasia. Complications occurred in 7 percent of cases of assisted suicide, and problems with completion (a longer-than-expected time to death, failure to induce coma, or induction of coma followed by awakening of the patient) occurred in 16 percent of the cases; complications and problems with completion occurred in 3 percent and 6 percent of cases of euthanasia, respectively. The physician decided to administer a lethal medication in 21 of the cases of assisted suicide (18 percent), which thus became cases of euthanasia. The reasons for this decision included problems with completion (in 12 cases) and the inability of the patient to take all the medications (in 5). CONCLUSIONS: There may be clinical problems with the performance of euthanasia and physician-assisted suicide. In the Netherlands, physicians who intend to provide assistance with suicide sometimes end up administering a lethal medication themselves because of the patient's inability to take the medication or because of problems with the completion of physician-assisted suicide. [Author abstract]

Groenewoud, Johanna H.; van der Maas, Paul J.; van der Wal, Gerrit; Hengeveld, Michiel W.; Tholen, Alfons J.; Schudel, Willem J.; and van der Heide, Agnes. Physician-Assisted Death in Psychiatric Practice in the Netherlands. New England Journal of Medicine 336(25): 1795-1801, 19 June 1997.

In 1994 the Dutch Supreme Court ruled that in exceptional instances, physician-assisted suicide might be justifiable for patients with unbearable mental suffering but no physical illness. We studied physician-assisted suicide and euthanasia in psychiatric practice in the Netherlands. METHODS: In 1996, we sent questionnaires to 673 Dutch psychiatrists -- about half of all such specialists in the country -- and received 552 responses from the 667 who met the study criteria (response rate, 83 percent). We estimated the annual frequencies of requests for physician-assisted suicide by psychiatrists and actual instances of assistance. RESULTS: Of the respondents, 205 (37 percent) had at least once received an explicit, persistent request for physician-assisted suicide and 12 had complied. We estimate there are 320 requests a year in psychiatric practice and 2 to 5 assisted suicides. Excluding those who had ever assisted, 345 of the respondents (64 percent) thought physician-assisted suicide because of a mental disorder could be acceptable, including 241 who said they could conceive of instances in which they themselves would be willing to assist. The most frequent reasons for refusing were the belief that the patient had a treatable mental disorder, opposition to assisted suicide in principle, and doubt that the suffering was unbearable or hopeless. Most, but not all, patients who had been assisted by their psychiatrists in suicide had both a mental disorder and a serious physical illness, often in a terminal phase. Thirty percent of the respondents had been consulted at least once by a physician in another specialty about a patient's request for assisted death. The annual number of such consultations was estimated at 310, about 3 percent of the estimated 9700 requests for euthanasia or physician-assisted suicide in medical practice. CONCLUSIONS: Explicit requests for physician-assisted suicide are not uncommon in psychiatric practice in the Netherlands, but these requests are rarely granted. Psychiatric consultation for medical patients who request physician-assisted death is relatively rare. [Author abstract]

Gunderson, Martin. A Right to Suicide Does Not Entail a Right to Assisted Death. Journal of Medical Ethics 23(1): 51-54, February 1997.

Many people believe that it is permissible for people who are suffering from terminal illnesses to commit suicide or even that such people have a right to commit suicide. Some have also argued that it follows that it is permissible for them, or that they have a right, to use the assistance of another person. First, I assume that it is permissible for a person to commit suicide and ask whether it follows that it is also permissible for the person to employ an agent to assist in the death. Second, I assume that people have a right to commit suicide and ask whether it follows that the right holders have a right to employ an agent to assist with the death. I argue that the permissibility of suicide does not by itself entail the permissibility of employing someone to assist in the suicide. I also argue that the right to commit suicide does not by itself entail the right to assisted death. Instead, what follows is that there is a right not to have unreasonable restrictions placed on the means by which one can exercise one's right to commit suicide. Whether a restriction is reasonable depends on the conclusion reached when one has weighed a number of policy considerations. [Author abstract]

Gunderson, Martin; Mayo, David J. Altruism and Physician Assisted Death. Journal of Medicine and Philosophy 18(3): 281-295, June 1993.

We assume that a statute permitting physician assisted death has been passed. We note that the rationale for the passage of such a statute would be respect for individual autonomy, the avoidance of suffering and the possibility of death with dignity. We deal with two moral issues that will arise once such a law is passed. First, we argue that the rationale for passing an assistance in dying law in the first place provides a justification for assisting patients to die who are motivated by altruistic reasons as well as patients who are motivated by reasons of self-interest. Second, we argue that the reasons for passing a physician assisted death law in the first place justify extending the law to cover some non-terminal patients as well as terminal patients. [Author abstract]


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Haverkate, Ilinka; Muller, Martien T.; Cappetti, Mirjam; Jonkers, Freerk; and van der Wal, Gerrit. Prevalence and Content Analysis Guidelines on Handling Requests for Euthanasia or Assisted Suicide in Dutch Nursing Homes. Archives of Internal Medicine 160(3): 317-324, February 14, 2000.

The growing number of requests for euthanasia or assisted suicide make it imperative that "all official requirements for prudent practice" be observed. The authors found variations in the guidelines usage, with only 65% complying with all requirements. [KIE annotation]

Haverkate, I., and van der Wal, G. Dutch Nursing Home Policies and Guidelines on Physician-Assisted Death and Decisions to Forego Treatment. Public Health 112(6): 419-423, November 1998.

The purpose of this study was to describe: (a) the prevalence and content of policies on euthanasia or assisted suicide (EAS) in three different types of nursing homes; (b) specific content items of written guidelines for EAS; and (c) the prevalence of guidelines on withholding or withdrawing treatment from severely demented patients and patients in a persistent vegetative state in the nursing homes. DESIGN: Descriptive, cross-sectional. METHODS: We have used a postal survey among directors of patient care of all (n = 304) Dutch somatic nursing homes (meant for physically handicapped patients), psychogeriatric nursing homes (meant for patients suffering from dementia) and combined nursing homes. Data were collected from October 1994 through January 1995. RESULTS: Results indicate that psychogeriatric nursing homes less often had a written EAS policy than somatic and combined nursing homes (62, 68 and 80% respectively). The most frequently reported aspects in the EAS guidelines, by the nursing homes with guidelines based on a policy that EAS was accepted under certain conditions; were consultation of another physician (97%), referral to another physician if the attending physician had in-principle objections (82%), and the involvement of the nurse in the decision-making procedure (82%). Of the nursing homes, 9% reported having specific written procedures concerning withholding or withdrawing treatment from severely demented patients. CONCLUSION: Guidelines in the nursing homes on euthanasia and assisted suicide might be improved. Especially with regard to withholding or withdrawing treatment from incompetent patients, more guidelines should be developed. [Author abstract]

Hendin, Herbert; Rutenfrans, Chris; and Zylicz, Zbigniew. Physician-Assisted Suicide and Euthanasia in the Netherlands: Lessons from the Dutch. JAMA 277(21): 1720-1722, 4 June 1997.

