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Books in the Contemporary World Issues series address vital issues in today’s society, such as genetic engineering, pollution, and biodiversity. Written by professional writers, scholars, and nonacademic experts, these books are authoritative, clearly written, up-to-date, and objective. They provide a good starting point for research by high school and college students, scholars, and general readers as well as by legislators, businesspeople, activists, and others. Each book, carefully organized and easy to use, contains an overview of the subject, a detailed chronology, biographical sketches, facts and data and/or documents and other primarysource material, a directory of organizations and agencies, annotated lists of print and nonprint resources, and an index. Readers of books in the Contemporary World Issues series will find the information they need in order to have a better understanding of the social, political, environmental, and economic issues facing the world today.
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EUTHANASIA A Reference Handbook, Second Edition
Jennifer Fecio McDougall Martha Gorman
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Santa Barbara, California Denver, Colorado Oxford, England
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Copyright © 2008 by ABC-CLIO, Inc. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, except for the inclusion of brief quotations in a review, without prior permission in writing from the publisher. Library of Congress Cataloging-in-Publication Data McDougall, Jennifer Fecio. Euthanasia : a reference handbook / Jennifer Fecio McDougall, Martha Gorman. — 2nd ed. p. cm. — (ABC-CLIO's contemporary world issues) Rev. ed. of: Euthanasia / Carolyn S. Roberts, Martha Gorman. c1996. Includes bibliographical references and index. ISBN 978-1-59884-121-3 (hard copy : alk. paper) 1. Euthanasia. I. Gorman, Martha, 1952- II. Roberts, Carolyn S., 1960- Euthanasia. III. Title. IV. Series: Contemporary world issues. [DNLM: 1. Euthanasia. WB 60 M4775e 2008] R726.R53 2008 179.7—dc22 2007025758
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ABC-CLIO, Inc. 130 Cremona Drive, P.O. Box 1911 Santa Barbara, California 93116-1911 This book is also available on the World Wide Web as an ebook. Visit www.abc-clio.com for details. This book is printed on acid-free paper
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Contents
Preface, xi 1
Background and History, 1 History of Euthanasia, 1 Attitudes toward Euthanasia throughout History, 2 The History of Euthanasia Becomes Personal, 6 Examining the Issue, 12 Medical-Bioethical, 12 Spiritual-Social-Cultural, 21 Legal-Political, 25 References, 27
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Problems, Controversies, and Solutions, 31 Problems, Controversies, and Solutions Related to End-of-Life Issues, 31 Differentiating between Key Concepts, 32 Medical-Bioethical Issues, 34 Spiritual-Social-Cultural Issues, 51 Legal-Political Issues, 58 References, 65
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Worldwide Perspective, 69 Examining Euthanasia throughout the World, 69 Data on a Global Scale, 69 Studying Euthanasia and End-of-Life Issues throughout the World, 70 United Kingdom, 70 Netherlands, 74 Australia, 76
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Africa, 78 Canada, 81 France, 83 Germany, 86 Japan, 88 China, 91 Belgium, 92 Colombia, 93 References, 95 4
Chronology, 99
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Biographical Sketches, 127 Janet Adkins, 127 Dr. Pieter Admiraal, 128 Kevin Andrews, 128 Dr. Margaret Pabst Battin, 129 Pope Benedict XVI, 129 Dr. Daniel Callahan, 130 Diane Coleman, 131 Nancy Cruzan, 131 Dr. Kathleen Foley, 132 Dr. Faye Girsh, 133 Dr. Herbert Hendin, 133 Vincent Humbert, 134 Derek Humphry, 134 Pope John Paul II, 135 Yale Kamisar, 136 Dr. Jack Kevorkian, 136 Dr. Elisabeth Kübler Ross, 137 Luis Kutner, 137 Barbara Coombs Lee, 138 Rita Marker, 138 Dr. Philip Nitschke, 139 Dr. Edmund Pellegrino, 139 Dr. Gertruida Postma, 140 Dr. Timothy Quill, 140 Karen Ann Quinlan, 141 Dr. James Rachels, 142 Dame Cicely Saunders, 142 Terri Schindler Schiavo, 143
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Wesley J. Smith, 143 Joni Eareckson Tada, 144 Thomas Youk, 144 References, 145 6
Data and Documents, 148 Facts and Data, 148 Meaning of the Word, 148 A Common Thread, 148 Elderly Suicide in America, 148 The Hospice Option, 150 Spiritual-Social-Cultural, 150 Health Care Today, 155 Legal-Political, 157 Documents, 160 Medical-Bioethical, 160 Spiritual-Social-Cultural, 164 Documents related to Individuals and Organizations, 174 Legal-Political, 175 Quotations, 182 In Favor of Euthanasia or Physician-Assisted Suicide, 182 Spiritual-Social-Cultural, 185 Legal-Political, 187 Opposed to Euthanasia or Physician-Assisted Suicide, 190 References, 195
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Directory of Organizations, 199 Organizations in the United States, 199 Organizations Overseas, 219
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Resources, 225 Resources to Assist in the Study of Euthanasia, 225 Print Resources, 226 Periodicals, 247 Nonprint Resources, 252 Databases, 256 Internet Sites, 257
Glossary, 263 Index, 267 About the Authors, 283
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Preface
P
eople approach euthanasia and other end-of-life issues in different ways. For a student assigned a paper, these issues are merely academic topics to be studied, researched, and addressed for presentation to a teacher or professor. For a casual observer, a newspaper article or conversation regarding end-oflife issues may lead to introspection. Such examination of one’s personal feelings about these issues may lead the individual to the conclusion that issues related to the end of life should not be left to chance. If this is the case, the individual may make decisions and prepare documents to cover some of the medical contingencies that may arise at the end of life. Finally, for a person dealing with his or her own end-of-life issues or those of a loved one, these issues frame the final months, weeks, days, and even hours of life. In cases like this, end-of-life issues are reality; they may even include a momentous choice between vastly different courses of action, such as making a final effort to prolong life or making a request for assistance in committing suicide. This book aims to assist people at all points along this spectrum. Whether the reader is a student conducting research, a legislator considering a bill, or a person facing a terminal illness, the following chapters contain information that will be invaluable in sorting through these issues. In addition to discussing the complexities surrounding end-of-life issues, this book contains valuable factual information, such as a chronology of events, a directory of organizations, and resources for additional study. Chapter 1 focuses on the background and history of euthanasia in the United States, including an examination of the nuances of end-of-life issues, relevant terminology, and the histo-
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ry of the issue up to the present time. This chapter also includes a synopsis of attitudes toward euthanasia throughout history. The issue is divided into three subtopics: medical-bioethical, spiritualsocial-cultural, and legal-political. This hierarchy of subtopics is used throughout the book. Chapter 2 offers insight into the problems, controversies, and solutions surrounding euthanasia. All sides of the issue are presented to provide a fair and balanced examination of the topic and to provide a solid overview of the complex problems, controversies, and solutions within it. This chapter includes a section highlighting relevant concepts to minimize confusion and foster greater understanding along with information about some of the more recent controversies involving end-of-life issues in the United States. In Chapter 3, the focus turns to an examination of euthanasia from a worldwide perspective. Information related to euthanasia and other end-of-life issues is presented in the context of various countries. The valuable information a country may offer to the United States, or the relevance of the country’s experience to that of the United States, is also examined. In addition to reminding readers and researchers that no country is alone in grappling with end-of-life issues, this chapter places the experiences of the United States with these issues into a broader context to provide additional perspective. A chronology of key events related to euthanasia and other end-of-life issues is found in Chapter 4. The chronology provides a valuable tool for examining these issues throughout history and putting events into the context of the ages. For someone just embarking on the study of euthanasia and other end-of-life issues, this historical timeline is a valuable reminder that these issues are not unique to our time. Rather, societies throughout history have faced death and all that it entails, and their experiences offer historical lessons and perspectives for modern societies working to address the issues that arise at or near the end of life. Chapter 5 highlights the people who frame the issue of euthanasia in some way. Some continue to contribute through their actions, words, or writing. Others are no longer active in this area but have left a legacy that will resonate for years to come. Chapter 6 examines the facts and data that underpin the issue of euthanasia. In addition to statistics, relevant documents,
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and quotations, this chapter includes information that places each informational item in its proper context. Chapter 7 highlights the various organizations that are active in the arena of euthanasia or other end-of-life issues. This chapter is divided into organizations located in the United States and those that are overseas to make it easier for researchers to narrow their focus if they so choose. Each entry is annotated with a description of the organization’s activities, and contact information for each organization is also included. Chapter 8 is valuable for those who wish to further explore euthanasia or other end-of-life issues. It features a list of written works, including books, articles, and newsletters, as well as DVDs, videos, Internet sites, and other valuable resources. Euthanasia and other end-of-life issues do not exist in a vacuum. By their very nature, they cover a variety of topics, including medicine, politics, law, philosophy, and religion. As a result, there is a great deal of terminology to contend with. The glossary lists many relevant terms and their definitions. We thank everyone who has helped make this book possible. To Dayle Dermatis, Mim Vasan, and the entire wonderful staff at ABC-CLIO: We could not have done this without you! We are also grateful to the staffs of the Buffalo and Erie County Public Library (Central Branch), the Canisius College Library, and the Eldredge Public Library in Chatham, Massachusetts. To the family members and friends who have provided loving support: Words cannot express the depth of our gratitude. Special thanks to Jack and Maureen Fecio for constant encouragement, Iris Skoog for the gift of writing, and Shelbie Callaghan for her special assistance. To Alex and Maeve McDougall: a lifetime of loving appreciation for your love, patience, support, and countless hugs. Thank you! And a special commemoration of Tim Gorman, whose fierce battle with muscular dystrophy decades ago inspired the ethical introspection that imbues this reference book with a warm heart and a tortured soul.
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1 Background and History
History of Euthanasia
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he Merriam-Webster Dictionary defines euthanasia as easy death or mercy killing (1998, 179). The dictionary defines suicide as the act of killing oneself purposely or one who commits or attempts suicide (517). Assisted suicide, by extension, would be the act of taking one’s own life purposely, but with the assistance of another person. Similarly, physician-assisted suicide would be the act of taking one’s own life purposely, with the aid of a physician. In other words, assisted suicide occurs when someone assists a person in ending his or her own life. When the person who assists is a doctor, the common term is physician-assisted suicide. In many cases, though, the person assisting is a layperson, such as a relative or friend who is sympathetic to the other person’s wish to end his or her own life. It is common in assisted suicide for the person who has chosen to die to actually perform the final act, or the act that actually results in death (Yount 2000, 4). Although these definitions provide insight into the meaning of these words in a scholarly or intellectual sense, they do not convey the emotion, controversy, and history related to them. Within the concept of euthanasia, there are various nuances which are useful in explaining the concept more fully. Passive euthanasia and active euthanasia, as their names imply, are differentiated by the amount of action one takes to bring about the
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intended result. Passive euthanasia is often described as letting someone die. In practical terms, this might mean “ceasing or not starting medical treatment that keeps a person alive, such as attachment to a respirator or provision of food and water through a tube.” In active euthanasia, someone “causes the death of a sick person without that person’s participation.” It is important to note that active euthanasia always involves someone other than the patient actually performing the action (Yount 2000, 4). There are three types of active euthanasia. Voluntary euthanasia is a form of active euthanasia that is performed at the request of the patient. Involuntary euthanasia is another term for what is sometimes known as “mercy killing,” or taking the life of a patient who has not requested death with the intent of relieving suffering. Nonvoluntary euthanasia denotes euthanasia that takes place even though the patient is not competent to give consent (Yount 2000, 4). Terminology is important in any discussion of end-of-life issues. For example, “[the] term self-deliverance is preferred by some over the term suicide, so as not to correlate the two events, because they believe they are entirely different, with self-deliverance stemming from a rational choice and traditional suicide resulting from emotional or psychological trauma” (Scherer and Simon 1999, 13).
Attitudes toward Euthanasia throughout History Today, the mention of euthanasia or physician-assisted suicide is guaranteed to elicit a reaction from most people. Like abortion, capital punishment, and other issues related to the beginning or end of human life, end-of-life issues crop up in a variety of situations including academic and other discussions, politics, the media, and everyday life. Although it is often assumed that contemporary perspectives are different from those throughout history, it would seem that the concept of euthanasia has always been the subject of debate. The difference today is that media coverage enables people and events relevant to the issue to gain wider exposure. Even the origin of the term euthanasia is not as straightforward as it may seem. Although the translation of “good death”
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History of Euthanasia
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may imply that the Greeks and Romans who coined the term agreed on the basic issues, history shows us that this is not the case. With official permission, residents of Athens could obtain a dose of poison which would allow them to choose death. Romans did not punish people who attempted suicide unless they were considered irrational. The flip side of this more permissive attitude was condemnation of euthanasia by Pythagoreans; they based their condemnation on the spiritual notion that only God had the right to take life. That dichotomy has continued throughout history. In various nations and at various times, there were people who advocated for the right to die and people who argued that euthanasia or assisted suicide, for a variety of reasons, were harmful and should not be legal. This knowledge is instructive because it reminds us that our society is not alone in examining these issues. As individuals and organizations on both sides of end-of-life issues engage in advocacy work, address legislation, assist people with problems, and educate the public, they may often feel as if they are alone in their battles. History shows that this is not so; throughout the world, civilizations have addressed these issues in various ways just as modern communities continue to address them today. New technology, which enables medical personnel to treat patients in ways that would have been considered miraculous a generation ago, raises new issues that those who address end-oflife matters continually work to address. Even that, though, is not new: New technology throughout the ages has historically raised unexpected new issues which each respective society has worked to address.
Christianity in the Roman Empire (First Century–Fifth Century) As the religion officially associated with the Roman Empire, Christianity had a profound impact on views on euthanasia. Not surprisingly, there is little gray area in terms of Christianity’s teachings on this issue. Even the term for suicide, felo de se, which means self murder, is a very straightforward indication of this. This terminology, and the philosophy attached to it, did not include a distinction between suicide as a result of emotional issues and suicide as a result of suffering from a terminal illness. Rather, suicide of any type was strictly forbidden on the grounds that making determinations regarding life and death was solely and completely the purview of God. As a result, people who com-
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Background and History
mitted suicide were denied a Christian burial; in fact, their bodies were sometimes left, impaled on a stake, at the roadside. Their family members suffered as a result of the suicide, as well: The person’s worldly belongings were taken away with the intention of punishing the family by leaving them impoverished.
The Middle Ages (Fifth Century–Fifteenth Century) Euthanasia was cast in a new, and further stigmatized, light when Christianity linked suffering with spiritual growth by citing the spiritual virtues of martyrdom. The Catholic Church cemented this religious condemnation of euthanasia when it declared that suicide or attempted suicide was grounds for excommunication. Taking a life, in general, was condemned. Although it was considered acceptable to take a life within a just war or to execute a criminal, it was most definitely not acceptable to commit suicide. Killing as a means of defending oneself was also deemed as being beyond the bounds of acceptability. Judaism at that time did not involve a gray area either: It was considered murder to cause a death, even if the person was already dying.
The Renaissance (Fourteenth Century–Seventeenth Century) The Renaissance, which offered a rebirth of learning in many areas, was the backdrop for quantum leaps in terms of scientific discovery. These discoveries resulted in the notion that the human body was understandable, at least to a certain degree, rather than a mystery of the divine variety, as many had previously thought. As part of this increased understanding, the practice of dissecting cadavers became commonplace because the dead provided physicians with unique opportunities to understand diseases, learn more about the organs and systems within the human body, and determine the source of illness. Tools were another aspect of this increased understanding; it was during this time period that it became common practice to use tools to perform acts we take for granted, such as taking a patient’s temperature. The notion that the body was not some sort of divine mystery gave rise to renewed discussions about euthanasia. Although the Catholic and Protestant churches remained steadfast in their condemnation of it, some people of the day began to examine the notion that euthanasia might not be such a grievous sin after all. Then, as today, scientific discovery resulted in increased
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dilemmas for people who were ill, as well as for their loved ones, and society in general. The scientific discoveries of the time had resulted in medical advances that provided physicians with the means to prolong life. However, prolonging life sometimes gave rise to other, often unanticipated, issues such as increased suffering, which resulted in the new dilemmas of the day.
The Age of Reason (Eighteenth Century) Further understanding of the human body dawned during the Age of Reason. The invention of the stethoscope, ophthalmoscope, and laryngoscope were important components of this increased body of knowledge. With this greater understanding came an increased sense of responsibility for many physicians of the day; many doctors throughout Europe and North America began talking about previously unexplored subjects such as humane death. As the notion of humane death began to crop up within the medical community, people outside the practice of medicine concurrently began to examine this concept and to consider the idea of some degree of choice in death. In fact, by 1798, six of the thirteen colonies no longer mandated legal penalties for people who attempted suicide.