For 2 decades, both physician-assisted suicide and euthanasia have been given legal sanction in the Netherlands. In response to domestic and international concern about their policies, the Dutch government appointed a commission that oversaw a study of the practice of physician-assisted suicide and euthanasia in 1990. That study, which was largely replicated in a 1995 study, was supported by the Royal Dutch Medical Association with the promise that physicians who participated would receive immunity from prosecution for anything they revealed. In 1996, the investigators published a report of their new findings in Dutch and summarized their work in 2 articles in the , which was supported by an editorial in that journal. These reports have given a favorable interpretation to what could be seen as evidence of little or no improvement by declaring that since matters have not grown worse there is no evidence physicians in the Netherlands are moving down a slippery slope. That conclusion is misleading. [Author abstract]

Hogan, Christopher; Lynn, Joanne; Gabel, Jon; Lunney, June; O'Mara, Ann; and Wilkinson, Anne. Medicare Beneficiaries' Costs and Use of Care in the Last Year of Life: Final Report. [Submitted to Medicare Payment Advisory Commission, Washington, DC, May 1, 2000] Online: Available for Download at Center to Improve Care of the Dying: Reshaping Medicare

Providing statistical data for Medicare expenditures for end-of-life care, this report focuses on such key measures as hospital versus hospice services, site of death, patient race and ethnicity of patients, and physician involvement by speciality.


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Is there a right to die? Christian Century 114(3): 70-71, 22 January 1997.
This news article documents the immediate response of religious groups to the Supreme Court's decision to hear arguments on the legality of assisted suicide. [KIE annotation]


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Jochemsen, Henk. Euthanasia in Holland: an Ethical Critique of the New Law. Journal of Medical Ethics 20(4): 212-217, December 1994.

In the Netherlands the government's proposal for the legal regulation of euthanasia, assisted suicide and the termination of a patient's life without request has been approved by Parliament. The defence of this proposal is to a large extent based on a specific interpretation of data about the practice of euthanasia in that country, published in 1991 (the ). This paper discusses both the interpretation of the data and the new law. On the basis of that and other data, the author concludes that many cases of euthanasia, assisted suicide and termination of a patient's life without request remain unnotified and therefore unreviewed by the legal authorities. It is argued that the new law will not guarantee an improvement to this situation. In short, the new law will not protect effectively the lives of patients, and must, therefore, be open to ethical and legal objection. [Author abstract]

Jonsen, Albert R. Living with Euthanasia: A Futuristic Scenario. Journal of Medicine and Philosophy 18(3): 241-251, June 1993.

In 1991 and 1992, citizens of Washington State and California voted on whether "aid-in-dying" should be legalized. In both states, the proposition was defeated. In this article, the author, who participated in the Washington State campaign, imagines what might have happened in the fictitious State of Redwood, had such a proposal passed. [Author abstract]


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Kade, Walter J. Death With Dignity: A Case Study. Annals of Internal Medicine 132(6): 504-506, 21 March 2000.

The author, a physician who voted against the Oregon Death With Dignity Act but subsequently received a request to help a young patient in her suicide, describes the emotional turmoil he experienced while aiding her. [KIE annotation]

Kelleher, Michael J. ; Chambers, Derek ; Corcoran, Paul ; Keeley, Helen S. ; and Williamson, Eileen. Euthanasia and Related Practices Worldwide. Crisis 19(3): 109-115, 1998.

The present paper examines the occurrence of matters relating to the ending of life, including active euthanasia, which is, technically speaking, illegal worldwide. Interest in this most controversial area is drawn from many varied sources, from legal and medical practitioners to religious and moral ethicists. In some countries, public interest has been mobilized into organizations that attempt to influence legislation relating to euthanasia. Despite the obvious international importance of euthanasia, very little is known about the extent of its practice, whether passive or active, voluntary or involuntary. This examination is based on questionnaires completed by 49 national representatives of the International Association for Suicide Prevention (IASP), dealing with legal and religious aspects of euthanasia and physician-assisted suicide, as well as suicide. A dichotomy between the law and medical practices relating to the end of life was uncovered by the results of the survey. In 12 of the 49 countries active euthanasia is said to occur while a general acceptance of passive euthanasia was reported to be widespread. Clearly, definition is crucial in making the distinction between active and passive euthanasia; otherwise, the entire concept may become distorted, and legal acceptance may become more widespread with the effect of broadening the category of individuals to whom euthanasia becomes an available option. The "slippery slope" argument is briefly considered. [Author abstract]

Kinsella, T. Douglas; Verhoef, Marja J. Assisted Suicide: Opinions of Alberta Physicians. Clinical and Investigative Medicine 18(5): 406-412, October 1995.

The legal status of assisted suicide and active euthanasia are receiving increasing attention among physicians, legislators, the judiciary, and public lobby groups. Many seem to assume that these forms of assisted dying reside naturally within the practice of medicine but, surprisingly, comprehensive data about the opinions of Canadian physicians are not available. We report the results of a survey of the opinions of Alberta physicians about assisted suicide, compare their opinions to those about active euthanasia, and determine their relationships with various demographic and bioethical matters. A stratified random sample (n = 2,002) was drawn from all Alberta physicians. The response rate was 69% (1,391) and was representative of the reference population for age, sex, and type of practice. Fifty-five percent believed assisted suicide should remain a criminal offence, whereas 18% did not, and 27% were uncertain. Strong relationships were found between opinions about assisted suicide, and age and religious activity. These data demonstrate no ground swell of support by Alberta physicians for the decriminalization of assisted suicide. Our data confirm the need for a national study of the opinions of Canadian physicians about physician-assisted dying, and caution against precipitate changes in relevant legislation and health policy. [Author abstract]

Kowalski, Susan D. Assisted Suicide: Is There a Future? Ethical and Nursing Considerations. Critical Care Nursing Quarterly 19(1): 45-54, May 1996.

It is imperative that nurses take a personal and professional stand in the debate regarding physician-assisted suicide. Through case examples, this article defines and illustrates forms of euthanasia, including active and passive, voluntary and involuntary, double-effect, physician-assisted suicide, and physician aid-in-dying. Ethical arguments against assisted suicide based on pain and suffering, quality of life, patient autonomy, and the common good are presented. The anticipated negative effects that legalized physician-assisted death would pose to the health professions and society are discussed. Guidelines and nursing implications conclude the article. [Author abstract]


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Lavery, James V.; Dickens, Bernard M.; Boyle, Joseph M.; Singer, Peter A. Bioethics for Clinicians: 11. Euthanasia and Assisted Suicide. Canadian Medical Association Journal 156(10): 1405-1408, 15 May 1997.

Euthanasia and assisted suicide involve taking deliberate action to end or assist in ending the life of another person on compassionate grounds. There is considerable disagreement about the acceptability of these acts and about whether they are ethically distinct from decisions to forgo life-sustaining treatment. Euthanasia and assisted suicide are punishable offences under Canadian criminal law, despite increasing public pressure for a more permissive policy. Some Canadian physicians would be willing to practise euthanasia and assisted suicide if these acts were legal. In practice, physicians must differentiate between respecting competent decisions to forgo treatment, providing appropriate palliative care, and acceeding to a request for euthanasia or assisted suicide. Physicians who believe that euthanasia and assisted suicide should be legally accepted in Canada should pursue their convictions only through legal and democratic means. [Author Abstract]

Lee, Melinda A.; Nelson, Heidi D.; Tilden, Virginia P.; Ganzini, Linda; Schmidt, Terri A.; and Tolle, Susan W. Legalizing Assisted Suicide -- Views of Physicians in Oregon. New England Journal of Medicine 334(5): 310-315, 1 February 1996.