Pre–World War II and Nazi Germany (1920s–1945) In the 1920s and 1930s in Germany, people who were handicapped, mentally ill, or in asylums were among those who were killed in a program secretly approved by the government. This example of government-sanctioned eugenics evolved into Adolf Hitler’s “Euthanasia Programme.” Hitler’s program was actually brutal murder of those least able to defend themselves and the euthanasia-related terminology had a tremendously negative impact on the euthanasia movement. As part of his campaign of horror, Hitler created an environment among Germans of festering hatred and resentment against those in asylums. His diabolical campaign included use of the term unnutze esser, or useless eater, to further demonize asylum residents as unfairly taking food from Germans already suffering from wartime conditions. Hitler’s actions forever changed the meaning of the word euthanasia. In the United States, for example, a poll after the war indicated that support for euthanasia was lower than it had been before the war. It seems that Hitler’s twisted use of the term had resulted in a greater negative attitude toward the entire concept.
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Background and History
Some, in fact, have argued that he succeeded in portraying euthanasia as an anti-American concept.
Modern Medicine (1940–Present) Although previous eras have yielded amazing advances in medical technology, such advances have been especially plentiful and technologically wondrous in the modern age. Although we take them for granted today, discoveries such as vaccines for polio and measles, certain new medications, pacemakers, and surgical techniques were actually landmark events that changed the practice of medicine. Certainly, these technological advances, and others like them, make it possible to save the lives of patients who would otherwise have faced certain death. Although such advances have provided doctors with the means to prolong life, patients have not always been happy to have their lives prolonged. These lifesaving and life-prolonging advances, in fact, were contemporaneous with increased patient requests for assistance in dying and a renewed interest, among both physicians and the public, in the concept of euthanasia.
The History of Euthanasia Becomes Personal When people read a newspaper article about a horrific automobile accident or watch a news report about someone struck with a terminal illness, they may feel a sense of relief that such tragedy has not visited them or their loved ones. Although they do not wish it on the unfortunate victim, they may still think, “I’m glad it’s not me or someone in my family.” Unfortunately, when such tragedies occur, they change the lives of all involved—for the worse, and forever. No discussion of the history of euthanasia would be complete without highlighting some of the most well-known, and often controversial, cases in the United States. For Karen Ann Quinlan, Nancy Cruzan, and Terri Schiavo, tragedy struck. For their families, the world tilted and they were left facing a loved one lying in a hospital bed, heartrending decisions, and seemingly endless court battles.
Karen Ann Quinlan The tragic story surrounding the case of Karen Ann Quinlan began on April 15, 1975. Quinlan, age 21, was admitted to a hospital in
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History of Euthanasia
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New Jersey because she was in a coma induced by drugs and alcohol. After monitoring her for several months, her doctors concluded that she was in a persistent vegetative state (PVS) and had suffered irreversible brain damage. Her parents determined that it would be in their daughter’s best interests to remove the respirator that was breathing for her. The respirator was considered an extraordinary means of life support and hospital officials initially agreed with the decision made by Karen Ann Quinlan’s parents. When hospital officials subsequently changed their minds and decided that they would not agree to the removal of the respirator, Mr. and Mrs. Quinlan took their fight to a court of law. As the court battles were fought, Karen Ann Quinlan remained in a persistent vegetative state in her hospital bed; however, her nurse had succeeded in weaning her from the respirator and Quinlan was breathing on her own without mechanical assistance. Although the court ultimately agreed with the Quinlans, the matter was made moot by the fact that Karen Ann Quinlan was, by that time, no longer dependent on the respirator. She remained in a persistent vegetative state for eight years and died of pneumonia in 1985. Effects of the Case of Karen Ann Quinlan.—Prior to the protracted battle surrounding the life of Karen Ann Quinlan, five states had addressed legislation regarding right-to-die issues. The case, and the national media attention that surrounded it, brought this issue to the forefront and sixty-seven bills regarding end-of-life matters were introduced within a year. Eight of these pieces of legislation became law. Hospital officials throughout the country responded to the case by establishing ethics committees which were charged with examining decisions made by guardians to verify that each decision was in the best interest of the patient in question. Hospital officials and state legislators were not the only people impacted by the Karen Ann Quinlan case, as evidenced by the fact that the number of requests for living wills increased dramatically at that time. It seems that the case was a clarion call to people throughout the United States to consider issues related to the end of their own lives. News accounts of such a young adult in this situation seemed to force many people to acknowledge the fact that catastrophic medical situations can arise unexpectedly; this acknowledgement was coupled with the awareness that addressing end-of-life issues in advance of such a situation is an effective way to make one’s wishes known.
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Background and History
In his book Taking Advance Directives Seriously, Robert S. Olick defines a living will as a document that includes “the individual’s wishes and instructions for health care” (2001, xiv). A living will must be prepared and signed when the person is in good health and mentally competent; in other words, it must be apparent that the person made the decisions contained in the living will freely and with a sound mind. Another type of advance directive, known as a durable power of attorney or health care proxy, was also developed during this time period. Olick defines this legal document as one which “may designate another person to make health care decisions on the patient’s behalf” (xiv). The durable power of attorney or health care proxy provides an additional degree of control for the person signing it: The individual can choose both the degree of authority he or she bestows upon the proxy and what form the authority will take. In this way, the individual can tailor the durable power of attorney or health care proxy to be appropriate and as effective as possible for his or her particular needs and wants. In addition, it is important to note that this document does not expire; it can be revoked only by the person who signed it. Although many people feel that their wishes will be covered if they have either a living will or a durable power of attorney, many legal and medical experts recommend preparing both.
Nancy Cruzan Nancy Cruzan, age 25, was traveling along a rural road in Missouri in 1983 when she lost control of her car and crashed into a ravine. She suffered extensive injuries, oxygen deprivation, and permanent brain damage and she was in a deep coma, which was later determined to be a persistent vegetative state. Although Cruzan’s family struggled to bring her out of this state by talking to her, providing stimulation, and making her comfortable, after four years, they began to acknowledge the fact that she might not emerge from it. As Nancy Cruzan remained in this persistent vegetative state and her family struggled to help her as best they could, extensive media coverage enabled people interested in the situation and in end-of-life issues to follow the case and track new developments. Like the case of Karen Ann Quinlan, the case of Nancy Cruzan prompted many people to begin examining their own wishes and preparations regarding end-of-life issues. Although the cases of Karen Ann Quinlan and Nancy
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Cruzan were similar in some ways, there was a significant difference in that Nancy Cruzan was not dependent on a ventilator. She received artificial nutrition and hydration through a feeding tube; this feeding tube garnered a great deal of attention when Mr. and Mrs. Cruzan stated that their daughter would not want to be kept alive as she was at that time. The feeding tube was the only option available as far as putting an end to life-sustaining treatment; thus, when her parents stated that it was their wish, on their daughter’s behalf, to allow her life to end, they asked that the tube be removed. When officials of the rehabilitation facility in which Nancy Cruzan resided opposed the decision, the Cruzans took the case to court. When the Cruzans declared, on their daughter’s behalf, that the feeding tube should be removed, the media coverage increased dramatically. Throughout the nation, the case spurred an outcry from those who deemed the removal of the feeding tube to be the beginning of an inhumane death. A feeding tube was considered ordinary treatment; some individuals and organizations charged that removing it would lead society on a slippery slope that would endanger people unable to speak for themselves. Others, however, argued that it was the right of Nancy Cruzan’s parents to allow her to die rather than live a life she would not have wanted to live. In the absence of any type of advance directives, the court declared that the state’s interest in maintaining life was greater than the family’s arguments about the quality of Nancy Cruzan’s life. The Cruzans appealed this verdict and the case went to the U.S. Supreme Court. The Court handed down a decision on June 25, 1990; in Cruzan v. Director, Missouri Department of Health, the Court sided with the Cruzans. In the decision, the Court declared that the right to die was a constitutionally protected liberty interest, maintaining that the right to refuse treatment, even artificial nutrition and hydration, is guaranteed through the liberty clause in the Constitution of the United States of America. However, such a guarantee was not absolute, according to the Court. The decision contained restrictions that mandated that no action could be taken unless there was proof that the action was in accordance with what the person’s wishes would have been. The Court further declared that states had to create guidelines outlining what standards of proof would be considered acceptable; in this way, a state could protect those facing end-of-life decisions
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Background and History
made by others and simultaneously protect its own interests in preserving life. As a result of the aforementioned limits placed by the Court, the Cruzans were required to go back to the state court in Missouri to determine if there was sufficient proof of what their daughter’s wishes might have been. Several of her friends testified regarding conversations they had shared with Nancy Cruzan about issues related to life, illness, and death. Based on this testimony, the state court, declaring that existing evidence was sufficient to surmise what Nancy Cruzan would have wanted, granted her the right to die. Nancy Cruzan’s feeding tube was removed on December 14, 1990. Protestors gathered outside the rehabilitation facility in which she resided, vocalized their opposition, and begged for the reinsertion of her feeding tube. Some people even attempted to reach her room to force reconnection of the feeding tube; their efforts were unsuccessful and Nancy Cruzan died on December 26, 1990. Effects of the Case of Nancy Cruzan.—Just as Karen Ann Quinlan’s case spurred increased attention to end-of-life issues, Nancy Cruzan’s case caused people throughout the United States and beyond to begin reexamining many of these issues. Senator John Danforth of Missouri was no exception. He introduced the Patient Self Determination Act (PSDA) in Congress in an attempt to bring a sense of uniformity and order to advance directives in the United States. As adopted, the legislation introduced greater clarification in this area by clearly delineating responsibilities of the various parties, including doctors, patients, families, and health care institutions. Effective December 1, 1991, it immediately supplanted existing state laws and made advance directives more accessible throughout the United States. Although the Patient Self Determination Act provided needed clarity in this area, there are still components that vary from state to state. The language used in advance directives, for example, varies for each state. Furthermore, advance directives are applicable only in the state in which the patient lives. Despite the inconsistencies and restrictions, the PSDA introduced an element of uniformity and a degree of clarification.
Terri Schindler Schiavo Terri Schiavo collapsed in 1990, when she was 26 years old. She suffered cardiac arrest and lapsed into what some physicians
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termed a persistent vegetative state. Like Karen Ann Quinlan and Nancy Cruzan, Terri Schiavo did not have advance directives; as a result, decisions regarding her care were left to her husband, Michael Schiavo. Although relations between Michael Schiavo and Terri Schiavo’s parents, Robert and Mary Schindler, seem to have been amicable for a time, the relationship began to deteriorate when there was a disagreement about her care (Levesque 2003; St. Petersburg Times 2004). Michael Schiavo argued that previous conversations with his wife, as well as his knowledge of her, gave him insight into what her wishes would have been in regard to a medical situation like the one she was in. An article that appeared in the St. Petersburg Times in 2003, during the ongoing legal battles, noted, “In 1998, Michael Schiavo petitioned the courts to have her feeding tube removed, saying she was in an irreversible persistent vegetative state. Schiavo said his wife told him several times during their marriage she would not want to be kept alive on life support” (Levesque 2003). Robert and Mary Schindler, however, opposed Michael Schiavo’s efforts. According to the St. Petersburg Times, the Schindlers “argue that their daughter recognizes and responds to them, and might be helped with more therapy.” Some physicians supported their claims, declaring that “she is not in a persistent vegetative state, so the tube legally cannot be removed.” In addition, Robert and Mary Schindler argued that “no matter what her medical condition, Schiavo would have wanted to be kept alive” (St. Petersburg Times 2004). The ongoing legal battles came to an end when Michael Schiavo prevailed in his efforts to have Terri Schiavo’s artificial nutrition and hydration discontinued. Terri Schiavo died on March 31, 2005. Effects of the Case of Terri Schiavo.—Just as the cases of Karen Ann Quinlan and Nancy Cruzan had ripple effects, the case of Terri Schindler Schiavo had an impact beyond the patient and her family. In addition to an increase in awareness of end-of-life issues in general, this situation yielded a focus on specific medical and endof-life issues related to nutrition and hydration at the end of life. The Schiavo case also prompted increased interest in advance directives. Again, although interest in advance directives as a general topic grew tremendously, many people now focused on their end-of-life wishes in terms of nutrition and hydration. Although it is not possible to cover every single issue that might arise at the
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Background and History
end of life, the case of Terri Schiavo was a catalyst for many people to examine their feelings and wishes about this particular issue vis-à-vis the end of life.
Examining the Issue As with any complex issue, the concept of euthanasia does not exist in a vacuum; it necessarily addresses numerous subtopics. In order to make this complex study easier, three chapters of this book contain sections which address these subtopics. For many people, the issue of euthanasia arises in the context of one’s own illness or the illness of a loved one. As a result, medical and bioethical issues are a major part of studying this issue; medical-bioethical issues are listed first because this area is, in many ways, the most logical starting point. However, study of this issue obviously cannot be limited to medical and bioethical issues. Spiritual issues are important for many people who are concerned with euthanasia; issues in this realm are included with social and cultural issues. The spiritual-social-cultural section examines and addresses many of the influences that rule the way individuals feel about this topic. Finally, although euthanasia is an intensely personal issue, it enters the legal realm on a regular basis, especially when the wishes of an individual, or the family members of a patient, are in conflict with a hospital’s medical or bioethical concerns. In addition, various legislative bodies in the United States and throughout the world have considered legislation related to euthanasia. The final section, legal-political, addresses both of these matters.
Medical-Bioethical If you want to start a lively discussion in any setting ranging from a classroom to a dinner party, euthanasia is a surefire conversation starter. It is a complex issue which is both intensely personal and politically charged. Although some people have not formed solid opinions on the issue, many people have very strong feelings. Some may believe that euthanasia is wrong and should not occur under any circumstances; conversely, others may be of the opinion that someone facing the end of life should be able to choose the cir-
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cumstances under which death occurs. The following topics highlight the quagmires related to end-of-life issues.
Terminology and Issues Related to the End of Life Quality of Life. Our society’s current definition of the concept of quality of life is largely predicated on an individual’s ability to determine when his or her life has become too painful to bear or has lost all meaning. This definition has been honed over a period of approximately four decades; various constituencies, including the courts, advocacy groups, physicians, patients, and the media have weighed in on it. The result is a loose definition that focuses on an individualistic approach rather than taking a one-size-fitsall stance regarding this amorphous concept. Quality of life can be the subject of controversy, especially when someone else attempts to gauge a particular patient’s quality of life. The concept is so subjective that a patient’s assessment of his or her quality of life can be very different from assessments made by others, including physicians, other medical professionals, family members, or friends. Brain Death.—The American Medical Association Complete Medical Encyclopedia defines brain death as the “irreversible cessation of all functions of the entire brain, including the brain stem.” The definition, the encyclopedia notes, was developed by Harvard Medical School in 1968. The encyclopedia goes on to explain that the diagnosis of brain death is “confirmed by a variety of tests that determine an absence of reflexes, unresponsiveness to stimuli, a lack of spontaneous respiration or movement, and the absence of electrical activity of the brain as indicated by a flat electroencephalogram (EEG)” once it has been determined that “nothing is suppressing the person’s responses, such as hypothermia . . . or drugs . . .” (Leikin and Lipsky 2003, 271). Pain.—For someone facing imminent death, numerous issues affect how the remaining hours, days, or months of life are spent. Pain is at the top of this list of issues: Someone who is experiencing a tolerable amount of pain has greater latitude to make choices about the end of life. For some people, a tolerable pain level might present the chance to spend additional time with loved ones or an opportunity for a final trip before traveling becomes impossible. For those with pain that has become intolerable, everything may seem overwhelming; in fact, intolerable pain removes choice from many facets of the remainder of a patient’s life. In some
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Background and History
cases, doctors can prescribe medication to lessen it; however, for some patients, such as those suffering from AIDS and certain types of cancer, relief, unfortunately, is nearly impossible. In addition, a patient’s efforts at achieving some measure of relief may, in some cases, be thwarted by medical personnel. Some physicians worry about patients becoming addicted to pain relief or assume that the patient is exaggerating the pain. In cases like these, physicians may prescribe a lower dose of pain medication. Regardless of the circumstances, good communication between the patient, family, medical personnel, and other caregivers is an essential component of ensuring that the patient’s pain level is as tolerable as it can be. Persistent Vegetative State.—Persistent vegetative state (PVS) is defined in Slee’s Health Care Terms as “the condition of a patient who is still breathing with or without the aid of medical assistance, but whose mental functions have ceased, as determined by examining the electrical activity of the brain” (Slee et al. 2001, 478). Taber’s Cyclopedic Medical Dictionary offers a definition that includes specific factors for determining whether a persistent vegetative state exists: A continuing and unremitting clinical condition of complete unawareness of the environment accompanied by sleep-wake cycles with either complete or partial preservation of hypothalamic and brain-stem autonomic functions. The diagnosis is established if the condition is present for 1 month after acute or nontraumatic brain injury or has lasted for 1 month in patients with degenerative or metabolic disorders or developmental malformations (Venes 2005, 1641–1642).
What Is Hospice? Dame Cicely Saunders is considered the founder of the modern hospice movement. As a result of her efforts, people in the United States and throughout the world have discovered the option of palliative care or “the management of pain and discomfort, without medical treatment that is curative in nature” (Scherer and Simon 1999, 13). Writing in The Case against Assisted Suicide: For the Right to End-of-Life Care, Dame Saunders, O.M., F.R.C.P., explains, “Hospice is a complex set of attitudes and skills, not a building.
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Much of this care and treatment can be accomplished at home with the support of teams so well developed in the United States . . .” (Foley and Hendin 2002, 287). Referring to hospice or palliative care as comfort care, Dr. Charles McKhann notes, in his book A Time to Die: The Place for Physician Assistance, that the purpose of such care is to “relieve pain and all other symptoms, including anxiety, to the extent that medication and personal support make it possible.” McKhann also cites an important tenet of the hospice movement: “Implicit in comfort care is the understanding that it will be given continuously to the very end, that the patient will not be abandoned by his caregivers.” This comfort extends to “supportive measures . . . limited to those that contribute directly to providing comfort . . .” (1999, 76). He explains: Most laboratory studies are eliminated, and drawing of blood is avoided if at all possible. X-rays are not taken unless they will influence the care being given. Nutrition and hydration are usually limited to what can be taken by mouth. Tube feedings and intravenous feeding are not started, but may be continued if they are already in place. Blood transfusions are not given, and oxygen is only provided when it is needed to provide comfort. Mechanical ventilation is not used (McKhann 1999, 77). Hospice care, however, does not end with the medical team. Hospice care programs generally use multidisciplinary teams to provide patients and families with a complete spectrum of care and services. In addition to medical care, hospice programs have the resources to provide patients and families with access to experts in various fields, including social work, counseling, religious and spiritual support, and so on.
Health Care Issues Managed Care.—Health care in the United States today is very different than it was for previous generations. One of the major changes is that managed care has replaced traditional health insurance plans with Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and similar organizations. This new structure has resulted in profound
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Background and History
changes in doctor-patient relationships. By the mid-1990s, a visit to the doctor had changed for many people: Instead of seeing the family physician, they saw their “designated medical provider.” In everyday terminology, this meant that they had a visit with the doctor on call in the clinic setting at that time; the fact that it could be a different person each time reduced the concept of continuity of care. This change has had two salient impacts on end-of-life care: 1. Doctors who had previously owned their medical practices are now generally employed by managed care organizations. This situation is significant for patients: Rather than the physician setting the treatment standards, practices, and priorities, the corporation fills that role. Since the corporation has a vested interest in maintaining a profitable bottom line, there is the chance that profit can take precedence over patient needs. This system has raised questions, including the following, for people who study health care: What if a patient has an illness that is very costly to treat and the corporation denies this treatment on the grounds that it is too expensive? If physician-assisted suicide is legal, does the doctor’s loyalty lie with the patient or the corporation—and its financial interests? What safeguards exist to protect the patient’s wishes? 2. Under this scenario, patients rarely have the opportunity to get to know their doctors and establish a relationship of trust. It is more difficult, then, for patients and family members to turn to the doctor for advice and wisdom regarding complex medical decisions, especially those related to end-of-life issues. It is more difficult for the physician, also, because he or she is placed in the unenviable position of giving life-changing advice to a patient who is a fairly recent acquaintance.
Doctor-Patient Relationships.—For many people, the days when the doctor was a trusted guide on healthcare issues are a mere memory; in the new environment, relationships between patients and their physicians may become more complex. It is more difficult for a patient to trust a doctor that he or she has met only once or twice. While it can be very challenging for a patient to raise a sensitive
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question with a doctor who is nearly a stranger, it can be excruciatingly difficult for a patient to face end-of-life decisions with a medical practitioner he or she barely knows. Added to the problems that arise from such lack of familiarity with one’s physician, the typical issues that have always framed the doctor-patient relationship remain. These typical issues can include patient anxiety, poor communication between the doctor and patient, patient embarrassment about sensitive issues, and many others depending on the individuals involved. Dr. Nancy Snyderman, writing in Good Housekeeping, explains how her own experience as a patient made those issues clear in a way that she has remembered throughout her medical career: The doctor-patient relationship is a sensitive one, requiring respect and openness on both sides. I believe that most physicians try to do their jobs well and that most patients understand their M.D.’s are only human. But today—with managed care and a climate of diminished time, privacy erosion, and information onslaught—the relationship has become strained. I feel lucky that when I was a young doctor, I was given an inside look into the world of a patient: I was misdiagnosed with a rare cancer. My physicians weren’t at fault. An unusual infection from a tick bite masqueraded as a terminal illness. But none of us had figured out the mystery before I was on the receiving end of painful needles, cold hands, [skimpy] hospital gowns, a surgeon’s scalpel, and anxiety-filled hours of waiting for lab reports. How I was treated, and the inevitable lapses, changed forever the way I take care of my patients (Snyderman 2005, 90). Good communication is essential as physicians and patients work together to build a level of trust that makes both parties comfortable with the doctor-patient relationship. This is especially true in the case of a patient who is facing end-of-life decisions. Regardless of the type of illness, the physician is responsible for ensuring that the patient fully understands the diagnosis, its implications, and available treatment options. When combined with the issues that have arisen as part of the managed care environment, the aforementioned obstacles cited by Dr. Nancy
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Background and History
Snyderman can be tremendous. For a patient who is already bewildered by a frightening diagnosis and concerns about what is to come, the unfamiliar, sterile environment can be a tremendous burden. This environment can be intimidating for many people; even the most articulate adults can find themselves overwhelmed and at a loss for words. To further complicate matters, when the environment is intimidating, medical personnel can become intimidating, as well. If that occurs, a positive doctor-patient relationship can provide the patient with the necessary building blocks to face the obstacles and move forward with making decisions and addressing medical issues. Should Religion Be Part of the Doctor-Patient Relationship?—What, if any, role should religion play in the doctor-patient relationship? Farr A. Curlin, M.D., and Peter P. Moschovis, writing in the Journal of Family Practice, examine patient views on this topic. They cite a “recent multicenter survey of outpatients,” which found that “in the setting of dying,” a majority would appreciate physician inquiries about their religion and would welcome the opportunity to engage in silent prayer. They also state that half of the patients in the survey responded affirmatively to a question about whether the physician should pray with them. Noting that “generic, one-size-fits-all spirituality is inadequate, especially for those patients who are devoutly religious,” they ask the best way for a physician to respond to the religious concerns of a patient. Declaring that these issues “have not been adequately answered,” they posit that “the ethical form and content of legitimate spiritual discussions between patient and physician remain ill defined (Curlin and Moschovis 2004, 633). Religion is different things for different people. For some people, it is not a factor at all; for others, it is merely another obligation to be fulfilled. Some people view religion as a source of comfort in times of stress or strife, whereas others consider it to be the center of their lives. For the latter group, their love for a supreme being, and their deity’s love for them, is a constant; they might view the idea of bringing religion into the healthcare setting as a logical extension of its presence in other facets of their lives. For people who are more casual about their religious beliefs, however, a physician raising the idea of religion could seem intrusive. As a result, clear channels of communication are necessary between the patient and the doctor in this area, as well. Patients who want to make religion part of their medical care may find that
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the most effective way to make that happen may be to raise the issue with the doctor. Doctors, in turn, must communicate their feelings, and comfort level, with the patient in a clear and sensitive manner. For example, if the doctor and patient subscribe to very different belief systems, but both are comfortable with making spirituality part of their relationship, the compromise might be that they talk about spirituality in a more general sense rather than in the context of a particular religion. Health Insurance.—Although many people who have health insurance take it for granted, most of those who lack it consider it a precious commodity. For people who do not have health insurance, life can seem like a tightrope without a net. Situations that result in a quick doctor visit or trip to the emergency room for people with healthcare coverage can become frighteningly ominous situations for people without health insurance: “The kids are really sick and I can’t afford to take them to the doctor. What do I do?” “I fell off my bike and really hurt my back but I can’t afford to go to the emergency room. I don’t know what to do.” Throughout the United States, many full-time workers and some part-time workers acquire health insurance through their employers. In many cases, however, rising insurance costs have increased the amount that many employees must contribute toward this coverage; such increases, unfortunately, make insurance unaffordable for an evergreater portion of the population. An article in the Buffalo News in November 2006 reported on the dramatic increases in insurance costs for residents of New York State from 2000 through 2006: Health insurance premiums rose 5.5 times faster than earnings for New York families during the last six years, according to a report by a health care advocacy group. The rising prices put many at risk of having to forego coverage, the report said. The Families USA study found that health care premiums rose 71.8 percent in New York from 2000 to 2006, while median earnings rose 13 percent. According to the report, New York health care premiums in the last six years rose to $12,183 from $7,090 for family coverage through the workplace. But median earnings for workers in the state in the same period rose to $31,811 from $28,153 (Epstein 2006).
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Background and History
For people who are not even eligible for such insurance coverage through their employers, insurance can remain maddeningly elusive. Paying for it privately can be prohibitively expensive, especially when coverage is required for several people in a family. The result, unfortunately, is that many people remain uninsured and continue to walk that tightrope without a safety net. An article in America magazine used data from the U.S. Census Bureau to illustrate the severity of this problem: The number of people below the U.S. poverty line increased by 1.3 million in 2003. More than 60 percent of the increase was among children under 18 years of age, according to the U.S. Census Bureau’s annual report on income, poverty and health insurance coverage. The Census Bureau also reported a 1.4 million rise in the number of people lacking health insurance . . . (America 2004, 5). A Newsweek article cited statistics from the Children’s Defense Fund to illustrate how serious the lack of health insurance has become for many people throughout the United States. The article highlights the fact that lack of health insurance is more common among some demographic groups than others. The article, which cites 2003–2004 averages, notes that 11 percent of White Americans lacked health insurance, while 20 percent of Black Americans lacked this type of coverage. The percentage was highest among America’s Hispanic population: fully 33 percent of Hispanic Americans lacked health insurance (Ulick 2005, 22). As costs continue to rise, and employers find it increasingly difficult to fund health insurance for employees, the numbers of Americans without health insurance will likely continue to rise among every demographic group. For some policy makers, this issue has risen to the top of the agenda; however, consensus must be reached before the issue can be addressed in a way that will help people without health insurance in a concrete and meaningful way. Such consensus appears impossible at times, given the plethora of plans, ideas, political obstacles, and people involved in the process.
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Spiritual-Social-Cultural Religion When people face end-of-life decisions, they sometimes rely on religious beliefs to help them cope with their fear or give them strength to deal with this uncharted territory. When people are not religious, they sometimes turn to religion as they search for the hope and succor they may require to help them face the issues that arise at the end of life and the dying process. In addition to offering hope, religions may also offer laws or guidelines for people who are facing death. This section examines the ways several religions address issues related to the end of life. Judaism.—Judaism is an ancient religion; as is the case with many other established religions, it offers insight into death and dying from a religious perspective. Essayist Elliot N. Dorff examines this insight in Must We Suffer Our Way to Death? In his essay, Dorff notes that “Jewish law and theology demand that we preserve good health and act as God’s partners in restoring it to the sick” (Hamel and DuBose 1996, 166). Dorff also examines issues related to the taking of a life in the context of the Jewish tradition. Noting that it has always been “technically possible” to kill “oneself or others,” he declares that it is “not surprising that the Jewish tradition, like many others, has much to say about these possibilities” (141). He continues, acknowledging that modern technology further complicates the issue: Among other things, [Judaism] delineates a prohibition against murder, a positive obligation for self-defense, and varying penalties for acts of homicide, depending upon the circumstances. In our time, however, the matter has been complicated by our new ability to sustain almost indefinitely people who would otherwise die (141).
Catholicism.—The Roman Catholic Church is known for its rejection of actions that are considered to interfere with the sanctity of life, including euthanasia. It is important to note, however, that this rejection does not preclude actions that would allow death to occur naturally. The Roman Catholic Church issued The Vatican’s Declaration on Euthanasia, prepared by the Sacred Congregation for the Doctrine of the Faith, in 1980. One section of this document addresses the question of using available technology to prolong
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Background and History
life, noting “it is very important to protect, at the time of death, both the dignity of the human person and the Christian concept of life, against a technological attitude that threatens to become an abuse.” The document goes on to examine the issue of whether it is “necessary in all circumstances to have recourse to all possible remedies” and offers the following: . . . It will be possible to make a correct judgment as to the means by studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources (The Vatican’s Declaration on Euthanasia 1980). In an article for America magazine titled “Catholicism, Death and Modern Medicine,” Lisa Sowle Cahill offers additional insight into the use, or lack thereof, of medical technology from the perspective of the Roman Catholic Church: . . . Not all technologies are equally appropriate and useful, and not all need be used by persons who are ill or approaching the end. The terms “ordinary” and “extraordinary” means of life support are used to differentiate between obligatory and optional treatment. As the Declaration on Euthanasia noted 25 years ago, the terms “proportionate” and “disproportionate” may now be preferable. The key point in the distinction is that various technologies cannot simply be classified according to type; instead they must be judged according to the circumstances of the individual patient (Cahill 2005, 15). Pope John Paul II, born Karol Wojtyla, served as the leader of Roman Catholics throughout the world from 1978 until his death in 2005. During his papacy, Pope John Paul II issued statements affirming that euthanasia remained unacceptable from the perspective of the Roman Catholic Church. As he neared the end of his life, the world watched as he suffered from Parkinson’s disease. A Newsweek article provided a glimpse of that suffering and
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explained why it was important in the context of the Roman Catholic Church: Few people can get close enough to Pope John Paul II to try to read the thoughts behind the mask of sickness . . . but some of those who have approached him say they’ve glimpsed the pain of a man with a vital mind, a man who has loved life enormously, trapped now in a body that brings him nothing but suffering. And yet—because he is the leader of a billion Roman Catholics; because he is the first pontiff of the satellite and Internet age, reaching out to billions more; and because he is John Paul II, who has ruled the church for more than 26 years—in that public experience of suffering lies enormous power. And he knows it (Dickey et al. 2005, 18).
Islam.—Described as one of the “fastest-growing major religions in the world,” Islam is estimated to have 1.4 billion followers throughout the world. Islam affirms the “significant value of persons” and emphasizes that each person is responsible for his or her own body and is “therefore entrusted with the capacities and responsibility to make appropriate decisions when confronting a treatment choice at the end of [his or her] own life or that of a loved one.” In addition, euthanasia is considered a violation of the sacredness that Islamic teachings attach to the “physician’s commitment or covenant to healing” (Campbell 2000, 38). Buddhism.—As an article in the Futurist noted, Buddhism “is based on the teachings of Siddartha Gautama, who became known as the Buddha or ‘the Enlightened one’ and the ultimate objective of the practice of Buddhism is to reach a state of perfect cosmic understanding, loosely translated as enlightenment or Nirvana” (Futurist 2006, 32). In an article addressing euthanasia in the context of religion, author Courtney Campbell delves into the complexities surrounding end-of-life issues for those who follow Hinduism and Buddhism. Noting that suicide is generally anathema for Hindus and Buddhists, Campbell explains that this does not necessarily preclude declining treatment if such a choice is made to “avoid imposing a heavy burden of caregiving on family or friends”
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Background and History
(Campbell 2000, 39). Campbell further examines the role that “physical suffering” may play in end-of-life decision making within this religious realm: When physical suffering impedes self-control and lucidity, it is permissible to shorten life. Pain or lethargy might cloud the awareness and consciousness at death that both Hindus and Buddhists believe is necessary to ensure a [favorable] rebirth. This pattern of reasoning . . . also applies to euthanasia through physician injection or administration of a lethal drug. Hindu and Buddhist scholars have found support for this so-called “active” euthanasia in their traditions by reflecting on the meaning of death as a door to liberation . . . (Campbell 2000, 39).
Unitarian Universalist.—The Unitarian Universalist Association (UUA) is a “religious organization in the United States” which was formed when the Universalist Church of America merged with the American Unitarian Association in May 1961 (Encyclopedia Brittanica Micropædia 2003, 137). It was at the 1988 meeting of its General Assembly that the Unitarian Universalist Association affirmed its commitment to a document titled “The Right to Die with Dignity,” which contained the following resolutions: • That the Unitarian Universalist Association calls upon its congregations and individual Unitarian Universalists to examine attitudes and practices in our society relative to the ending of life, as well as those in other countries and cultures; • That Unitarian Universalists reaffirm their support for the Living Will, as declared in a 1978 resolution of the General Assembly, declare support for the Durable Power of Attorney for Health Care, and seek assurance that both instruments will be honored; • That Unitarian Universalists advocate the right to selfdetermination in dying, and the release from civil or criminal penalties of those who, under proper safeguards, act to honor the right of terminally ill patients to select the time of their own deaths; • That Unitarian Universalists advocate safeguards against
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abuses by those who would hasten death contrary to an individual’s desires; • That Unitarian Universalists, acting through their congregations, memorial societies, and appropriate organizations, inform and petition legislators to support legislation that will create legal protection for the right to die with dignity, in accordance with one’s own choice (General Assembly of Unitarian Universalists, 1988 Proceedings, 74).