: Since the Oregon Death with Dignity Act was passed in November 1994, physicians in Oregon have faced the prospect of legalized physician-assisted suicide. We studied the attitudes and current practices of Oregon physicians in relation to assisted suicide. : From March to June 1995, we conducted a cross-sectional mailed survey of all physicians who might be eligible to prescribe a lethal dose of medication if the Oregon law is upheld. Physicians were asked to complete and return a confidential 56-item questionnaire. : Of the 3944 eligible physicians who received the questionnaire, 2761 (70 percent) responded. Sixty percent of the respondents thought physician-assisted suicide should be legal in some cases, and nearly half (46 percent) might be willing to prescribe a lethal dose of medication if it were legal to do so; 31 percent of the respondents would be unwilling to do so on moral grounds. Twenty-one percent of the respondents have previously received requests for assisted suicide, and 7 percent have complied. Half the respondents were not sure what to prescribe for this purpose, and 83 percent cited financial pressure as a possible reason for such requests. The respondents also expressed concern about complications of suicide attempts and doubts about their ability to predict survival at six months accurately. : Oregon physicians have a more favorable attitude toward legalized physician-assisted suicide, are more willing to participate, and are currently participating in greater numbers than other surveyed groups of physicians in the United States. A sizable minority of physicians in Oregon objects to legalization and participation on moral grounds. Regardless of their attitudes, physicians had a number of reservations about the practical applications of the act. [Author abstract]

Little, Miles. Assisted Suicide, Suffering and the Meaning of a Life. Theoretical Medicine and Bioethics 20(3): 287-298, June 1999.

Noting that the "ethical problems surrounding voluntary assisted suicide remain formidable, and are unlikely to be resolved in pluralist societies," Little examines historical, religious, and moral attitudes toward suicide and says that it is necessary for arguments seeking to justify ending the lives of others to be grounded "in concepts of the meaning of life." [KIE annotation]

Loewy, Erich H. Healing and Killing, Harming and Not Harming: Physician Participation in Euthanasia and Capital Punishment. Journal of Clinical Ethics 3(1): 29-34, Spring 1992.

I have argued that communities that kill for other reasons and those that have legalized suicide find themselves in an illogical position when they deny necessary help to hopelessly ill and suffering would-be suicides who are incapable of carrying out their will. That, however, does not address the question of the probity (or wisdom) of physicians actively helping their patients to die or of allowing physicians to act in this manner. It might be the case that something deeply embedded in the medical ethos precludes physicians from acting in such a way; or it may be that society does not wish to give such power to its physicians. I have suggested that the way we look at "harm" is the crux of the matter. [Author abstract]

Lynn, Joanne; Cohn, Felicia; Pickering, John H.; Smith, Joel; and Stoeppelwerth, Ali M. American Geriatrics Society on Physician-Assisted Suicide: Brief to the United States Supreme Court. Journal of the American Geriatrics Society 45(4): 489-499, April 1997.

The authors describe the development of the American Geriatrics Society (AGS) amicus curiae brief on physician-assisted suicide, and summarize the legal arguments brought forth in the amicus brief of the Project on Death in America of the Open Society Institute upon which the AGS brief was based. The full text of the AGS brief is included after the discussion. [KIE annotation]

Lynn, Joanne; Harrold, Joan; and The Center to Improve Care of the Dying. Handbook For Mortals: Guidance For People Facing Serious Illness. New York: Oxford University Press, 1999. 242 p.

[This compendium contains] a wealth of sensible advice on how to make decisions about care, where to find support and treatment resources, how to communicate with physicians, how to get effective pain management, when to let go of medical treatment, issues in hastening death, and a host of other fundamental concerns. There's a discussion of the ethical issues of assisted suicide that balances arguments from several sides of the question. [Author abstract]


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Matz, Robert ; Sulmasy, Daniel P. ; and Pellegrino, Edmund D. Euthanasia: Morals and Ethics. [Letter and Response]. Archives of Internal Medicine 159(15): 1815-1816, 9-23 August 1999.

Mayo, David J.; and Gunderson, Martin. Physician Assisted Death and Hard Choices. Journal of Medicine and Philosophy 18(3): 329-341, June 1993.

We argue that after the passage of a physician assisted death law some inequities in the health care system which prevent people from getting the medical care they need will become reasons for choosing assisted death. This raises the issue of whether there is compelling moral reason to change those inequities after the passage of an assisted death law. We argue that the passage of an assisted death law will not create additional moral reasons for eliminating inequities because they become motives for someone to opt for assisted death. We also argue that it is not feasible to eliminate these reasons for opting for assisted death by granting a right to health care because of an intractable scarcity of medical resources. [Author abstract]

McGough, Peter M. Washington State Initiative 119: The First Public Vote on Legalizing Physician-Assisted Death. Cambridge Quarterly of Healthcare Ethics 2(1): 63-67, Winter 1993.

In the fall of 1991, voters in Washington state were asked to consider a public initiative that sought to legalize physician-assisted death: Initiative 119. Drafted by Washington Citizens for Death with Dignity, the initiative was intended to amend the existing state natural death act in several ways....It was the proposal to legalize "aid-in-dying," however, that represented a radical shift in the conduct of physicians towards their patients and a dramatic shift in social policy...."Aid-in-dying," as defined in Initiative 119, would have legalized something more: the injection of lethal drugs by physicians with the primary intent of killing their patient. Had 119 passed, Washington would have become the first region in the world where active euthanasia would have been legally permitted by statute and provided by the medical profession....Everyone wants death with dignity. Clearly, even when everything that compassionate medicine can do is provided to all dying patients, there will still be those that suffer terribly. Yet, in trying to help these patients by legalizing physician-assisted death, society would be establishing a dangerous precedent that potentially could create greater harm. Although Washington's Initiative 119 was defeated by a vote of 54% to 46%, the emotional debate on active euthanasia will undoubtedly continue. [Author abstract]

Meier, Diane E. Physician-Assisted Dying: Theory and Reality. Journal of Clinical Ethics 3(1): 35-37, Spring 1992.

There appears to be a conflation of physician-assisted suicide (the doctor makes the means of suicide available by, for example, writing a prescription for barbiturates) with active euthanasia (the doctor actively intervenes to kill the patient). I believe that these two entities are quite distinct in terms of several factors: they require very different roles for the physician, they involve distinct and disparate power relationships between physician and patient, and they would likely have a substantially different impact on the ethos of the medical profession. Thus, I would argue that it may be reasonable to support easing constraints on physician-assisted suicide while retaining them for active euthanasia, and that the distinction between the two entities should be addressed, particularly in discussions of legalization. [Author abstract]

Miller, Franklin G.; Quill, Timothy E.; Brody, Howard; Fletcher, John C.; Gostin, Lawrence O.; and Meier, Diane E. Regulating Physician-Assisted Death. New England Journal of Medicine 331(2): 119-123, 14 July 1994.