Legal-Political Washington v. Glucksberg and Vacco v. Quill. Carl E. Schneider served as the editor of a book titled Law at the End of Life: The Supreme Court and Assisted Suicide (2000). In his introduction to this book, Schneider describes the evolution of assisted suicide from a political question into a judicial one: For a number of years, assisted suicide was the prototype of a (nonpartisan) political question. Almost suddenly, however, this classic political process was transformed into a judicial one by the startling and strongly stated opinions of the Second and Ninth Circuit Courts of Appeals. Now, in a case called Washington v. Glucksberg (and, of course, its companion case, Vacco v. Quill), the Supreme Court has reversed the decisions of the Second and Ninth Circuits (1). These two cases, namely Washington v. Glucksberg and Vacco v. Quill, are important in the modern history of end-of-life issues. They have provided the legal cornerstones for subsequent court battles since the Supreme Court of the United States decided them in 1997. Various legal scholars have analyzed the impact of these decisions on both sides of the right-to-die discussion. One issue in particular has been the subject of a great deal of analysis. It is the concept of double effect. Pain medication is typically used to relieve a patient’s pain and reduce suffering; however, when administered in sufficient doses, it can end the patient’s life. Under this scenario, relieving pain is the primary purpose and
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Background and History
ending life is a secondary one; together, the two are often known as a double effect. Writing in Law at the End of Life: The Supreme Court and Assisted Suicide, Rebecca Dresser examined Washington v. Glucksberg and Vacco v. Quill in an essay entitled “The Supreme Court and End-ofLife Care: Principled Distinctions or Slippery Slope?” Noting that the decisions “upheld the constitutionality of state criminal laws prohibiting assisted suicide,” Dresser opined that the decisions provided ways for people at the end of life to reduce their suffering (Schneider 2000, 83). She seems to be of the opinion that the Court’s permissiveness regarding double effect is intentional: By conferring their approval on [a constitutionally protected interest in obtaining adequate palliative care, including pain medication that could hasten death, and terminal sedation], the Justices [writing for the majority] advanced current efforts to lessen the suffering of dying patients. The Court’s position on palliative care has important implications for patients and clinicians. Although proponents of legalized physician-assisted suicide were disappointed by the Court’s decisions, the Justices did give patients explicit legal authority to control many dimensions of the dying process. And in granting patients this authority, the Justices also shielded clinicians acting to fulfill patients’ choices from legal liability (83). In addition to serving as the editor of Law at the End of Life: The Supreme Court and Assisted Suicide, Carl E. Schneider wrote several essays which appear in the book. In one of these essays, he expresses a point of view that is distinctly different from Rebecca Dresser’s regarding double effect; the crux of his statement seems to be that the Court’s permissiveness of double effect is unintentional: Not only does the court misperceive the motives doctors and patients might have in terminating medical treatment or in seeking relief from pain, it seems not to have considered the consequences of equating those acts with suicide (173).
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Oregon’s Death with Dignity Act Just as the aforementioned Supreme Court decisions are very important in terms of the legal aspects of end-of-life issues and decisions, Oregon’s Death with Dignity Act is a legislative and political milestone in this context. Introduced in Oregon’s Legislative Assembly in 1994 as Measure 16, the bill aimed to provide physicians with a means of prescribing medication to end life to terminally ill patients. The bill limited this option to competent patients who met specific criteria of eligibility. Measure 16 passed but was subsequently blocked by a restraining order; when it eventually became effective in October 1997 (Yount 2000, 34), the Oregon Death with Dignity Act was the first law of its kind in the United States (Foley and Hendin 2002, 144). However, a subsequent bill aimed at repealing it was put before the voters in the election of November 1997. This bid failed; in fact, some said it backfired because it passed by a margin even wider than that of the original measure (Yount 2000, 34). As the only law of its kind in the United States, the Oregon Death with Dignity Act provides Oregonians with the option of choosing to die rather than continuing to suffer from a terminal illness. Not surprisingly, the Death with Dignity Act has been the subject of scrutiny since it was proposed. Individuals and organizations on both sides of the issue have examined it, its implications, and its implementation thoroughly and continuously. Those who favor the right-to-die movement cheer the Death with Dignity Act for providing terminally ill people with a choice about death, but they sometimes cite its safeguards as restrictions or constraints which limit choice. Those who oppose assisted suicide argue that it represents the beginning of a slippery slope for America and that its safeguards do not go far enough to prevent abuse.
References America. 2004. “Census Bureau Counts More Poor and Uninsured.” America 191 (6): 5. “Brain Death.” Leikin, Jerrold B., and Martin S. Lipsky, eds. 2003. American Medical Association Complete Medical Encyclopedia. New York: Random House, 271.
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Cahill, Lisa Sowle. 2005. “Catholicism, Death and Modern Medicine.” America 192 (14): 14–17. Campbell, Courtney S. 2000.“Euthanasia and Religion.” UNESCO Courier 53 (1): 37–39. Curlin, Farr A., and Peter P. Moschovis. 2004. “Is Religious Devotion Relevant to the Doctor-Patient Relationship?” Journal of Family Practice 53 (8): 632–636. Dickey, Christopher, Rod Nordland, Anne Underwood, Robert Blair Kaiser, Edward Pentin, Barbie Nadeau, and Jacopo Barigazzi. 2005. “‘Precious’ Suffering.” Newsweek, 18–23, Atlantic edition. Epstein, Jonathan D. 2006. “N.Y. Families Squeezed by Health Costs.” Buffalo News, November 5, D1. Foley, Kathleen, and Herbert Hendin., eds. 2002. The Case against Assisted Suicide: For the Right to End-of-Life Care. Baltimore, MD: Johns Hopkins University Press. General Assembly of Unitarian Universalists. Proceedings, 74. Hamel, Ronald P., and Edwin R. DuBose, eds. 1996. Must We Suffer Our Way to Death? Dallas, TX: Southern Methodist University Press. Levesque, William R. “Schiavo’s Family Ends Legal Fight.” St. Petersburg Times, October 15, 2003. http://www.sptimes.com/ 2003/10/15/news_pf/Tampabay/Schiavo_s_family_ends. shtml (accessed October 28, 2006). “Major World Religions.” 2006. Futurist, September–October: 32. McKhann, Charles F. 1999. A Time to Die: The Place for Physician Assistance. New Haven, CT: Yale University Press. Olick, Robert S. 2001. Taking Advance Directives Seriously. Washington, DC: Georgetown University Press. Scherer, Jennifer M., and Rita J. Simon. 1999. Euthanasia and the Right to Die. Lanham, MD: Rowman & Littlefield. Schneider, Carl E., ed. 2000. Law at the End of Life: The Supreme Court and Assisted Suicide. Ann Arbor, MI: University of Michigan Press. Slee, Vergil, Debora Slee, and H. Joachim Schmidt. 2001. Slee’s Health Care Terms. 4th ed. St. Paul, MN: Tringa Press.
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Snyderman, Nancy. September 2005. “Bedside Manners.” Good Housekeeping: 90–94. Times Staff Writer. 2004. “Q&A: Schiavo Story Is Long, with Ending Still Unwritten.” St. Petersburg Times, September 24. http://www.sptimes.com/ 2004/09/24/State/QA__Schiavo_story_is_.shtml. Venes, Donald, ed. Taber’s Cyclopedic Medical Dictionary. 2005. Philadelphia, PA: F. A. Davis Company, 1641–1642. Merriam-Webster Dictionary. 1998. Springfield, MA: MerriamWebster, 179, 517. Ulick, Josh. 9/19/2005. “Portrait of the Poor.” (Accessed October 29, 2006). Newsweek: 22–23, Atlantic edition. The Vatican’s Declaration on Euthanasia. 1980. Rome: Vatican. “Unitarian Universalist Association.” Encyclopedia Brittanica Micropædia. Vol. 12. Chicago: Britannica, 2003. Yount, Lisa. 2000. Physician-Assisted Suicide and Euthanasia. New York: Facts on File.
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2 Problems, Controversies, and Solutions
Problems, Controversies, and Solutions Related to End-of-Life Issues
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eath can be a difficult subject to discuss, or even think about. In addition to forcing people to face their own mortality, discussions of death can cause them to examine how satisfied they are with life, worry about family, and face their fears of the unknown. Discussions of euthanasia and physician-assisted suicide raise these issues, but they add myriad other complex points, including those related to autonomy, spirituality, and ethics. In addition to these matters, which cause one’s focus to turn inward, discussions of euthanasia must necessarily consider external issues, including the legality of the action, or lack of action, that would result in death. This chapter examines various problems, controversies, and solutions surrounding euthanasia, including the aforementioned issues of autonomy, spirituality, and ethics. The problems, controversies, and solutions are divided into the categories established in Chapter 1: medical-bioethical, spiritual-social-cultural, and legal-political.
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Differentiating between Key Concepts To begin with, it is important to gain a clear understanding of the terminology relevant to this discussion. There are various nuances within the language of end-of-life issues. These nuances are important because they represent distinctions between actions; they also represent boundaries of acceptability for individuals and groups.
Euthanasia Passive euthanasia is often described as letting someone die. “Letting die” is the operative phrase because it is more about lack of action than taking an action. It can be described as “ceasing or not starting medical treatment that keeps a person alive, such as attachment to a respirator or provision of food and water through a tube.” Active euthanasia, on the other hand, involves an action that “causes the death of a sick person without that person’s participation” (Yount 2000, 4). Active euthanasia, which always involves someone other than the patient actually performing the action, is divided into three types: • Voluntary euthanasia is a form of active euthanasia that is performed at the request of the patient. • Involuntary euthanasia, or “mercy killing” as it is sometimes called, involves taking the life of a patient who has not requested death, with the intent of relieving suffering. • Nonvoluntary euthanasia denotes euthanasia that takes place even though the patient is not competent to give consent. (4)
Assisted Suicide In assisted suicide, the patient is involved. In addition to making the decision to die, the patient participates in the act. As the term implies, someone assists the patient in taking the action to end life. When the person who assists is a doctor, the act is termed physician-assisted suicide. In some cases, the person assisting is a layperson who is sympathetic to the person’s wish to end his or her own life. The person who has chosen to die actually performs the final act, or the act that ultimately results in death (4). It is important to note that some people and organizations active in right-to-die issues consider it anathema to term this suicide
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because it removes the concept of rationality from the action. The term self-deliverance is considered preferable “so as not to correlate the two events, because they believe they are entirely different, with self-deliverance stemming from a rational choice and traditional suicide resulting from emotional or psychological trauma” (Scherer and Simon 1999, 13).
Concept of Rational Suicide When individuals and organizations opposed to assisted suicide argue the issue, they sometimes base a portion of their argument on the concept that it is irrational to end one’s life. Harvey M. Chochiniv and Leonard Schwartz examine this issue in The Case against Assisted Suicide: For the Right to End-of-Life Care. Their essay, titled “Depression and the Will to Live in Terminally Ill Patients,” addresses the risk factors associated with requests for hastened death by people who are terminally ill. They write that such risk factors for people in the advanced stages of disease can include “physical problems, such as pain, delirium, and fatigue” as well as “social factors, such as the extent of emotional or family support; and prior psychopathology and psychiatric history,” and note that “depression is the one factor that has the most empirical support” (Foley and Hendin 2002, 269). Those who argue for the right to assisted death, however, counter that suicide is sometimes a very rational choice. Charles F. McKhann, M.D., explains the concept of rational suicide in his book A Time to Die: The Place for Physician Assistance: Traditional medical and psychiatric thinking considers all suicides to be the product of disturbed mentation, usually depression, and therefore irrational. But the concept of rational suicide, widely held in ancient Greece, is reawakening in our culture. Although it will always apply to only a small minority of all deaths, this concept is rapidly gaining acceptance among patients with terminal illnesses and the physicians who care for them, as well as with medical ethicists and others who concern themselves with end-of-life decisions (McKhann 1999, 44). McKhann states that the concept of rational suicide rests on two foundations:
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1. The desire to avoid unnecessary suffering 2. The desire to exercise one’s autonomy and self-determination He explains that the first is “an essential reason for wishing to have an earlier and more comfortable death” while the second “provides the impetus for actually doing it or asking for help.” McKhann asserts that the criteria for rational suicide are relevant to all forms of assisted dying because “all such actions are initiated by the patient and are similar in many ways” (45, 46).
Medical-Bioethical Issues Concepts and Issues That Arise at the End of Life When a person is reaching the end of life as a result of a terminal illness, numerous problematic issues can arise. For the person facing death, these issues frame the final months, weeks, days, and even hours of life. If the patient is aware, the issues necessitate decision making that can range from simple to agonizing. Decisions on the simpler end of the spectrum can include things like deciding whether to spend a few minutes outside enjoying the sunshine or whether to receive visitors on a given day. On the more agonizing end of the decision-making spectrum, a person with ALS (amyotrophic lateral sclerosis), or Lou Gehrig’s disease, for example, may face a decision about whether to go on a ventilator. Similarly, a person with terminal cancer may face a decision about whether to try one last dose of chemotherapy. Decisions, simple and complex, determine how the remainder of the patient’s limited time will be spent. If the patient is not capable of making decisions and did not indicate wishes in an advance directive document, the decision falls to the person’s health care proxy or family members. For family members watching a loved one suffer and die, each decision can be an agonizing struggle to determine what the person would have wanted. In this context, where life hangs in the balance and death is imminent, end-of-life issues are not academic or theoretical: They are reality. In many cases, they are also subjective. For individuals and organizations on opposing sides of right-to-die issues, these are the issues on which opinions diverge. Terminology, as previously
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noted, is important because it is the language of end-of-life issues and it defines the points at which divergences occur. This is true not only in the macro sense of the societal debate surrounding end-oflife issues, but in the micro sense of a particular family’s struggle to address the approaching end of a loved one’s life. For example, if a loved one is near death and family members disagree about the appropriate course of action, family disagreements and discord can be unnecessarily magnified by lack of understanding regarding medical procedures, terminology related to the end of life, and the ramifications of any wishes the patient may have stated.
Quality of Life Quality of life is a subjective issue that is the topic of intense debate. Although some people who study end-of-life issues argue that quality of life can be measured, at least to some degree, using specific objective standards, others argue that the subjectivity of the concept makes it too amorphous to allow for empirical measurement. The crux of the issue of quality of life is what the individual gains from life. Even for two individuals at the same terminal point of the same debilitating condition, there can be two different answers. One might find the incapacitation of the illness too debilitating to allow for any meaning in life, while the other may view the period of incapacitation as a final chance to bid farewell to family and friends. David W. Kissane addresses the subjectivity of this issue in The Case against Assisted Suicide: For the Right to End-of-Life Care. An excerpt from his essay, entitled “Deadly Days in Darwin,” illustrates just how personal the concept of quality of life is and explains how quality of life can be difficult to assess, especially for family members, as they grapple with the patient’s illness. Research has repeatedly shown how quality of life is appraised differently by patient, caregiver, and clinician. A patient with cancer can adjust to the experience of gradual frailty over time, so long as adequate reassurance is given about the thoroughness of care along the way. Family onlookers can have a more difficult task, especially when the onlookers work or worked in medicine and have a variety of memories of decay, bodily disintegration, and disability, sometimes associated with revulsion and disgust (Foley and Hendin 2002, 204).
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Just as the concept of quality of life is personal, the concept of suffering is equally personal. For some people, there is a point at which suffering becomes too great to bear. For others, suffering is valued in a spiritual sense. For people who decide that their suffering has become unbearable, there are various possibilities. One possibility is that the person simply loses the will to live; for that person, death may be hastened simply because they have decided that it is not worth it to cling to life. A second possibility is that the person could begin refusing any further treatments, including major treatments such as surgery, radiation, chemotherapy, or dialysis. On the other hand, the person could decide to refuse things that many consider more basic, such as nutrition, hydration, or medications. Finally, the person could begin examining the possibilities available to them in terms of ending life. In the absence of an option like Oregon’s Death with Dignity Act, the person may begin examining ways to end his or her own life, either alone or with the assistance of another person.
Who Should Ultimately Decide? Who should decide the circumstances under which medical treatment should be provided—or denied—to a patient? Some have argued that the policy of always working to save a patient’s life is not appropriate and should be replaced by an empirical consideration of the situation to determine the best course of action. In an article in Philanthropy Magazine, Wesley J. Smith writes, “Dr. Donald J. Murphy, a Colorado physician and ethics consultant . . . believes that ‘the community’ should define . . . under what circumstances it is inappropriate for doctors to provide medical treatment.” Murphy was director of the Colorado Collective for Medical Decisions, an organization dedicated to eliminating the uncertainty of this process by establishing protocol to clearly define when certain types of treatment should be withheld or discontinued. The protocol, as proposed by the Colorado Collective for Medical Decisions, would rule the day, regardless of what the patient or family members wanted (Smith 2001). Upon receipt of a grant from a philanthropic organization known as the Colorado Trust, the Colorado Collective for Medical Decisions “[convened] community focus groups intended to determine . . . the public’s attitudes towards end-of-life care.” To the surprise of Dr. Murphy and the members of the organization he headed, the focus group participants rejected the concept
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behind the guidelines. Following this outcome, the Colorado Trust decided to discontinue funding the Colorado Collective for Medical Decisions, which became inactive (Smith 2001). Although Dr. Murphy and the members of the Colorado Collective for Medical Decisions believed that they had developed a solution to determine the type and extent of medical care that should be administered in a given situation, the members of their focus groups rejected their proposal. It seems that, as much as endof-life issues generate discussion, debate, and controversy, the idea of another person or entity making these decisions—without input from the patient, family members, or medical personnel— was anathema to them. Many organizations on both sides of euthanasia and assisted suicide issues disagree about whether patients should have the option of assisted suicide, but few in the United States seem to be of the opinion that neither the patient (or patient’s family, if the patient is incapable of making decisions) nor the doctor should be part of that decision-making process. Rather, organizations and individuals supportive of providing patients with the right to die argue that such decisions should be made by the patient (or patient’s family, as the case may be), with assistance and support from the physician or someone else, while those who oppose euthanasia and assisted suicide argue that life should always be preserved.
Technology In this day and age, physicians can make use of technological innovations that were unavailable to previous generations. Technological innovations include machines, or systems, such as ventilators and cardiac monitors. Technological innovations also include medications and techniques that were discovered as a result of more advanced technology. Examples include certain antibiotics, surgical techniques, and CPR (cardiopulmonary resuscitation). Although these examples may seem mundane, some of them were unavailable even a generation ago. The reality is that these and other innovations make it possible to save lives of people who would have died otherwise. Although patients, family members, and medical personnel might take many technological innovations for granted, some advances introduce a whole new set of issues that all of these parties must face. For example, in the absence of advance directives, the goal is always to save the patient’s life. If a person is critically
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injured in an automobile accident, the emergency medical services (EMS) personnel at the scene will treat the immediate and most critical issues so that the patient can be stabilized and transported to a hospital. Once the patient arrives at the hospital, doctors, nurses, and other members of the medical team assess the situation and try to save the patient’s life using every possible means at their disposal. This might include performing cardiopulmonary resuscitation, performing surgery, administering antibiotics to ward off infection, or placing the patient on a ventilator. If family members arrive at the scene after any of these initial steps have been performed and indicate that the patient had an advance directive indicating that he or she did not wish to have certain procedures performed under certain circumstances, it is too late. The doctors, nurses, and other medical personnel, having cared for the patient to the best of their ability, saved the person’s life. In a scenario like this, technology enabled caregivers to save a life, even if that is not the outcome that patient might have wanted. In addition to technological innovations that are geared to saving life, such as those mentioned above, some technological innovations are geared more to improving life. Examples include knee and hip replacements, prosthetic devices, and certain medications, such as antidepressants. Although innovations like these are generally considered to improve—rather than save—lives, they represent the crossroads where technology and quality of life meet. For an older person who has been shut in for years due to lack of mobility, a hip replacement can mean a new outlook and the end of the idea of giving up on life. For a burn victim who lost a limb, a prosthetic device can mean the end of a heartfelt wish to die. For a person who has faced years of clinical depression and contemplated suicide, an antidepressant can mean the end of such suicidal thoughts and a totally new outlook. In some scenarios, like these, innovations designed to improve life can change the person’s quality of life so much that they ultimately save life.
Issues Related to People with Disabilities The issue of euthanasia can be especially polarizing for people with disabilities and disability advocacy groups. Some people with disabilities view euthanasia or physician-assisted suicide as a means of providing choice in dying and they advocate for legalization. A principal argument from individuals and organizations with this view is that some people with severe handicaps may be
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physically incapable of committing suicide and that denying them assistance with performing the act is unfair to the point of discrimination. On the opposite side, people who oppose legalization of euthanasia or physician-assisted suicide argue that people with disabilities would be especially vulnerable to abuse in this area by doctors and other medical personnel. Quality of life, they argue, is subjective and physicians and others who perceive a patient’s quality of life as low because of his or her disability might place a higher value on their own assessment than the patient’s assessment of his or her own quality of life. Claire Rayner (2000) describes the chasm that separates these groups in an article for New Scientist. The article focuses on the people who attended a forum on euthanasia at the Science Museum in London, England. The forum was held to mark the donation of a “euthanasia machine . . . to the museum . . . by its developer, Dr. Philip Nitschke.” Rayner notes that the speakers represented “various shades of opinion” and were, “to be honest, far less interesting than the audience.” Most striking were the disabled people, who—eloquently and passionately—argued that a society which [legalizes] the killing of sick people, even if it is supposed to be limited to those who actively request it, sends a dangerous message to its members: the lives of those who are sick, in pain, limited in their ability to operate in a self-sufficient manner, are worthless. Their opponents countered that those who are terminally ill, in a state of constant physical as well as emotional and mental pain, have a hellish experience. Modern hospice care does not work for everyone, and anyway isn’t available everywhere. And what of those who are not terminally ill but in a state they find unbearable—[paralyzed], helpless, communicating only with eye blinks, and liable to live so for many years? (Rayner 2000, 31).
Special Concerns for Incompetent Patients There are also unique circumstances in the cases of incompetent patients. Some people, such as those newly diagnosed with Alzheimer’s disease, may have enough advance notice to prepare a living will before they reach a point where they are unable to care for
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themselves and make decisions. For many incompetent patients, however, this is not possible. Newborns with serious birth defects are an example of this; for them and other incompetent patients lacking advance directives, end-of-life decisions must be made by someone else. The medical profession, in the absence of a do not resuscitate (DNR) order or other type of advance directive, uses every possible means to save the patient’s life. This protocol becomes a thorny issue when family members of an incompetent patient would rather let the person die. These cases often end up before hospital ethics committees because the wishes of the family and the protocol of the medical personnel are so diametrically opposed. Many proponents of euthanasia argue that parents, guardians, or other persons charged with the person’s care should have the ability to decide when it is time to end life. These people, they argue, have the best knowledge of the patient so the decisionmaking ability should lie with them. Many opponents, on the other hand, counter that ending lives in this way is tantamount to murder and charge that such a system would be rife with abuse because the patients are unable to speak for themselves. Critics also note that the person charged with making the decision could have ulterior motives to decide a certain way; such motives would create a conflict that could result in taking the patient’s life even if that is not what the patient wanted or would have wanted. Robert S. Olick (2001), author of Taking Advance Directives Seriously, examines the legal aspects of making this type of decision on behalf of a patient: In fact, the substantive standard of choosing as the patient would has been the most controverted and troublesome aspect in life-and-death litigation. The primary reason is that implementing this standard and determining whether to authorize the surrogate to direct forgoing of life support can become a thorny evidentiary question. Couched against the law’s timehonored presumption in favor of life, the burden of proof that the patient would refuse life support rests with the surrogate (15).
Doctor-Patient Relationships Health care has changed in many ways. As a result of managed care, HMOs (health maintenance organizations), PPOs (preferred
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provider organizations), and similar entities have supplanted traditional health insurance plans. This, in turn, has caused a dramatic change in the character of doctor-patient relationships. Instead of seeing a family physician, patients see a doctor who bears a title, such as “designated medical provider,” that reflects the less personal aspects of this system. Patients see an assigned doctor; however, such arrangements often undermine the concept of continuity of care because, in reality, the assigned doctor could be a different person each time. This system impacts patients in many ways. In terms of routine matters, the patient might find it intimidating to talk about difficult subjects, including embarrassing symptoms or problems, with a doctor he or she just met. In terms of more serious matters, such as a diagnosis of a serious illness, the lack of a prior relationship can leave the patient feeling as if he or she is adrift without a trusted medical professional to turn to for advice. In terms of endof-life matters, the results can be catastrophic. The lack of a prior relationship can leave the patient feeling as if he or she is facing death without the benefit of a trusted medical advisor to provide counsel about the best way to navigate the medical aspects of the dying process.
Instances of Euthanasia and Physician-Assisted Suicide Except for the Oregon Death with Dignity Act, there are no laws in the United States that allow physicians to assist patients in hastening death in any way. However, anecdotal reports and other evidence indicate that instances of assisted suicide and euthanasia are clearly not limited to Oregon. In an attempt to quantify this to some degree, several researchers conducted a national survey and published their findings in the New England Journal of Medicine. Their methodology was as follows: “In 1996, we mailed questionnaires to . . . 3102 physicians in the 10 specialties in which doctors are most likely to receive requests from patients for assistance with suicide or euthanasia.” Noting that they weighted the results to “obtain nationally representative data,” the researchers reported the following based on the 1,902 completed questionnaires that were returned to them: Eleven percent . . . said that under current legal constraints, there were circumstances in which they would be willing to hasten a patient’s death by prescribing
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medication, and 7 percent said that they would provide a lethal injection; 36 percent and 24 percent, respectively, said that they would do so if it were legal. Last: 18.3 percent . . . (unweighted number, 320) reported having received a request from a patient for assistance with suicide and 11.1 percent (unweighted number, 196) had received a request for a lethal injection. Sixteen percent . . . receiving such requests (unweighted number, 42), or 3.3 percent of the entire sample, reported that they had written at least one prescription to be used to hasten death, and 4.7 percent (unweighted number, 59), said that they had administered at least one lethal injection (Meier et al. 1998, 1193). What are the ramifications of this? Some cases are never determined to be the result of assisted suicide. Of the cases that come to light, some are prosecuted, with varying degrees of success. Such was the case with Dr. Jack Kevorkian; although he was tried and acquitted three times, his fourth trial resulted in a conviction and prison sentence. Dr. Jack Kevorkian.—For people who might be less familiar with issues surrounding euthanasia and assisted suicide, discussion of these topics often begins with one name: Dr. Jack Kevorkian. Dr. Kevorkian’s methods came under fire from critics who “[decried] his seeming quest for publicity, his idiosyncratic process and criteria for patient selection, his lack of clinical knowledge of the patients’ earlier diseases, and his relatively short-term association with his patients” (McKhann 1999, 83). In addition, even people who agreed with him in principle about right-to-die issues criticized him because “he did not know his patients well and did not take any steps to confirm their diagnoses. This criticism became especially sharp when autopsies on several of the people he had helped to kill themselves showed no sign of physical disease at all” (Yount 2000, 27). Dr. Charles McKhann (1999) cites “three acquittals on murder charges” as proof that “jurors in Michigan felt that [Dr. Kevorkian’s] activities were justified” (83, 84). The acquittals ended, however, when Dr. Jack Kevorkian was tried on charges of first-degree murder in the death of Thomas Youk. The charge came after Kevorkian had “administered a lethal injection to 52-
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year-old Thomas Youk, who suffered from Lou Gehrig’s disease.” In a twist, though, “Kevorkian captured most of the experience, including Youk’s request for death and his own giving of the injection, on videotape. He then sent the tape to CBS’s news program 60 Minutes, which broadcast it to more than 15 million households on November 22, 1998”; the charge of first-degree murder came three days later on November 25, 1998 (Yount 2000, 37). Prosecutors focused on the fact that the tape showed “Kevorkian, not Youk, [administering] the fatal drug dose . . . from a legal standpoint, that fact was the most important difference between the Youk trial and Kevorkian’s three earlier ones, in which he had been acquitted.” Kevorkian’s series of acquittals officially ended on March 26, 1999, when “the jury found Kevorkian guilty of second-degree murder (rather than the firstdegree murder charge demanded by the prosecutor) and delivery of a controlled substance” (Yount 2000, 38). Judge Jessica Cooper subsequently handed down a “10 to 25 year prison sentence for murder.” During the sentencing, Judge Cooper said, “You had the audacity to go on national television, show the world what you did and dare the legal system to stop you. Well sir, consider yourself stopped” (BBC News 2000). The Hurricane Katrina Cases: Euthanasia? Murder? Neither?—A 2005 hurricane named Katrina left a path of destruction nearly unprecedented in the United States: When it made landfall near the Louisiana-Mississippi border on August 29, 2005, wind gusts of more than 125 miles an hour produced storm surges that demolished many coastal communities. Within hours, many homes, roads, bridges, hospitals, and schools in Louisiana, Mississippi, and Alabama were completely destroyed. More than 1,800 people were killed, and hundreds of thousands were left homeless. Since most of New Orleans lies below sea level, it was especially vulnerable. After a storm surge toppled levees, river and lake water poured in, flooding about 80 percent of the city (McCabe 2006, 8). In the midst of this destruction, medical personnel struggled to care for patients in their care, as reported in the Washington Post: “In the flooded city, some of the greatest desperation was at hos-
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pitals and nursing homes where frail people were left without air conditioning, medicine and basic care. Doctors pleaded for helicopters and boats and feared looters.” At Memorial Medical Center, conditions presented an environment that challenged doctors and nurses trying to care for patients: “Temperatures inside Memorial Medical Center rose to 100 degrees, the generators didn’t work, toilets backed up, and nurses had to resort to improvising care.” It was against this backdrop that Dr. Anna Pou and nurses Lori L. Budo and Cheryl A. Landry were accused of murdering four patients: “An investigation into mercy killings during the chaos after Hurricane Katrina has led to the arrests of a doctor and two nurses who allegedly administered lethal doses of morphine and another drug to four New Orleans hospital patients” (Whoriskey and Skipp 2006). Although some law enforcement officials and media termed these acts euthanasia given the circumstances, Charles C. Foti, Louisiana attorney general, said the actions constituted murder. Dr. Pou, Budo, and Landry were arrested and charged with second-degree murder on July 17, 2006. Rick Simmons, Dr. Pou’s attorney, disputed the charges, saying that Dr. Pou had no reason to murder the patients (Whoriskey and Skipp 2006). An article in the New Orleans Times Picayune noted that Simmons declared that Dr. Pou is neither “on the barricades of the ethical debate on euthanasia” nor “‘some advocate for assisted suicide.’” In addition, the article included information from experts indicating that death might not have been the intent of the injections: Morphine and Ativan, one of the drug combinations that a Foti witness says were administered to the patients, is an extremely unreliable way to induce death, pharmacologists and forensic pathologists say. It is used to relax agitated patients and to relieve severe pain (Varney 2006). The Washington Post story included a statement regarding euthanasia from Tenet Healthcare, the company that owns Memorial Medical Center: Tenet Healthcare, which owns the medical center, said, “Euthanasia is repugnant to everything we believe as
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ethical health-care providers, and it violates every precept of ethical behavior and the law. It is never permissible under any circumstances” (2006). In the November 7, 2006, edition of the Greater Baton Rouge Business Report, columnist Jason Berry assailed State Attorney General Charles Foti’s actions in this case. After first examining the concept of euthanasia and whether this crime was related to it, he focused on Charles Foti’s role in the case, noting that the case would actually fall under the jurisdiction of New Orleans District Attorney Eddie Jordan: Three months after the arrests, there have been no indictments. The case now sits with New Orleans District Attorney Eddie Jordan, in whose jurisdiction the deaths occurred. Jordan needs evidence to present to a grand jury. A pivotal factor for Jordan is how Orleans Parish Coroner Dr. Frank Minyard decides to classify toxicology data from lab specimens of the four deceased seniors. Samples have gone to out-of-state labs, with toxicology consultants yet to render opinions. Police can arrest and prosecutors can charge or seek indictments, but only a coroner can classify a death as a homicide. Without that classification, there can be no murder case (Berry 2006). The aftermath of Hurricane Katrina was a nightmare for residents who lived in communities devastated by the destruction. Some have argued that Dr. Pou and nurses Budo and Landry were simply trying to help patients cope with the untenable conditions by providing them with medication to ease their pain and suffering, as well as their fear of the hurricane conditions. Others, however, have argued that these caregivers abused their positions by taking their patients’ lives. Whether these medical professionals are punished or exonerated, this case represents a unique chapter in the ongoing history of end-of-life issues in the United States.