: The ethical norms of relieving suffering and respecting patients' rights to self-determination support the permissibility of voluntary physician-assisted death as a last resort for terminally or incurably ill patients. The availability of the extraordinary option of lethal treatment, however, must be accompanied by careful regulation to minimize the risk of abuse. We recommend that physician-assisted death be legalized with adequate safeguards to protect vulnerable patients, preserve the professional integrity of physicians, and ensure accountability to the public. The policy we have outlined would ensure independent and impartial review of decisions to provide physician-assisted death in response to unrelievable suffering, without undue disruption of the doctor-patient relationship. We hope one or more states will decide democratically to expand the options for dying or incurably ill patients by implementing a policy that both promotes comfort care and permits voluntary physician-assisted death as a last resort. [Author abstract]

Miller, Franklin G.; and Brody, Howard. Professional Integrity and Physician-Assisted Death. Hastings Center Report 25(3): 8-17, May-June 1995.

The practice of voluntary physician-assisted death as a last resort is compatible with doctors' duties to practice competently, to avoid harming patients unduly, to refrain from medical fraud, and to preserve patients' trust. It therefore does not violate physicians' professional integrity....A narrative account of how a profession has evolved over time remains a key mode of discovering elements of professional integrity....Some proponents might argue that professional integrity in some cases a physician to assist in the death of a patient by prescribing or administering a lethal dose of medication....How can persons trust doctors who have the socially sanctioned power to kill patients? [Author abstract]

Misbin, Robert I. Physicians' Aid in Dying. New England Journal of Medicine 325(18): 1307-1311, 31 October 1991.

If Initiative 119 passes, Washington will be the only state in the nation in which euthanasia and assisted suicide can be practiced legally. Physicians in Washington should therefore be prepared to be deluged with requests from all over the country and abroad. The Adkins-Kevorkian affair shows that some patients may be so desperate to obtain a physician's aid in dying that they will travel long distances. Similarly, Dutch physicians report that they receive many requests for euthanasia from people all over the world. For Washington to become a center for physician-assisted dying might not necessarily be inappropriate. Patients with difficult or unusual medical problems often travel to special centers for treatment. I can imagine that a patient with cancer would be willing to travel to Washington for intensive chemotherapy followed by bone marrow transplantation, with the expectation of being able to receive a physician's aid in dying in case things turned out badly. On the other hand, the situation could easily be abused. I can imagine the horror of a euthanasia clinic in Washington at which patients arrive, undergo a superficial medical evaluation, sign a form, and are then euthanized. It will be incumbent on supporters of Initiative 119 to see to it that the measure's beneficent motives are not transformed into a windfall for self-serving doctors willing to profit from the misery of dying patients....Whether or not Initiative 119 passes in the November election, it has prompted an important debate among physicians about the ethical boundaries of their profession. There are powerful arguments on both sides, but in the final analysis I think Initiative 119 should be defeated. [Author abstract]

Momeyer, Richard. Does Physician Assisted Suicide Violate the Integrity of Medicine? Journal of Medicine and Philosophy 20(1):13-24, February 1995.

This paper evaluates the arguments against physician assisted suicide which contend that it violates the integrity of medicine and the physician-patient relation; i.e., that it contradicts the goal of seeking health and healing, violates an absolute prohibition against killing, and undermines the patient's trust in the physician. These arguments against physician assisted suicide (1) misuse notions of teleology and teleological explanation; (2) rely on inappropriate notions of "ideal medicine", for which death is a defeat; (3) turn on a highly selective reading for the Hippocratic tradition; and (4) are unacceptably paternalistic. [Author abstract]

Muller, Martien T. ; Kimsma, Gerrit K. ; and van der Wal, Gerrit. Euthanasia and Assisted Suicide: Facts, Figures and Fancies with Special Regard to Old Age. Drugs and Aging 13(3): 185-191, September 1998.

The objective of this paper is to describe the ethics and incidence of euthanasia and physician-assisted suicide (EAS) with special regard to old age. It is based on an assumption that if and when a practice of euthanasia and EAS is allowed, several vulnerable groups, including the elderly, may become a 'population at risk'. We describe some of these claims, and make an inventory of the arguments against a permissive policy concerning euthanasia and EAS which emphasise inherent dangers for the elderly. We then give an overview of the results of empirical studies about incidence of (request for) euthanasia and assisted suicide in the Netherlands, Australia, the UK, the US, Denmark and Norway. These results confirm that practitioners do receive requests for EAS and that EAS is performed in all these countries. However, there are large differences between these countries with regard to the numbers of requests and performances. Dutch findings concerning the age distribution of patients who received euthanasia or assisted suicide indicate that these procedures are rare in the elderly and in nursing homes. We conclude that, although euthanasia and assisted suicide are illegal, there is evidence that these practices occur in all countries studied. Most surveys on the incidence of euthanasia show lower figures than those in the Netherlands. Dutch studies do not provide any evidence for the elderly being in danger of becoming 'victims' of euthanasia or assisted suicide. [Author abstract]


N

New York State Task Force on Life and the Law. When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context. New York, NY: New York State Task Force on Life and the Law, May 1994. 217 p.

New York State Task Force on Life and the Law. When Death Is Sought: Assisted Suicide and Euthanasia in the Medical Context; Supplement to Report. New York, NY: New York State Task Force on Life and the Law, April 1997. 18 p.


O

Oregon Health Division (Ed.). (2000, June 23 - last update). Oregon's Death with Dignity Act Homepage [Online]. Available: http://www.ohd.hr.state.or.us/chs/pas/pas.htm [2000, August 31]
This Web site provides a brief legislative history of the Death with Dignity Act, its legislative language, the forms developed to implement the Act, annual reports of reported cases, and a link to the Guidebook for Health Care Providers prepared by the Task Force to Improve the Care of Terminally-Ill Oregonians. [KIE annotation]

Orentlicher, David, and Caplan, Arthur. The Pain Relief Promotion Act of 1999: A Serious Threat to Palliative Care. JAMA 283(2): 255-258, 12 January 2000.

Recent educational efforts in the US medical community have begun to address the critical issue of palliative care for terminally ill patients. However, a newly introduced bill in Congress, the Pain Relief Promotion Act of 1999 (PRPA), could dramatically hinder these efforts if enacted. The act criminally punishes the use of controlled substances to cause -- or assist in causing -- a patient's death. The primary purposes of PRPA are to override the physician-assisted suicide law currently in effect in Oregon and prohibit other states from enacting similar laws. The act also includes valuable provisions for better research and education in palliative care, but the benefits of those provisions are outweighed by the punitive sections of the act. Under PRPA, the quality of palliative care in the United States could be compromised when physicians, fearing criminal prosecution, err on the side of caution rather than risk their patients' deaths by using highly aggressive pain treatments. Furthermore, PRPA would put Drug Enforcement Administration officials, who have no medical expertise, in the position of regulating medical decisions. The act also would interfere with individual states' long-standing authority over medical practice. Finally, PRPA would discourage physicians from engaging in experimentation and innovation in palliative care, again out of concern for crossing the line between relief of suffering and physician-assisted suicide. Other bills have been introduced that go much further than PRPA to encourage palliative care, without its problematic provisions. Regardless of the controversy surrounding physician-assisted suicide in the United States, the need for quality end-of-life care will be far better served if Congress enacts one of these bills rather than PRPA. [Author abstract]


P

Peruzzi, Nico; Canapary, Andrew; and Bongar, Bruce. Physician-Assisted Suicide: The Role of Mental Health Professionals. Ethics and Behavior 6(4): 353-366, 1996.

A review of the literature was conducted to better understand the (potential) role of mental health professionals in physician-assisted suicide. Numerous studies indicate that depression is one of the most commonly encountered psychiatric illnesses in primary care settings. Yet, depression consistently goes undetected and undiagnosed by nonpsychiatrically trained primary care physicians. Noting the well-studied link between depression and suicide, it is necessary to question giving sole responsibility of assisting patients in making end-of-life treatment decisions to these physicians. Unfortunately, the use of mental health consultation by these physicians is not a common occurrence. Greater involvement of mental health professionals in this emerging and debated area is advocated. Beyond describing mental health professionals' role in the assessment of patient competency or decision making capacity, other areas of potential involvement are described. A discussion of ethical principles relevant to this area follows, along with comments on the training necessary to adequately serve patient needs. [Author abstract]

Post, Stephen G. Physician-Assisted Suicide in Alzheimer's Disease. Journal of the American Geriatrics Society 45(5): 647-651, May 1997.

This paper takes up the question of physician-assisted suicide (PAS) in Alzheimer's disease (AD), reviewing arguments for and against in a broad interdisciplinary context. Preemptive PAS-AD involving competent patients raises the further question of AD-euthanasia. The author concludes, after thorough assessment of the literature, that caution in moving toward AD-PAS is necessary. However, where PAS is legalized, it may be difficult to justify precluding people with AD from access. [Author abstracts]

Prado, C.G. and Taylor, S.J. Assisted Suicide: Theory and Practice in Elective Death. Amherst, NY: Humanity Books, 1999. 223 p.

The authors' stated aim "is to contribute to the ethical guidance that is becoming so necessary regarding assisted suicide." Topics discussed include the criteria for rational suicide, the need for unimpaired choice, the importance of motivation, and the dangers of the "slippery slope." [KIE abstract]


Q

Quirk, Patrick. Euthanasia in the Commonwealth of Australia. Issues in Law and Medicine 13(4): 425-446, Spring 1998.

This article describes the debate over the euthanasia law of the Northern Territory of Australia in its constitutional context. After considering the juridical status of the Northern Territory and related topics, this article outlines the judicial and legislative challenges to the Rights of the Terminally Ill Act (RTI Act) of the Northern Territory and concludes by offering some justifications for the passing of the Euthanasia Laws Act 1997 (Commonwealth), which effectively repeals the RTI Act. In dealing with these issues special emphasis will be given to the problem of Commonwealth law overriding Territory law and the concept of fundamental common law rights. The appropriateness of a Parliamentary solution -- as opposed to a resolution through the courts -- is defended. [Author abstract]


R

Reisner, Michelle; and Damato, Anthony N. Attitudes of Physicians Regarding Physician-Assisted Suicide. New Jersey Medicine 92(10): 663-666, October 1995.

A survey of New Jersey physicians reveals no clear consensus as to whether physician-assisted suicide should be legalized, and most physicians stated that they would not participate in such activities where it is legal to do so. Further studies need to be undertaken. [Author abstract]

Roberts, Laura Weiss; Roberts, Brian B.; Warner, Teddy D.; Solomon, Zachary; Hardee, James T.; and McCarty, Teresita. Internal Medicine, Psychiatry, and Emergency Medicine Residents' Views of Assisted Death Practices. Archives of Internal Medicine 157(14): 1603-1609, 27 July 1997.

BACKGROUND: Although studies have revealed conflicting attitudes within the medical community regarding assisted death practices in the United States, the views of current resident physicians have not been described. OBJECTIVE: To investigate the perspectives of residents from 3 medical specialty fields regarding the acceptability of assisted suicide and euthanasia practices as performed by 4 possible agents (the resident personally, a referral physician, physicians in general, or nonphysicians in general) in 6 patient scenarios. METHODS: An anonymous survey exploring responses to 6 patient vignettes was conducted with a convenience sample of all residents in the internal medicine, psychiatry, and emergency medicine training programs. RESULTS: A total of 96 residents, 72% of those asked, participated in this study. Overall, residents expressed opposition or uncertainty regarding assisted suicide and euthanasia. The residents were disinclined to directly perform such practices themselves and did not support the conduct of assisted suicide practices by nonphysicians. Respondents were somewhat more accepting of other physicians' involvement in assisted death activities. Conflicting views were expressed by residents, with emergency medicine residents more likely to support assisted suicide practices in 4 of 6 patient vignettes than either internal medicine or psychiatry residents. Residents who reported being influenced by religious beliefs (21 respondents [22%]) did not support assisted death practices, whereas those influenced by personal philosophy (74 respondents [77%]) expressed less opposition. CONCLUSIONS: This study explores the uncertainty and differing views of residents from 3 fields about physician-assisted suicide practices. Study findings are considered within the larger literature on clinician attitudes toward assisted suicide and euthanasia. [Author abstract]

Rosenfeld, Barry ; Breitbart, William ; Stein, Kelly ; Funesti-Esch, Julie ; Kaim, Monique ; Krivo, Suzanne ; and Galietta, Michele. Measuring Desire for Death Among Patients with HIV/AIDS: The Schedule of Attitudes Toward Hastened Death. American Journal of Psychiatry 156(1): 94-100, January 1999.

As physician-assisted suicide is debated, a need for standardized measurement of desire for death among medically ill individuals has emerged. The authors present preliminary validation data for a new self-report instrument, the Schedule of Attitudes Toward Hastened Death. METHOD: The participants were 195 patients with HIV/AIDS from two sites: 148 ambulatory patients and 47 patients who had been recently admitted to a facility for end-of-life care. The ambulatory participants completed the 20-item Schedule of Attitudes Toward Hastened Death and several other instruments, including the Beck Depression Inventory and Brief Symptom Inventory. The terminally ill patients also completed the Schedule of Attitudes Toward Hastened Death, along with other measures, and were assessed by clinicians with the Hamilton Depression Rating Scale and the Desire for Death Rating Scale, a global clinician rating of the patient's desire for death. RESULTS: The Schedule of Attitudes Toward Hastened Death demonstrated high reliability. The total score significantly correlated with the clinician rating on the Desire for Death Rating Scale and with ratings of depression and psychological distress. In addition, the Schedule of Attitudes Toward Hastened Death score significantly correlated with pain intensity and physical symptom distress. Factor analysis supported a single factor structure for the instrument. CONCLUSIONS: These results indicate that the Schedule of Attitudes Toward Hastened Death is a reliable, valid measure of desire for death among patients with HIV/AIDS. Further research with this measure may help address many of the unanswered questions emerging from the ongoing debates regarding legalization of assisted suicide. [Author abstract]


S

Savulescu, Julian. The Trouble with Do-Gooders: The Example of Suicide. Journal of Medical Ethics 23(2): 108-115, April 1997.