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Role of Physicians Although it is always important for a doctor and patient to have good communication and trust, it is especially important when a patient is facing end-of-life issues and decisions. The doctor can be very helpful in terms of providing information regarding treatment, offering guidance about what to expect, and dispensing advice about ways to deal with problems that may arise. For some patients, there is a point, cited in the quality of life section of this chapter, at which suffering is so great that everything else, including life, has lost meaning. While quality of life is a subjective concept, a theoretical point at which life loses meaning is perhaps the most subjective concept imaginable. For some people, such a point does not even exist; for someone who believes that life is inviolable regardless of the circumstances, there is seemingly no point at which life loses meaning. For a person who believes that such a point exists, the point may come at a certain predetermined time, such as when a specific life-sustaining function cannot be performed without mechanical intervention. For someone who believes that such a point exists but does not have a set point in mind, each day of suffering may equal another step toward a decision that life is intolerable and no longer worth living. For a patient who has reached such a point, the doctor might seem to be the most logical person to turn to for relief in the form of assistance to hasten death. McKhann examines the suggestion that patients should turn to people other than physicians for assistance in dying; he concludes, however, that physicians are the most logical choice: Some who suggest transferring the responsibility [for providing assistance in dying] outside of medicine are opposed to physician-assisted dying in any form and hope that the medical profession will continue to refuse to support or participate in it. But the profession’s opposition is already softening, and there is no need to look beyond our physicians for aid in dying. Many acknowledge having helped people die, and many more indicate willingness to do so, particularly if it were legal (McKhann 1999, 86). How does a physician respond to a patient’s request for aid in dying? Anthony L. Back, M.D., examines issues related to com-
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munication about end-of-life issues in an essay titled “DoctorPatient Communication about Physician-Assisted Suicide,” which appears in Physician-Assisted Dying: The Case for Palliative Care and Patient Choice. In a section on improving communication between doctors and patients about aid in dying, Back notes: Existing recommendations stress the importance of clarifying the request, exploring the reasons underlying it, emphasizing that the patient will not be abandoned, and providing excellent palliative care. First, aid in dying may be a patient concern that is often blocked by physicians. When physicians say that their patients never ask about it, that may be because the physicians themselves block the discussion (Quill and Battin 2004, 112). Back asserts that patients who raise the issue of assisted suicide may actually be less interested in “just a prescription” and more interested in building a “therapeutic alliance” with someone who can “guide them through the dying process”: In dealing with a request for aid in dying, a therapeutic relationship between patient and doctor may be as important as a prescription for physician-assisted suicide. The combination of openness to discussions about assisted suicide and expertise in dealing with the dying process are what makes a continued clinician-patient relationship possible when a patient pursues a hastened death (114).
Double Effect A concept known as double effect “allows physicians to help significantly in the deaths of some patients by giving large doses of narcotics to relieve pain, with the knowledge that respiration will be suppressed and death may ensue” (McKhann 1999, 8). Although it is condemned by some as a way of helping a patient to die by simply turning a blind eye to the notion that death may occur as a result of these drugs, others view it as a sort of de facto middle ground in which death is a secondary result, or double effect, of drugs to relieve the patient’s pain.
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Leon R. Kass, M.D., Ph.D., argues that it is never right for doctors to assist patients in committing suicide. In his essay “‘I Will Give No Deadly Drug’: Why Doctors Must Not Kill,” which appears in The Case against Assisted Suicide: For the Right to End-ofLife Care, Kass says it is ironic that people seek assistance from the “death defying art of medicine”: Because we want to live and not to die, we resort to medicine to delay the inevitable. Yet in some cases, medicine’s success in preserving life has been purchased at a heavy price, pain in the coin of how we die: often in conditions of great pain and suffering, irreversible incompetence, and terminal loss of control. In these circumstances, many Americans increasingly seek great control over the end of life, and some even wish to elect death to avoid the burdens of lingering on. Ironically, they also seek assistance in doing so from the death-defying art of medicine. People no longer talk only about refusing medical treatment. The demands of the day are for physician-assisted suicide and euthanasia (Foley and Hendin 2002, 17). If a patient requests a physician’s assistance in hastening death, how does the physician respond? If such an action is in conflict with the physician’s beliefs, as in the essay by Dr. Kass, the answer would most likely be no. However, as Dr. Back notes, the patient may be looking more for someone to guide him or her through the dying process. Even in refusing to assist a patient in committing suicide, a physician can phrase the refusal in a way that indicates understanding of the patient’s suffering and concerns. In this way, the physician can show that he or she understands the patient’s fears and would be helpful to the patient as a guide through the unknown and sometimes frightening experiences leading to death. Drs. Quill and Battin offer the following guidance on this topic: If a physician is aware of all the last-resort options and is opposed to granting a request for assisted suicide by a particular patient, the physician might explore those options that he or she can support to see whether common ground can be found. Clearly, physicians should
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attempt to extend themselves to remain responsive to such suffering patients and their families, but that should not include violating fundamental personal moral values for either the physician or the patient (Quill and Battin 2004, 327). They conclude with the following caveat that encapsulates the point of their book, which is that palliative care should be available to everyone and that physician-assisted death should be available as a last resort: “It is imperative that we now recognize that the patient’s fundamental moral values may include physician-assisted suicide and that this option, for those who are dying, should be part of recognized law” (327). If the physician is not opposed to assisting a patient with dying, the patient and physician enter into a unique partnership of sorts. In addition to sharing the decision making, they consider the central operational issues: how and when the assistance will happen. McKhann summarizes these issues as follows: Suicide, which is legal, is a private act. Because it requires no interaction with anyone else, it is also the only completely autonomous step that one can take to end life. As soon as a physician is included to assist in any way, autonomy must be shared. The patient shares autonomy in finding a physician who is willing to help and in agreeing on terms, the timing, and the method to be used (McKhann 1999, 229). McKhann also notes that legalization would not mean the end of these and other constraints: “Legalization of assisted dying will introduce specific requirements, including some form of public oversight. The confidential nature of the patient-physician relationship will necessarily be qualified. This invasion of the privacy of both patient and physician is the unavoidable cost of legal approval and protection” (229).
Abuse As McKhann notes, patients who choose physician-assisted suicide give up some degree of autonomy; they share autonomy, in his parlance. Some people cite this sharing of autonomy as creating a potential for abuse. Critics also declare that certain groups,
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including disabled people and incompetent people, are more vulnerable to abuse than the general public. Many opponents cite this potential for abuse as chief among their objections. Felicia Cohn, Ph.D., and Joanne Lynn, M.D., M.A., M.S., assert that concerns regarding another person or persons making decisions about end-of-life issues are not relevant just to those immediately involved; those decisions, they declare, will impact all of us at some point. Their assertions are included in “Vulnerable People: Practical Rejoinders to Claims in Favor of Assisted Suicide,” an essay that appears in The Case against Assisted Suicide: For the Right to End-of-Life Care. Dr. Cohn and Dr. Lynn begin by acknowledging that there are some people for whom physician-assisted suicide holds some degree of appeal and “seems to offer an answer” as well as the ability to “prevent suffering and maintain control over what once seemed uncontrollable” (Foley and Hendin 2002, 238). The flip side, they note, is as follows: For others, however, physician-assisted suicide conjures fear that someone else will determine what is to be considered excessive suffering or costs, and that others might seek to eliminate the suffering or the costs by eliminating those persons who are perceived to be suffering or costly. The elderly and the poor are particularly vulnerable to the effects of inadequate health care resources and the attendant constraints on medical decision making. The issue of physician-assisted suicide, however, is not merely a matter for “other” groups. “The poor” is a lifelong or end-of-life reality for many Americans; “the elderly” is a group that most of us would eventually like to join; and “the dying” is a category we cannot reasonably avoid (Foley and Hendin 2002, 238). Charles F. McKhann, M.D., asserts that, although there are some risks associated with legalizing assisted suicide, the aforementioned objections and concerns are not universal. In addressing some of these concerns in his book A Time to Die: The Place for Physician Assistance, he acknowledges the existence of “understandable concern that legalization of assisted dying will entail risks” but cautions that although some are “immediate and realis-
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tic,” others are “at the remote limits of imagination.” He declares that many of the most common arguments are hypothetical—and, therefore, “impossible to weigh and evaluate in advance.” He further notes the need to evaluate these arguments prior to any sort of legalization (McKhann 1999, 160, 161).
Spiritual-Social-Cultural Issues As noted in Chapter 1, euthanasia, physician-assisted suicide, and other issues related to the end of life do not exist in a vacuum. Spiritual, social, and cultural issues are part of the context in which these issues exist and studying them is a useful part of examining end-of-life issues more fully. This particular area of study is also helpful because it provides information relevant to the context in which people view these issues: For many people, feelings about euthanasia and physician-assisted suicide grow partly from their spiritual or cultural background.
Spiritual Issues Part of the first chapter examined the ways that various religions address euthanasia and physician-assisted suicide, as well as the ways that people may rely on religious beliefs and traditions when they are facing the end of life. This section focuses more on the problems, controversies, and solutions within the realm of religion and spirituality vis-à-vis euthanasia and physician-assisted suicide. It is important to introduce this discussion by clarifying that assisted suicide is not universally condemned by existing religious faiths. Many people mistakenly believe that all religions are united in opposition to such acts. Courtney S. Campbell examines this issue in an article entitled “Euthanasia and Religion” for UNESCO Courier. Noting that “suicide is sinful according to [the monotheistic faiths of Judaism, Christianity, and Islam],” Campbell writes that: . . . Some faith communities in Protestant Christianity and in Reformed Judaism have argued otherwise. When faced with terminal illness, one may well be disposed to ending life, and one’s immediate community (or family) may support this method of death (Campbell 2000, 38).
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Roman Catholic.—Within the Roman Catholic tradition, suffering is considered meaningful. As Pope John Paul II neared the end of his life, his suffering became obvious to the world at large. An article in Newsweek examined what his experience meant for him, for the Catholic Church, and for Roman Catholics throughout the world. Excerpts from the article indicate that Pope John Paul II used his own suffering to teach and to lead: More than 20 years ago, after recovering from the pistol shot that almost took his life in front of St. Peter’s, John Paul declared that suffering, as such, is one of the most powerful messages in Christianity. “Human suffering evokes compassion,” he wrote in 1984, “it also evokes respect, and in its own way it intimidates.” In 1994, as age and infirmity began to incapacitate John Paul publicly, he told his followers he had heard God and was about to change the way he led the church. “I must lead her with suffering,” he said. “The pope must suffer so that every family and the world should see that there is, I would say, a higher gospel: the gospel of suffering, with which one must prepare the future” (Dickey et al. 2005, 18). The Newsweek article also noted that the pope’s remarks, considered controversial by some, likely met with varying degrees of acceptance: “This exaltation of suffering may be difficult for many non-Catholics to understand” (19). For many Catholics, though, the pope’s remarks, and even his suffering itself, served as an affirmation of the Catholic Church’s stance on euthanasia. The fact that the pope had written and spoken frequently during his papacy on the sanctity of life further cemented that stance and his commitment to it. Although the Catholic Church teaches that life is sacred and must be preserved, the church does not require the use of all available technology to preserve life. A 1982 statement issued by the Catholic Health Association explained it in this way: Christians believe that through death life is merely changed, not taken away and that death need not be resisted with every possible means. Dying is a natural part of life that should be made as comfortable as pos-
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sible for the patient and should not be unnecessarily prolonged. Not unduly prolonging the dying process affirms belief in eternal life (Zucker 1999, 104). The Catholic Church is not alone in teaching that it is not required to employ every available technology to preserve life. As Courtney Campbell writes in “Euthanasia and Religion,” “the major faith traditions of the West have rejected a view known as ‘vitalism,’ which holds that biological life is to be preserved at all costs and with all available technologies” (Campbell 2000, 38). Furthermore, the Catholic Church’s teaching that it is not necessary to use every available means of technology to preserve life has resonated with some Catholics, because it provides firm ground for them to stand on if they choose to succumb to the dying process rather than fighting it with every means of technology available. Pope John Paul II’s words about the spiritual value of suffering were controversial to some people outside the Catholic Church and daunting for some within it, but the idea of being able to forego certain types of technology provides patients with a sense of control in making decisions about the dying process within the scope of Catholic teachings. A Lutheran Theologian’s Perspective. James M. Childs, Jr. authored the essay “Anna, Ambiguity, and the Promise: A Lutheran Theologian Reflects on Assisted Death,” which is in Must We Suffer Our Way to Death? In his essay, Childs tells of a woman named Anna, whom he encountered during his seminary days. He tells of his experiences with this psychiatric patient who was “blind, alone, and suffering assorted physical ailments of advanced age.” He writes that he “held her hand, and we prayed for death to come quickly and soon” but he worried that “somehow it was theologically wrong to pray for death” (Hamel and DuBose 1996, 207). His experience illustrates a conundrum that spiritual advisors can face: how to counsel and advise a follower who is suffering and wants to die when the religious tradition in question is neutral, or even opposed, to such a desire to die. Based on his recounting of this experience, it is obvious that Childs was guided by a desire to be humane and compassionate as he counseled Anna and offered her comfort. The memory of Anna stayed with him, causing him to consider how this experience might offer a lesson about despair and hope:
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Perhaps the mystery of Anna’s blend of despair and hope, like that blend in Jesus on the cross, is a signpost to the mystery of the cross as a symbol of both despair and hope; a sign of anguish and healing; a sign of the tragedy of sin, suffering, and death, and a sign of redemption and new life; a sign of our alienation from God and a sign of God taking upon God’s self our suffering and death; a sign of estrangement and a sign of forgiveness and reconciliation (207). Ministers, priests, rabbis, and other spiritual advisers are often called upon to provide words of comfort that will ease a patient’s fears of dying. The notion of being a guide through the dying process is a weighty one and the complexity of the situation may be compounded if the patient is suffering or worried about matters pertaining to life, such as family members who will be left behind. The aforementioned example of Anna illustrates the fact that spiritual advisers face a daunting task in their efforts to provide comfort—and even hope—within the constraints of their religious beliefs and traditions, even as the patient struggles with illness and faces death. Unitarian Universalist Church. The Unitarian Universalist Church has issued public support for “The Right to Die with Dignity” as stated in a resolution passed at the Unitarian Universalist General Assembly in 1988. The resolution acknowledges the differences of opinion that exist among people on this topic, including the fact that some faiths promote prolonging life at all costs, and addresses the notion that abuses may occur. Highlights of the resolution include the following: WHEREAS, differences exist among people over religious, moral and legal implications of administering aid-in-dying when an individual of sound mind has voluntarily asked for such aid; and WHEREAS, many counselors, clergy and healthcare personnel value prolongation of life regardless of the quality of life or will to live; and BE IT FURTHER RESOLVED: That Unitarian Universalists advocate the right to self-determination in dying, and the release from civil or criminal penalties of those who, under proper safeguards, act to
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honor the right of terminally ill patients to select the time of their own deaths; and BE IT FURTHER RESOLVED: That Unitarian Universalists advocate safeguards against abuses by those who would hasten death contrary to an individual’s desires . . . (General Assembly of Unitarian Universalists 1998). Although people may assume that all religions oppose euthanasia and physician-assisted suicide, the Unitarian Universalist church’s stance on this issue demonstrates that some religious organizations allow for more latitude on issues related to providing aid in dying. In addition to supporting the notion that people should have the option to choose assisted suicide, the resolution acknowledges that there are differences of opinion on this issue and urges safeguards against abuse.
Cultural Factors and Traditions The United States is often referred to as a melting pot, meaning that each citizen’s cultural background was added together and mixed to create a blending of culture and traditions. Alternatively, the result is sometimes referred to as a salad bowl: Although everyone’s culture and traditions get tossed together, each remains intact but becomes part of the whole. Whether one views the United States as a melting pot or a salad bowl, the fact is that an individual’s cultural background can be a major determinant of the ways that individual views certain issues. One’s viewpoint on critical issues, such as those related to life and death, are often influenced by culture and cultural traditions, especially in situations where cultural and religious traditions are intertwined. The United States has a diverse population that includes people of many cultures. In some cases, where cultural traditions are part of the patient’s life, they may become part of the patient’s care in some way. Such cultural traditions may be unfamiliar or problematic for medical personnel, who must determine a way to respect these customs if they are to effectively treat the patient. If, for example, a person’s cultural traditions dictate that a dying person is spared the knowledge of impending death, the physician and medical team must address the situation both legally and sensitively. Similarly, if a person’s cultural traditions call for the dying person to be surrounded by family at all times, the physician and
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medical team must determine how to effectively deliver care given the patient’s wishes vis-à-vis that cultural constraint. Culture of Youth. Although the United States has a diverse population that reflects a variety of races, ethnicities, and religions, people share many things in common: One common aspect is that we all age, and another is that we all die. Author and physician Charles F. McKhann says the United States has a mindset which makes aging an especially difficult and intimidating process. Declaring that our culture is “oriented toward youth,” he notes that the “increasing number of aged in the population is often seen as a social embarrassment, a political problem, and a financial liability.” He states one possible reason for this attitude: “The culmination of old age and illness is death, and our society fears death” (McKhann 1999, 107). This culture of youth has marginalized older members of our society in some ways, but the baby boomer generation seems to be challenging that position. The baby boomers represent a large segment of the nation’s population and they are simultaneously challenging the culture of youth and redefining what it means to be middle age and older. The baby boomer generation is establishing itself as a force to be reckoned with and various components of our society are appealing to this generation in new ways. Much of the marketing aimed at this generation, for example, features active, vibrant people who are enjoying life; far from lamenting their age, they seem to relish each new stage of life. This generation has changed the way society views retirees; as the baby boomers age, they will also change the way society views the elderly. In addition, they will likely eventually change the way society views the dying, as well. Baby boomers, as a group, have demonstrated that they are not reticent about identifying problems and working to solve them. If they continue in that vein as members of the baby boomer generation face issues related to death and dying, baby boomers will be vocal about ensuring that their voices are heard and their needs are met as they approach the end of life. Culture of Poverty. Throughout the United States of America, there are people who live in poverty. Poverty is closely linked to poor healthcare because the United States does not have a universal health care system. Health care, therefore, is inextricably linked to one’s ability to pay. Scherer and Simon, in Euthanasia and the Right to Die, address the ways that income affects the availability and quality of health care for patients in the United States:
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. . . [The] United States has developed a health care system that is profit based—a direct-fee system. In this system, the patient is responsible for payment for all treatment or services rendered. Forms of payment for health care include personal financial resources or insurance coverage funded fully or partially through an employer or purchased privately at one’s own expense. Obviously, those with higher incomes can afford to have better medical care than those who are less affluent (Scherer and Simon 1999, 30). As Scherer and Simon note above, health insurance funds health care costs to some extent, but having health insurance often depends on one’s ability to pay for it. For the poorest of the nation’s poor, health insurance may be unattainable. Although some people are eligible to attain health insurance through their employers, the employee contribution that is usually required may prove burdensome enough to keep that coverage out of reach, as well. The poor in our society are vulnerable in many ways, including in terms of health care. When people cannot afford to pay for insurance, their health care may be limited to emergency room visits in dire situations. This kind of care, in which the poor seek medical assistance for only the most serious problems, means that there is generally no preventive care, such as flu shots and/or an annual checkup, where problems may be detected early and treatment begun. The result is that a minor health problem may turn into a catastrophic medical situation before the patient is aware that any problem even exists. Although serious health problems are overwhelming, they are even more problematic for a patient who is poor because the cycle of inadequate care generally continues for poor patients. De Facto Euthanasia. The end result of the worst-case health-care scenario for the poor is de facto euthanasia, a concept that can best be explained by an example. Imagine a scenario in which a 76year-old man, otherwise healthy, falls ill. He does not have health insurance so he visits a local clinic; the diagnosis is cancer. Even if it is not terminal, he cannot afford treatment and he eventually succumbs to the disease that is ravaging his body. This type of scenario is too common in the United States. The lack of health insurance is attributable to a variety of factors, but the result is the
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same: People die because they lack the ability to pay for treatment. Advocates across the country have begun to speak out about this issue, which many have begun to refer to as de facto involuntary euthanasia. It is not active euthanasia or physician-assisted suicide; that is, death did not occur at the hand or with the assistance of another. It occurred because nothing was done.