This paper describes the concept of a do-gooder: a person who does unwanted good. It illustrates why doing-good is a problem and argues that patients should not be compelled to do what is best. It shows the ways in which doctors covertly do-good and offers a critique of these. The discussion focuses on the example of the treatment of patients who attempt suicide. [Author abstract]

Schneider, Carl E. Making Sausage: The Ninth Circuit's Opinion. Hastings Center Report 27(1): 27-28, January-February 1997.

As I write, the Supreme Court has just agreed to hear and , the two cases in which United States circuit courts of appeals held that a state may not constitutionally prohibit physicians from helping a terminally ill person who wishes to commit suicide to do so. These cases have already received lavish comment and criticism, and no doubt the Supreme Court's opinion will garner even more. Reasonably enough, most of this analysis addresses the merits of physician-assisted suicide as social policy. I, here, want to talk about how setting bioethical policy through constitutional adjudication actually works and how its usefulness is diminished by some practical deficiencies. [Author abstract]

Schoevers, Robert A. ; Asmus, Frank P. ; and Van Tilburg, Willem. Physician-Assisted Suicide in Psychiatry: Developments in the Netherlands. Psychiatric Services 49(11): 1475-1480, November 1998.

Physician-assisted suicide can now be officially and legally carried out for psychiatric patients in The Netherlands who request it, provided that criteria are met. The authors describe two recent cases of psychiatric patients whose suicides were assisted by their psychiatrist. They critically examine the guidelines for physician-assisted suicide in psychiatry. The criteria address the decision of the patient to be assisted with suicide, which must be voluntary and well considered, and the patient's desire to die, which must endure over time. The patient's suffering must be unacceptable, and the disorder incurable. The authors conclude that important aspects of psychiatric practice are not addressed in the guidelines, which were originally developed for use in somatic medicine. The assessment of treatment prognosis in psychiatry is not accurate enough to allow a final decision about incurability. Boundaries of the psychiatric therapeutic relationship are violated in physician-assisted suicide. The therapist's inability to objectively assess the patient's wish to die is overlooked. Because the general public will continue to ask for clarity on the issue of euthanasia and physician-assisted suicide, the authors believe that an open discussion of both ethical and professional issues is the best option. [Author abstract]

Slome, Lee R.; Mitchell, Thomas F.; Charlebois, Edwin; Benevedes, Jeffrey Moulton; and Abrams, Donald I. Physician-Assisted Suicide and Patients with Human Immunodeficiency Virus Disease. New England Journal of Medicine 336(6): 417-421, 6 February 1997.

Data are limited on the attitudes and practices of physicians regarding assisting the suicide of patients with human immunodeficiency virus (HIV) disease. METHODS: Between November 1994 and January 1995, we used an anonymous, self-administered questionnaire to survey all 228 physicians in the Community Consortium, an association of providers of health care to patients infected with HIV in the San Francisco Bay area. The responses were compared with those in a 1990 survey of consortium physicians. Physician-assisted suicide was defined as a physician providing a sufficient dose of narcotics to enable a patient to kill himself. Respondents were to assume that the patient is a mentally competent, severely ill individual facing imminent death. RESULTS: One hundred eighteen of the questionnaires were evaluated. Respondents reported a mean of 7.9 direct and 13.7 indirect requests from patients for assistance. In responses based on a case vignette, 48 percent of the physicians said they would be likely or very likely to grant the request of a patient with the acquired immunodeficiency syndrome (AIDS) for assistance in a suicide, as compared with 28 percent of the respondents in 1990. Asked to estimate the number of times they had granted the request of a patient with AIDS for assistance in committing suicide, 53 percent said they had done so at least once (mean number of times, 4.2; median, 1.0; range, 0 to 100). In a multivariate analysis, factors positively associated with having, in fact, assisted a suicide were having had a higher number of patients with AIDS who had died, a higher number of indirect requests from patients for assistance, a stated gay, lesbian, or bisexual orientation on the part of the physician, and a higher intention to assist score (as calculated from the physician's responses to the case vignette). CONCLUSIONS: Within a group of physicians caring for patients with HIV disease, the acceptance of assisted suicide increased between 1990 and 1995. A majority of respondents in 1995 said they had granted a request for assisted suicide from a patient with AIDS at least once. [Author abstract]

Stone, Geo. Suicide and Assisted Suicide: Methods and Consequences. New York: Carroll and Graf Publishers, 1999. 480 p.

This compendium of suicide data provides statistics for and descriptions of the various means for killing oneself. [KIE annotation].

Sullivan, Amy D. ; Hedberg, Katrina ; and Fleming, David W. Legalized Physician-Assisted Suicide in Oregon -- The Second Year. New England Journal of Medicine 342(8): 598-604, 24 February 2000.

In 1997, Oregon legalized physician-assisted suicide. We have previously reported data on terminally ill Oregon residents who received prescriptions for lethal medications under the Oregon Death with Dignity Act and who died in 1998. We now report similar data for 1999, obtained from physicians' reports, death certificates, and interviews with physicians. We also report data from interviews with family members. RESULTS: Information on 33 persons who received prescriptions for lethal medications in 1999 was reported to the Oregon Health Division; 26 died after taking the lethal medications, 5 died from their underlying illnesses, and 2 were alive as of January 1, 2000. One additional patient, who received a prescription in 1998, died after taking the medication in 1999. Thus, 27 patients died after ingesting lethal medications in 1999 (9 per 10,000 deaths in Oregon), as compared with 16 patients in 1998 (6 per 10,000). The median age of the 27 patients who died in 1999 after taking lethal medications was 71 years. The most frequent underlying illnesses were cancer (in 17 patients), amyotrophic lateral sclerosis (in 4), and chronic obstructive pulmonary disease (in 4). All 27 patients had health insurance, 21 were receiving hospice care, and 13 were college graduates. According to both physicians and family members, patients requested assistance with suicide for several reasons, including loss of autonomy, loss of control of bodily functions, an inability to participate in activities that make life enjoyable, and a determination to control the manner of death. CONCLUSIONS: In the second as compared with the first year of legalized physician-assisted suicide in Oregon, the number of patients who died after ingesting lethal medications increased, but it remained small in relation to the total number of persons in Oregon who died. Patients who request assistance with suicide appear to be motivated by several factors, including loss of autonomy and a determination to control the way in which they die. [Author abstract]


T

Thomasma, David C. Assessing the Arguments for and against Euthanasia and Assisted Suicide: Part Two Cambridge Quarterly of Healthcare Ethics 1998 7(4): 388- 401, Fall 1998.

After suggesting that the expression "assisted death" might be used to discuss taking a life without producing the immediate polarization that the words "euthanasia" and "assisted suicide" provoke, the author analyzes the terms of the moral debate regarding assisted suicide - intention, mercy, compassion, self-interest, pragmatism/advance planning, foresight, and sacrifice - and recalls their historical significance. Thomasma concludes that "[i]f quality of life judgments and social utility judgments are constantly held in check by both a public philosophy of examining intentionality and our cultural and historical memory of the Holocaust, then we will be well on the way toward providing a humane solution to the problem of suffering at the end of life." [KIE annotation]


U

U.S. Court of Appeals, Second Circuit. Quill v. Vacco. [Date of Decision: 2 April 1996] Federal Reporter, 3d Series. 1996; 80: 716-743.

The U.S. Court of Appeals, Second Circuit, held that physicians may prescribe drugs to be self-administered by mentally competent patients who seek to end their lives during the final stages of a terminal illness. The action was brought by physicians and patients seeking to declare unconstitutional a New York statute penalizing assistance in suicide. The court rejected the plaintiffs' argument that there is a fundamental right to assisted suicide under the due process clause of the U.S. Constitution. However, the court found that the state statute violated the equal protection clause because it did not treat equally all competent persons in the final stages of fatal illness wishing to hasten their death. Treatment was not equal in that a competent person may order removal of life-support systems, while those persons whose treatment does not include life support cannot hasten their death. The court found this unequal treatment lacked any rational basis. (KIE abstract)

U.S. Court of Appeals, Ninth Circuit, en banc. Compassion in Dying v. State of Washington. [Dated Filed: 1996 March 9] 3109-3263 (3 v.).

The U.S. Court of Appeals for the Ninth Circuit, sitting en banc, affirmed a district court judgment that ruled unconstitutional a Washington statute banning assisted suicide, as applied to competent, terminally ill adults who wish to obtain prescription medication to hasten their deaths. The statute, which was challenged by a group of patients, physicians, and the nonprofit organization Compassion in Dying, was held to be unconstitutional because it violated the due process clause of the U.S. Constitution. The court took into consideration the interests of the state in protecting life, preventing suicides, preventing undue, arbitrary, or unfair influences on an individual's decision to end his life, and ensuring the integrity of the medical profession. These interests were balanced against an individual's strong liberty interest in determining how and when one's life should end. The court recognized this interest after assessing the growing public support for assisted suicide, changes in the causes of death and medical advances, and Supreme Court cases addressing due process liberty interests. The court then determined that the state's interest, which could be protected by adopting sufficient safeguards, did not outweigh the severe burden placed on the terminally ill, and thus the statute as applied was unconstitutional. (KIE abstract).

U.S. District Court, S.D. New York [Date of Decision: 15 December 1994]. Quill v. Koppell. Federal Supplement. 1994; 870: 78-85.

The U.S. District Court, S.D. New York upheld the constitutionality of a statute criminalizing physician-assisted suicide. The claimants argued that the statute violated the due process and equal protection clauses of the Fourteenth Amendment for both the patients and the physicians. They claimed that competent, terminally-ill persons have a constitutional right to take their own lives, and that enabling physicians have a corresponding protection under the constitution. However, while the court recognized constitutional protections for many personal decisions as central to the liberty protected by the Fourteenth Amendment, it determined that precedent failed to establish such right under the constitution. The court validated state authority to distinguish between "allowing nature to take its course" and the intentional use "of an artificial death-producing device" by reasoning that suicide evokes a different legal significance than refusing medical treatment. (KIE abstract)

U.S. District Court, D. Oregon. Lee v. State of Oregon. [Date of Decision: 27 December 1994] Federal Supplement. 1994; 869: 1491-1503.

The U.S. District Court, District of Oregon, granted the plaintiffs' motion for a preliminary injunction to Measure 16, a ballot measure passed by Oregon voters that authorizes physician-assisted suicide for the terminally ill. The plaintiffs were physicians, terminally ill patients, and residential care facilities, and they sued the state, challenging the constitutionality of Measure 16. The court held that (1) the plaintiffs had standing; (2) serious questions were presented as to whether the measure violated the plaintiffs' freedom of association, freedom of religion, due process, and equal protection rights; and (3) the balance of hardships favored the plaintiffs. The public interest in protecting vulnerable citizens from irreparable harm of death was held to be greater than the hardship to terminally ill patients who want physician-assisted suicide to be immediately available. (KIE abstract)

U.S. Supreme Court. State of Washington v. Glucksberg [Date of Decision: 26 June 1997] Supreme Court Reporter. 1997 Jun 26 (date of decision). 117: 2258-2293. Bench Opinion, No. 96-110 (Full Text)

The U.S. Supreme Court upheld Washington's ban against assisted suicide as applied to competent, terminally ill adults who wish to hasten their deaths by obtaining medication prescribed by their doctors. The Court refused to expand the liberty interest under the Due Process Clause of the U.S. constitution to include a right to commit suicide under it, a right to assisted suicide. The state has prevailing interests in the preservation of human life, the prevention of suicide, the integrity of the medical profession, the protection of vulnerable groups, and avoidance of a slippery slope into euthanasia. (KIE abstract)

U.S. Supreme Court. Vacco v. Quill [Date of Decision: 26 June 1997] Supreme Court Reporter. 1997 Jun 26 (date of decision). 117: 2293-2312. Bench Opinion, No. 95-1858 (Full Text)

The U.S. Supreme Court held that the terminally ill do not have a right to physician-assisted suicide under the Equal Protection Clause of the U.S. constitution. A New York prohibition on assisted suicide did not on its face treat the terminally ill who could hasten death by ending life support differently from those terminally ill who were not on life support. The Court reasoned that all competent persons are entitled to refuse life-sustaining treatment and no one is permitted to assist a suicide. The Court also noted as important the distinction between assisted suicide and withdrawal of life-sustaining treatment, a distinction recognized by both the medical and legal professions. (KIE abstract)


V

van der Wal, Gerrit; van der Maas, Paul J.; Bosma, Jacqueline M.; Onwuteaka-Philipsen, Bregje D.; Willems, Dick L.; Haverkate, Ilinka; and Kostense, Piet J. Evaluation of the Notification Procedure for Physician-Assisted Death in the Netherlands. New England Journal of Medicine 335(22): 1706-1711, 28 November 1996.

BACKGROUND: In the Netherlands, a notification procedure for physician-assisted death has been in use since 1991. It requires doctors to report each case to the coroner, who in turn notifies the public prosecutor. Ultimately, the Assembly of Prosecutors General decides whether to prosecute. Although physician-assisted death remains technically illegal, doctors are extremely unlikely to be prosecuted if they comply with the requirements for accepted practice. In 1995, the ministers of health and justice commissioned an evaluation to determine the adequacy of the notification procedure. METHODS: A random sample of 405 physicians were interviewed. We also interviewed 147 physicians who had reported cases of physician-assisted death and 116 coroners, and we reviewed 353 judicial files of reported cases. In addition, we interviewed 48 public prosecutors and reviewed the minutes of the Assembly of Prosecutors General for 1991 to 1995 and all published court decisions from 1981 through 1995. RESULTS: In 1995, about 41 percent of all cases of euthanasia and physician-assisted suicide were reported. There were no major differences between reported and unreported cases in terms of the patients' characteristics, clinical conditions, or reasons for the action. Most patients had cancer and were described as suffering "unbearably" and 'hopelessly." Of the 6324 cases reported during the period from 1991 through 1995, only 13 involved prosecution of the physician. The majority of respondents in the groups interviewed thought that all cases of physician-assisted death should be reviewed, although most doctors thought the review should be performed by other doctors, and there was substantial concern about the burden associated with the reporting procedure. CONCLUSIONS: Substantial progress in the oversight of physician-assisted death has been achieved in the Netherlands. The reporting procedure could be more streamlined and less threatening. [Author abstract]


W

Weir, Robert F. The Morality of Physician-Assisted Suicide. Law, Medicine and Health Care 20(1-2): 116-126, Spring-Summer 1992.