Legal-Political Issues It is obvious that there are a variety of opinions surrounding euthanasia and physician-assisted suicide. In addition to the medical-bioethical and spiritual-social-cultural components of these end-of-life issues, there are also legal and political issues to consider. Various parties have gone to court in an attempt to resolve these issues in a legal manner; some of these cases have set precedents which are important to note when studying these issues. In addition, end-of-life issues become part of the political realm in various ways, such as when candidates address them in campaigns or elected officials propose legislation in an effort to pass a law regarding some aspect of end-of-life issues.
Legal Issues Issues related to euthanasia and physician-assisted suicide end up in court because the parties are unable to come to an agreement and they seek a legal decision to resolve the issues. However, even the matter of going to court becomes a subject of controversy in some cases because some people believe that rightto-die issues should be decided individually. Although people with such feelings might allow for the possibility of input from the medical community or guidance from a spiritual advisor, the idea of a legal decision is anathema because the very action of involving someone else as the decision maker interferes with one’s autonomy. Is Assisted Suicide a Constitutional Right? Many legal cases regarding right-to-die issues cite the United States Constitution to buttress their arguments. They cite the rights to liberty and privacy, guaranteed under the Constitution, as providing the foundation for one’s right to choose the time and manner in which death should occur. Many of the organizations and individuals in favor of assisted suicide argue that the logical next step is to make the
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right to die a constitutional right. Although legal rulings that favor assisted suicide in some way set precedents which supporters can then cite in future scenarios and cases, making assisted suicide a constitutional right would provide greater protection under the law than legal precedents do. Opponents of assisted suicide, on the other hand, argue just as strongly that assisted suicide should not be made a constitutional right. They cite the potential for abuse as one of the main reasons for their opposition.
Legal Cases Although numerous legal cases have touched on various issues related to euthanasia and physician-assisted suicide, two cases are particularly noteworthy. They have been cited in subsequent legal battles and they form much of the contemporary legal basis for the fact that assisted suicide is not recognized as a legal act in any state other than Oregon. Washington v. Glucksberg. This case, which began in 1994, was originally known as Compassion in Dying et al. v. State of Washington because Compassion in Dying “sponsored and helped to pay for the litigation” when a “group of physicians and . . . terminally ill patients filed suit against the state, claiming that the . . . law against assisted suicide was unconstitutional because it violated the rights guaranteed under . . . the Due Process Clause and the Equal Protection Clause of the Fourteenth Amendment” (Yount 2000, 31). The Glucksberg portion of the name came about because “cancer specialist Harold Glucksberg . . . [was] one of five physicians who agreed to be plaintiffs in Compassion in Dying’s suit” (30). Judge Barbara Rothstein, the chief judge of the Federal District Court for the western part of the state, heard the case. She ruled that “the Washington law violated both clauses of the Fourteenth Amendment and was therefore unconstitutional.” But when the state subsequently appealed the decision, the case went to a three-judge panel of the Ninth Circuit Court of Appeals, which reversed Judge Rothstein’s ruling. As a result of an appeal by Compassion in Dying and the other plaintiffs, “the full 11judge panel of the appeals court heard the case” and overturned the decision of the three-judge panel (31). Vacco v. Quill. In the meantime, a New York case was wending its way through that state’s judicial system. The case began as Timothy E. Quill v. G. Oliver Koppell, or Quill v. N.Y. Attorney General. It was so named because Timothy E. Quill “was the physi-
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cian and right-to-die advocate who had achieved fame after describing his role in the assisted suicide of ‘Diane.’” The name by which the case is known was subsequently changed because Dennis Vacco replaced Koppell as New York’s state attorney general. Similar to the case in Washington, the New York case involved physicians and patients who filed suit citing the unconstitutionality of state law. Judge Thomas Griesa disagreed and ruled against them. The plaintiffs appealed and the case went before the Second Circuit Court of Appeals; this panel found in favor of the plaintiffs (Yount 2000, 31, 32). Washington v. Glucksberg and Vacco v. Quill. Both Washington and New York, dissatisfied with the rulings against them, appealed their cases to the Supreme Court of the United States, which determined the cases would be heard together. Although “it was clear to even the most ardent supporters of assisted suicide that the Supreme Court was unlikely to agree with their claim that there was a ‘constitutional right to die,’” both sides were anxious as they awaited the decision (Yount 2000, 32). As with almost all cases before the Supreme Court, there was a great deal of passion and emotion on both sides. Supporters and opponents added to the overall chaos of the situation, with various organizations staging demonstrations outside the courthouse to show their stances on the cases. Given the fact that many people on both sides of the issue felt that the Court would side with the states of New York and Washington, the Court’s decision that the state laws were constitutional was not entirely unexpected (33). However, Chief Justice William Rehnquist, writing for the Supreme Court, concluded the ruling with the following words that resonated with the right-to-die community: His words were considered a silver lining even though the decision conflicted with the outcome they had sought: Throughout the Nation, Americans are engaged in earnest and profound debate about the morality, legality and practicality of physician-assisted suicide. Our holding permits this debate to continue, as it should in a democratic society (McKhann 1999, 216).
Oregon’s Death with Dignity Act. Oregon voters who went to the polls in 1994 faced a ballot question known as Measure 16, the Death with Dignity Act. The language was such that it provided
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voters with a different way of looking at the issue and kept the focus narrowed on a very tightly defined topic: Technically, the proposal did not even legalize assisted suicide. Rather, it defined activities that fit within its guidelines as not being assisted suicide and, therefore, not breaking the state’s existing law against assisting a suicide (Yount 2000, 30). The vote, however, was not allowed to stand for long: The Oregon referendum took an unexpected turn, the legality of which was not clear, when the state legislature insisted on having a second referendum on the same question. This was held in November 1997, with the surprising result that 60 percent of the voters favored physician-assisted suicide. Some observers have suggested that the large majority resulted from voter resentment of outside pressure (McKhann 1999, 210). Implementation of Oregon’s Death with Dignity Act As it was implemented, Oregon’s Death with Dignity Act has several provisions which are intended to serve as safeguards, including: • An adult who is capable, is a resident of Oregon, and has been determined by the attending physician and consulting physician to be suffering from a terminal disease, and who has voluntarily expressed his or her wish to die, may make a written request for medication for the purpose of ending his or her life in a humane and dignified manner in accordance with ORS 127.800 to 127.897. • No person shall qualify under the provisions of ORS 127.800 to 127.897 solely because of age or disability. [1995 c.3 §2.01; 1999 c.423 §2] • In order to receive a prescription for medication to end his or her life in a humane and dignified manner, a qualified patient shall have made an oral request and a written request, and reiterate the oral request to his or her attending physician no less than fifteen (15) days after making the initial oral request. At the time the qualified
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patient makes his or her second oral request, the attending physician shall offer the patient an opportunity to rescind the request. [1995 c.3 §3.06] A patient may rescind his or her request at any time and in any manner without regard to his or her mental state. No prescription for medication under ORS 127.800 to 127.897 may be written without the attending physician offering the qualified patient an opportunity to rescind the request. [1995 c.3 §3.07] No less than fifteen (15) days shall elapse between the patient’s initial oral request and the writing of a prescription under ORS 127.800 to 127.897. No less than 48 hours shall elapse between the patient’s written request and the writing of a prescription under ORS 127.800 to 127.897. [1995 c.3 §3.08] Only requests made by Oregon residents under ORS 127.800 to 127.897 shall be granted. Factors demonstrating Oregon residency include but are not limited to: (1) Possession of an Oregon driver license; (2) Registration to vote in Oregon; (3) Evidence that the person owns or leases property in Oregon; or (4) Filing of an Oregon tax return for the most recent tax year. [1995 c.3 §3.10; 1999 c.423 §8] * [Reporting requirements]: (a) The Department of Human Services shall annually review a sample of records maintained pursuant to ORS 127.800 to 127.897. (b) The department shall require any health care provider upon dispensing medication pursuant to ORS 127.800 to 127.897 to file a copy of the dispensing record with the department. The department shall make rules to facilitate the collection of information regarding compliance with ORS 127.800 to 127.897. Except as otherwise required by law, the information collected shall not be a public record and may not be made available for inspection by the public. The department shall generate and make available to the public an annual statistical report of information collected under subsection (2) of this section. [1995 c.3 §3.11; 1999 c.423 §9; 2001 c.104 §40]
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• Nothing in ORS 127.800 to 127.897 shall be construed to authorize a physician or any other person to end a patient’s life by lethal injection, mercy killing or active euthanasia. Actions taken in accordance with ORS 127.800 to 127.897 shall not, for any purpose, constitute suicide, assisted suicide, mercy killing or homicide, under the law [1995 c.3 §3.14]. (State of Oregon, Department of Human Services, Legislative Statutes) Critics argue, however, that the safeguards are not enough. Kathleen Foley, M.D., and Herbert Hendin, M.D., (2002) editors of The Case against Physician-Assisted Suicide: For the Right to End of Life Care, authored the essay “The Oregon Experiment,” which appears in their book. They argue that the Oregon Health Division (OHD), “charged with monitoring the law,” has “interpreted its mandate” in a “restrictive manner” and offer several objections, including the following: OHD limits its yearly reports to general epidemiological data and collects limited information from physicians who have prescribed lethal medication. Physicians who declined to prescribe the lethal medication, as well as nurses and social workers who cared for the patients, are not interviewed. Not all the information collected is made public, and OHD defends its limited data collection and censorship of released information as necessary to protect doctors’ and patients’ confidentiality. There is no provision for an independent evaluator or researcher to study whatever data are available. This OHD process has prevented a full and open discussion (144–145). Foley and Hendin address the requirement that a second physician evaluate the person who wishes to die by noting that “no provision is made for the independent selection of this consulting physician” and stating, “Unless the selection is truly independent, the consultant, even if not a colleague of the attending physician, is likely to be a known proponent and practitioner of assisted suicide” (150). A question about an “informed decision” is also raised. Foley and Hendin declare:
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Without a proper psychiatric evaluation, it is not possible even to ascertain if a patient has impaired judgment that would make him or her not “capable” of an “informed decision” as required by Oregon law (153).
Making One’s Wishes Known Advance directives provide people with a means to let physicians, loved ones, and any other relevant parties know what their wishes are for care at the end of life. Absent such a document, family members must try to determine what the person might have wanted in a given situation. In addition to being nearly impossible given the countless permutations of medical situations one might encounter and types of care available at the end of life, it is very difficult to make such a determination when a loved one is dying. Robert S. Olick (2001), author of Taking Advance Directives Seriously, notes that such difficult situations have led to the current state of acceptance of advance directives: “The quest for responses to this dilemma and the value we attach to dying on our own terms has led to widespread acceptance of advance directives in the medical, legal, and academic communities and throughout society.” Olick goes on to say that as a result of this widespread acceptance of advance directives, “ . . . all 50 states and the District of Columbia have enacted legislation recognizing the right to plan ahead for important decisions near the end of life at a time of future decisional incapacity by executing an advance directive” (xiv). Olick admits, however, that enforcement remains a problem: . . . [The] law has yet to develop the teeth of enforceability. It has not lived up to the maxim that for every right there is a remedy, and it has given clinicians reason to believe that there is little or no price to pay for disregarding a patient’s directive. The same is true of the law’s response to family members who resist following a patient’s directive (28). Living wills provide another way for people to make their end-of-life wishes known. The St. Petersburg Times reported a dramatic increase in interest in living wills in response to the Terri Schiavo case. The newspaper article cautioned, however, that living wills that do not address specific issues might still leave prob-
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lematic questions for family members to face: “ . . . [Lawyers] familiar with living wills say just having a living will may not be enough. Not all such documents answer crucial questions— specifically whether or not a feeding tube should be removed under certain circumstances” (Sandler 2005). Given the range of illnesses, accidents, and conditions that can affect human beings, it is basically impossible to cover every possible situation that could arise. However, a living will provides a valuable starting point. The Schiavo case, far from answering all of the possible questions that could face the family of a suffering patient, raised countless new questions. The mere fact that the case prompted so many people throughout the nation and the world to make their wishes known is important because for people who did not previously have a living will, just creating the document provides answers to questions that family members might face at some point in the future. The aforementioned article in the St. Petersburg Times describes the extent of new interest from “thousands of people once unfamiliar” with living wills: “We are overwhelmed,” said Dr. Joseph Barmakian, founder of the U.S. Living Will Registry. The registry . . . electronically stores advance directives, organ donor information and emergency contact information, and makes [the information] available to health care providers across the country 24 hours a day . . . Barmakian . . . said the Web site traditionally has 500 hits a day. This week, it has had more than 30,000 on some days (Sandler 2005).
References BBC News. “‘Dr. Death’: Pushing the Law.” Health Briefings. November 28, 2000, http://news.bbc.co.uk/1/low/health/ background_briefings/euthanasia/331269.stm (accessed November 18, 2006). Berry, Jason. “Foti’s Crusade.” Greater Baton Rouge Business Report. November 7, 2006, http://www.businessreport.com/news Detail.cfm?aid=10036&cid=25 (accessed November 18, 2006).
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Campbell, Courtney S. 2000. “Euthanasia and Religion.” UNESCO Courier 53 (1): 38. Dickey, Christopher, Rod Nordland, Anne Underwood, Robert Blair Kaiser, Edward Pentin, Barbie Nadeau, and Jacopo Barigazzi. “‘Precious’ Suffering.” Newsweek, February 28, 2005, 18–23. Foley, Kathleen, and Herbert Hendin. 2002. The Case against Assisted Suicide: For the Right to End-of-Life Care. Baltimore, MD: Johns Hopkins University Press. General Assembly of Unitarian Universalists. 1988 Proceedings, 74. Hamel, Ronald P., and Edwin R. DuBose. 1996. Must We Suffer Our Way to Death? Dallas, TX: Southern Methodist University Press. McCabe, Suzanne. 2006. “Hurricane Katrina: One Year Later.” Junior Scholastic, September 4, 7–9. McKhann, Charles F. 1999. A Time to Die: The Place for Physician Assistance. New Haven, CT: Yale University Press. Meier, Diane E., Carol-Ann Emmons, Sylvan Wallenstein, Timothy Quill, R. Sean Morrison, and Christine K. Cassel. 1998. “A National Survey of Physician-Assisted Suicide and Euthanasia in the United States.” New England Journal of Medicine 338 (17): 1193–1201. Olick, Robert S. 2001. Taking Advance Directives Seriously. Washington, DC: Georgetown University Press. Quill, Timothy E., and Margaret P. Battin., eds. 2004. PhysicianAssisted Dying: The Case for Palliative Care and Patient Choice. Baltimore, MD: Johns Hopkins University Press. Rayner, Claire. 2000. “You Say Murder, I Say Euthanasia.” New Scientist, June 19, 31. Sandler, Michael. “Case Has Created Sudden Interest in Living Wills.” St. Petersburg Times, March 26, 2005, http://www. sptimes.com/2005/03/26/news_pf/Tampabay/Case_has_ created_sudd.shtml (accessed November 16, 2006). Scherer, Jennifer M., and Rita J. Simon. 1999. Euthanasia and the Right to Die. Lanham, MD: Rowman & Littlefield. Smith, Wesley J. “Philanthropy’s Brave New World: Will Those Who Give Decide Who Should Live?” Philanthropy Magazine, January 1, 2001, http://www.philanthropyroundtable.org/ article.asp?article=1013&paper=0&cat=147 (accessed November 17, 2006).