The time has come for a serious discussion of the morality and legality of physician-assisted suicide. I hope to contribute to that discussion by first analyzing the concept of assisted suicide and describing the diversity of possible legal responses to acts of PAS. I will then provide an ethical analysis of PAS by discussing the cases of Janet Adkins and "Diane," sorting out the competing ethical arguments about this issue, and making some recommendations for professional practice and public policy. [Author abstract]

Welie, Jos V.M. The Medical Exception: Physicians, Euthanasia and the Dutch Criminal Law. Journal of Medicine and Philosophy 17(4): 419-437, August 1992.

The legalization of euthanasia, both in the Netherlands and in other countries, is usually justified in reference to the right to autonomy of patients. Utilizing recent Dutch jurisprudence, this article intends to show that the judicial proceedings on euthanasia in the Netherlands have not so much enhanced the autonomy of patients, as the autonomy of the medical profession. [Author abstract]

Willems, Dick L. ; Daniels, Elisabeth R. ; van der Wal, Gerrit ; van der Maas, Paul J. ; and Emanuel, Ezekiel J. Attitudes and Practices Concerning the End of Life: a Comparison Between Physicians from the United States and from the Netherlands. Archives of Internal Medicine 160(1): 63-68, 10 January 2000.

This study compares attitudes and practices concerning the end-of-life decisions between physicians in the United States and in the Netherlands, using the same set of questions. METHODS: A total of 152 physicians from Oregon and 67 from the Netherlands were interviewed using the same questions about (1) their attitudes toward increasing morphine with premature death as a likely consequence, physician-assisted suicide (PAS), and euthanasia; and (2) their involvement in cases of euthanasia, PAS, or the ending of life without an explicit request from the patient. Odds ratios, with 95% confidence intervals, were calculated to investigate relation between attitudes and various characteristics of the respondents. RESULTS: American physicians found euthanasia less often acceptable than the Dutch, but there was similarity in attitudes concerning increasing morphine and PAS. American physicians found increasing morphine and PAS more often acceptable in cases where patients were concerned about becoming a burden to their family. There was a discrepancy between the attitudes and practices of Dutch physicians concerning PAS. The proportions of physicians having practiced euthanasia, PAS, or ending of life without an explicit request from the patient differ more between the countries than do their attitudes, with American physicians having been involved in these practices less often than the Dutch. CONCLUSIONS: In this study of American and Dutch physicians, 2 important differences emerge: different attitudes toward the patient who is concerned over being a burden, and different frequency of euthanasia and PAS in the two countries. [Author abstract]

Wilson, Janet K. ; Fox, Elaine ; and Kamakahi, Jeff J. Who is Fighting for the Right to Die? Older wWmen's Participation in the Hemlock Society. Health Care for Women International 19(5): 365-380, September-October 1998.

Who is fighting for the right to die? Past literature has been mixed as to the membership of this social movement. In the current study, 6,398 Hemlock Society members were surveyed in an effort to answer questions concerning who is participating in the right to die movement, whether these participants are rapidly approaching their own death or reacting to the death of a loved one, and whether the movement is invigorated by singular activists. The findings indicate that older, white, wealthy, highly educated, economically and politically active women are in the forefront of the right to die movement. These women report currently being mentally and physically healthy, yet already having taken the steps that will allow them to have an element of control over their death. Finally, right to die support seems to be part of a larger collective network concerning health care and political policy issues. [Author abstract]


Z

Zucker, Arthur. Law and Ethics: Experimentation; Assisted Suicide. Death Studies 21(2): 221-225, March-April 1997.

Noting that the "right to die" conceptually is not an issue because we all die, the author holds that "[w]hat is at stake in assisted suicide is the right of a physician to act in a manner consistent with patient wishes - if that physician would choose to do so." [KIE annotation]



Additional References:

Anderson, Carl A. Waiting for Hippocrates: the "right to die" and the U.S. Constitution. Linacre Quarterly. 1996 August; 63(3): 60-72.

Annas, George J. The bell tolls for a constitutional right to physician-assisted suicide. New England Journal of Medicine. 1997 Oct 9; 337(15): 1098-1103.

Annas, George J. Death by prescription: the Oregon initiative. New England Journal of Medicine. 1994 November 3; 331(18): 1240-1243.

Annas, George J. The promised end -- constitutional aspects of physician-assisted suicide. New England Journal of Medicine. 1996 August 29; 335(9): 683-687.

Astrow, Alan B. Thoughts on euthanasia and physician-assisted suicide. In: Spiro, Howard M.; Curnen, Mary G. McCrea; Wandel, Lee Palmer, eds. Facing Death: Where Culture, Religion, and Medicine Meet. New Haven, CT: Yale University Press; 1996: 44-51.

Avila, Daniel. Rodriguez v. Attorney General of Canada. [Note]. Issues in Law and Medicine. 1994 Spring; 9(4): 389-393.

Bartholome, William G. Physician-assisted suicide, hospice, and rituals of withdrawal. Journal of Law, Medicine and Ethics. 1996 Fall; 24(3): 233-236.

Batavia, Andrew I. Disability and physician-assisted suicide. New England Journal of Medicine. 1997 Jun 5; 336(23): 1671-1673. dt>

Battin, Margaret Pabst. Physician-assisted suicide. In: [her] Ethical Issues in Suicide. Englewood Cliffs, NJ: Prentice Hall, 1995: 198-227.

Battin, Margaret Pabst. The Least Worst Death: Essays in Bioethics on the End of Life. New York: Oxford University Press, 1994. 305 p.

Beauchamp, Tom L. Suicide. In: Regan, Tom, ed. Matters of Life and Death: New Introductory Essays in Moral Philosophy. Third Edition. New York: McGraw-Hill; 1993: 69-120. (

Beauchamp, Tom L. Refusals of treatment and requests for death. Kennedy Institute of Ethics Journal. 1996 Dec; 6(4): 371-374.

Bender, Leslie. A feminist analysis of physician-assisted dying and voluntary active euthanasia. Tennessee Law Review. 1992 Spring; 59(3): 519-546.

Bernat, James L.; Gert, Bernard; Mogielnicki, R. Peter. Patient refusal of hydration and nutrition: an alternative to physician-assisted suicide or voluntary active euthanasia. Archives of Internal Medicine. 1993 December 27; 153(24): 2723-2728.

Bjorck, Catherine L. Physician-assisted suicide: whose life is it anyway? SMU Law Review. 1994 January/February; 47(2): 371-397.

Blake, David C. Reconsidering the distinction of ordinary and extraordinary treatment: should we go back to the future? HEC (HealthCare Ethics Committee) Forum. 1996 Dec; 8(6): 355-371.

Boyd, K. Moral and religious dilemmas. In: Tinker, Jack; Browne, Doreen R.G.; Sibbald, William J., eds. Critical Care: Standards, Audit and Ethics. New York, NY: Oxford University Press; 1996: 391-399.

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Winslade, William J. Physician-assisted suicide: evolving public policies. In: Weir, Robert F., ed. Physician-Assisted Suicide. Bloomington, IN: Indiana University Press; 1997: 224-239.

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Last update: August 31, 2000

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