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State of Oregon, Department of Human Services. Legislative Statutes, http://oregon.gov/DHS/ph/pas/docs/statute.pdf (accessed October 22, 2006). Varney, James. “Doctor’s Drug Mix Not Ideal Killer.” New Orleans Times Picayune, August 6, 2006, http://www.nola.com/ news/t-p/frontpage/index.ssf?/base/news–6/1154844156102520. xml&coll=1&thispage=1 (accessed November 18, 2006). Whoriskey, Peter, and Catharine Skipp. “3 Arrested in New Orleans Hospital Deaths.” Washington Post, July 19, 2006, http://www.washingtonpost.com/wp-dyn/content/ article/2006/07/18/AR2006071800448_pf.html (accessed November 18, 2006). Yount, Lisa. 2000. Physician-Assisted Suicide and Euthanasia. New York: Facts On File. Zucker, Marjorie B. 1999. The Right to Die Debate: A Documentary History. Westport, CT: Greenwood Press.
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3 Worldwide Perspective
Examining Euthanasia throughout the World
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learly, the United States is not alone in grappling with euthanasia, physician-assisted suicide, and other end-of-life issues. Countries throughout the world have addressed these issues in some fashion; their experiences help fill in the emerging picture of this issue on a worldwide scale.
Data on a Global Scale When studying issues related to death and the end of life throughout the world, it is important to note that the quality and reliability of data varies. The Bulletin of the World Health Organization featured an article on global death data. Through their research, the article’s authors “sought to assess the current status of global data on death registration and to examine several indicators of data completeness and quality.” The authors’ basic conclusion was that “few countries have good-quality data on mortality that can be used to adequately support policy development and implementation.” They cited “an urgent need for countries to implement death registration systems . . . or enhance their existing sys-
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tems . . . to . . . improve knowledge about the most basic of health statistics: who dies from what?” (Mathers et al. 2005, 171). As noted in the article, “good-quality data on mortality . . . can be used to adequately support policy development and implementation” (171). End-of-life issues, as a policy area, would clearly benefit from this type of data quality. In addition to allowing researchers to more accurately gauge how certain diseases and conditions impact the population, such data would make it easier to determine compliance with existing laws. The article provides a clear breakdown of the quality and completeness of the data available for each country. The findings are summarized as follows: . . . Death registration is considered to be essentially 100% complete in only 64 of the 115 countries reporting data, and predominantly these are developed countries in Europe, the Americas and the Pacific regions (173). The authors make it clear that quality data is an important building block in efforts to examine health care, disease, death, and issues related to the end of life throughout the world.
Studying Euthanasia and End-of-Life Issues throughout the World The issue of euthanasia does not exist in a vacuum in other countries any more than it does in the United States. In this section, the stances of several countries on euthanasia and other end-of-life issues are covered in separate listings. In order to help place these issues in the proper context, information about health care, euthanasia history, and relevance to the United States is included with each country’s listing.
United Kingdom Officially known as the United Kingdom of Great Britain and Northern Ireland, the UK consists of England, Scotland, Wales, and Northern Ireland. London being its capital city, England has a
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diverse population. Christianity is a prominent religion and a significant portion of the population follows Islam.
Health Care Health care services in the United Kingdom, as in many European countries, are quite different from the system currently in place in the United States. The United Kingdom offers a “comprehensive social-security system” which “provides cash benefits for sickness . . .”; in addition, the National Health Service, which was established in 1948, “offers free medical treatment to all citizens through a network of about 2,400 hospitals” (Encyclopedia Britannica Micropædia 2003, v. 12, 144). Infant mortality rates for the United Kingdom are described as “relatively high for a developed country.” Overall “life expectancy is 72 years for males and 78 years for females (142).
Euthanasia History Britain’s history in this area includes the formation of the British Voluntary Euthanasia Society in 1935. Founded by Lord Moynihan and Dr. Killick Millard, the organization offered a publication called A Guide to Self-Deliverance, which included guidelines on committing suicide. The publication resulted partly from members’ frustration with what they perceived as lack of assistance from the medical community for their efforts. Although the organization agreed to limit distribution to members at least twenty-five years of age, A Guide to Self-Deliverance was to become especially controversial because “the Suicide Act of 1961 called for imprisonment for a period of up to fourteen years for anyone who assisted suicide, and it still was questionable as to whether disseminating information about how to successfully complete the act was technically assisting suicide.” Another publication followed in 1980 when the Voluntary Euthanasia Society of Scotland broke away from the British Voluntary Euthanasia Society. The new society’s How to Die with Dignity was the first publication of its kind in the world (Scherer and Simon 1999, 61). In more recent developments, Dignitas, an organization based in Switzerland, urged the United Kingdom to relax existing suicide laws so that people facing chronic depression could choose assisted suicide as a means of ending their lives. Ludwig Minelli, head of the organization, said in an interview in All Headline News,
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“The question for politicians in Britain today is why do you force your citizens, people in the most terrible circumstances who are determined to end their suffering in a way of their own choosing, to leave their country and travel to Switzerland to exercise their free will” (Roque 2006). Minelli’s words drew attention from individuals and organizations who shared his views, as well as from those who disagreed with him. James Le Fanu, writing in the Telegraph, declares “ . . . the protracted campaign in [favour] of voluntary euthanasia seems to be over,” so traveling to Switzerland for assistance in ending one’s life continues. He points out that UK laws prohibit assisting someone with committing suicide and that anyone who chooses to do so risks fourteen years in prison. Citing an article “by Dr. David Garwood in the medical journal Update,” however, he reveals that while assisted suicide remains illegal in Britain, that does not mean it is impossible to obtain, “so long as those seeking it have the necessary funds (around £3000), and a partner willing to take them abroad” (Le Fanu 2006). Making the trip to Switzerland may not be a necessary step for everyone in Britain, however. It seems that some patients have succeeded in finding physicians willing to assist them in ending their lives, despite the fact that it is illegal, according to a 2006 article in the Guardian. The article reported on a study conducted by Professor Clive Seale, of west London’s Brunel University, which showed that “doctors help about two-thirds of terminally ill patients to die by withholding treatment or giving them painkillers they know will shorten life—but do it only when they believe death is a few days away and after consulting patients, relatives or other doctors.” The article noted Professor Seale’s assertion that his research showed that “in Britain doctors take a more cautious approach than elsewhere” and “the degree to which life is shortened in the UK is very low [while] consultation with patients and relatives and colleagues is fairly high” (Boseley 2006).
Relevance to the United States Like the United States, the United Kingdom continues to grapple with end-of-life issues in various ways on several fronts. There are some similarities. For example, both nations are home to organizations representing both sides of the assisted suicide and euthanasia debates. In addition, research and anecdotal reports in both the United States and the United Kingdom document the fact that
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assisted suicide, including physician-assisted suicide, occurs to some degree even where it is not legalized. The health care system in the United Kingdom is very different from that in the United States. Examining these differences is an important part of fully understanding the differences between the countries in terms of issues related to the end of life. The United Kingdom’s National Health Service addresses many of the issues that face Americans who do not have health insurance. For example, an American without health insurance may delay a visit to the doctor, even when it is very clear that there is something wrong, because of an inability to pay for the visit. A resident of the United Kingdom, though, can make use of the National Health Service to visit the doctor and determine the root of the problem in a more timely fashion. Despite the obvious advantage for a resident of the United Kingdom who may be able to obtain necessary care more quickly regardless of ability to pay, the country’s system does not seem to be a cure-all, either. An article by Donald Light, Ph.D., in the American Journal of Public Health, notes that some people in the ongoing debate over the health care system in America cite problems with the National Health Service, including “low salaries, rundown facilities, poor quality, and endless waits to see a doctor” (Light 2003, 25). The article, however, cautions that these problems are no reason to reject the National Health Service out of hand, provided that funding levels are adequate: “Most of the . . . dreary features . . . stem from chronic underfunding and undersupply of personnel and equipment” (Light 2003, 25). What lessons does the National Health Service offer for those who are trying to reform health care in the United States? Clearly, although it is paramount to have a well-designed system, it is also crucial to have an adequately funded system. As people throughout the United States struggle with the problems that arise from a lack of health insurance, it is disingenuous to think that a universal healthcare system would automatically solve all of the healthcare problems and issues that arise for Americans. Britain’s National Health Service is an example of the fact that problems, including those related to funding, never completely disappear. Whatever solution is devised to serve Americans, the British National Health Service teaches us that good design and adequate funding are merely two of the elements necessary to create a system that works and meets the healthcare needs of residents.
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Netherlands The Netherlands, also called Holland, is officially known as the Kingdom of the Netherlands. Amsterdam is the capital and the “seat of government is The Hague.” Although the people are mostly Dutch, other groups, including Turks, Moroccans, and Germans, also make up sizable portions of the population. Many people, perhaps as much as one-third of the nation’s population, are not affiliated with any religion and the remainder of the people are approximately equally split between Roman Catholics and Protestants. Life expectancy is considered high, at 74 years for males and 80 for females (Encyclopedia Britannica Micropædia 2003, v. 8, 615).
Health Care Health conditions in the Netherlands are considered to be comparable with health conditions in other developed countries. The country’s social welfare programs “include . . . reimbursement of exceptional medical expenditures for all residents,” while employed workers receive “health benefits and services” (616).
Euthanasia History Since 1973, physicians in the Netherlands have assisted patients with committing suicide sans fear of prosecution—as long as certain conditions exist. After 28 years of allowing such actions de facto, the Dutch parliament moved to allow them de jure, with the passage of a statute that “formally legalized euthanasia and physician-assisted suicide” (Foley and Hendin 2002, 97). Today, the legal status of euthanasia and physician-assisted suicide in the Netherlands is celebrated by those in favor of the right to die and assailed by those who oppose it. Organizations on both sides of the issue frequently cite the Netherlands as an example: Those who favor the right to die hold the country up as a haven where people who are suffering have an option to choose death on their own terms. Those who oppose it claim the Netherlands is an environment in which patients are vulnerable and abuse is rampant. Even the genesis of the practice, and the subsequent law, is somewhat controversial. Jennifer Scherer and Rita J. Simon, in Euthanasia and the Right to Die, cite the trust in doctor-patient relationships as one of the building blocks of the law: The unique situation that exists with euthanasia and physician-assisted suicide practices in the Netherlands
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is due to an unusual combination of historical factors in the development of the trusting physician-patient relationship and the extraordinary level of health care available to all citizens. Economics does not influence medical decisions at the end of life, as the medical institutional system does not stand to profit from these choices and the family of the patient is not burdened with health care expenses . . . (Scherer and Simon 1999, 54). Herbert Hendin, M.D., in an essay in The Case against Assisted Suicide: For the Right to End-of-Life Care, describes the situation in the Netherlands much less benevolently. He posits that the Dutch are on a slippery slope. The “slippery slope” is the gradual extension of assisted suicide to widening groups of patients after it is legally permitted for patients designated as terminally ill. In the past three decades, the Netherlands has moved from considering assisted suicide (preferred over euthanasia by the Dutch Voluntary Euthanasia Society) to giving legal sanction to both physicianassisted suicide and euthanasia, from euthanasia for terminally ill patients to euthanasia for those who are chronically ill, from euthanasia for physical illness to euthanasia for psychological distress, and from voluntary euthanasia to nonvoluntary and involuntary euthanasia (Foley and Hendin 2002, 101).
Relevance to the United States With the exception of Oregon’s Death with Dignity Act, the United States does not have any laws in place to allow for any type of assistance with ending life. The Netherlands, therefore, is thought to offer a unique body of knowledge, research, and experience from which the United States should learn. Exactly what the United States should learn, however, depends on whom one asks. For people who advocate end-of-life options and choices, including euthanasia and/or physician-assisted suicide, the Netherlands offers an example of how legalization enables doctors and patients to work together in allowing patients to make choices about when and how suffering should end. For those opposed to euthanasia and physician-assisted suicide, the Netherlands offers an example
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of abuses and an illustration of a country sliding down a slippery slope towards an environment in which assistance in ending life is available to anyone who simply no longer wishes to live.
Australia The Commonwealth of Australia, whose capital is Canberra, has a very homogeneous population as a result of immigration policies that remained in effect until the latter part of the twentieth century. When the policies were relaxed in the 1960s and 1970s, immigrants began entering the country in much greater numbers. Christianity is the principal religion, and Roman Catholics and Anglicans make up the greatest portion of the population. Australia has enjoyed substantial population growth since the end of World War II; this population growth has been attributed to immigration: The country’s low birth and death rates, comparable to those of other developed countries, have contributed only a modest natural increase to the population. Life expectancy, at 73 years for males and 79 years for females, is among the highest in the world (Encyclopedia Britannica Micropædia 2003, v. 1, 712).
Health Care Australia’s health conditions are considered very favorable. The country’s “high levels of nutrition, sanitation, disease control, and medical technology prevent the development and spread of infectious diseases.” In addition, Australia has “a high proportion of doctors and hospital beds to population and a low infant mortality rate.” The federal government administers a universal health insurance program (713).
Euthanasia History Euthanasia was legal in Australia’s Northern Territory for nine months. During this period, which lasted from July 1996 until March 1997, four people availed themselves of this law. Three others died before they could finalize their own attempts to make use of it (Foley and Hendin 2002, 9; Scherer and Simon 1999, 75). The law, known as the Rights of the Terminally Ill Act (ROTI), was
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passed by the Northern Territory government. In Euthanasia and the Right to Die, authors Jennifer Scherer and Rita J. Simon note that the passage of such a law was not exactly shocking given the character of the Northern Territory: It is not at all surprising that the law had its origins in this crocodile-infested, sparsely populated, rugged area that is twice the size of the state of Texas. The Northern Territory has been self-governing since 1978 and has enjoyed a reputation as a trailblazer, often asserting itself through maverick, rebellious tendencies and legislation. A prime target of this free-spirited and free-thinking region is the Australian federal government. Although the federal government is among the largest employers in the region, Territorians remain highly antagonistic toward being told what to do by outsiders (Scherer and Simon 1999, 75). Marshall Perron and Dr. Philip Nitschke emerged as central figures in the passage of ROTI. Perron, who led the Northern Territory government at that time, began the process when he introduced the legislation. Interestingly, he “resigned his government position the morning the euthanasia debate began,” declaring that “he did not want the vote to be influenced by that position.” His explanation, however, was not universally accepted: “Some observers . . . claim that he resigned in order to sway undecided votes to his side” (Scherer and Simon 1999, 75–76). Nitschke’s involvement began when he stated that he would not be opposed to assisting patients with euthanasia. His statement was in direct conflict with the position of the Northern Territory chapter of the Australian Medical Association. From that day, he became a constant media personality campaigning for the introduction of the regulations and availability of the act. Patients began to seek him out for assistance in accessing the ROTI Act, and he developed what he called his “deliverance machine,” a computer that asked patients to confirm their intention to die and wish to proceed by further pressing the computer’s spacebar (Foley and Hendin 2002, 195).
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The Rights of the Terminally Ill Act was repealed when the Euthanasia Laws Bill of 1996, introduced by Kevin Andrews, was passed. In a vote in which “parliamentarians were permitted a conscience vote rather than having to vote with their parties . . . the Commonwealth Parliament strongly upheld the bill that rescinded the ROTI Act” (205, 206).
Relevance to the United States Australia’s limited experience with euthanasia demonstrates how representatives elected by voting citizens can have very different views on what the public wants. Marshall Perron introduced the Rights of the Terminally Ill legislation and it passed; Kevin Andrews subsequently introduced legislation to overturn it, which also passed. Although the fact that both pieces of legislation passed might seem contradictory, two factors merit consideration. First, implementation of Perron’s legislation had given other elected representatives the opportunity to observe exactly what would occur with such legalization in place. It is possible that some realized that they (or their constituents) did not agree with the realities of legalization and chose to vote in favor of Andrews’ legislation. Second, this implementation gave advocacy groups on both sides of the issues the opportunity to rally their supporters, shore up their arguments, and make their opinions known. Strong lobbying undoubtedly was a factor in the passage of Andrews’ bill. Australia’s experience illustrates that the United States is not alone in addressing end-of-life issues. Like some of their American counterparts, some elected officials in Australia have addressed these issues by introducing legislation aimed at changing laws related to euthanasia and assisted suicide. Both Australia and the United States have raised awareness of end-of-life issues simply because of the legislation and discussion surrounding them; however, citizens in both Australia and the United States continue to grapple with euthanasia and other issues related to the end of life.
Africa Although Africa is the world’s second-largest continent, the population density is low because many desert areas are unfit for human habitation. Africa is estimated to have an annual rate of population growth of around three percent, with birth and death
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rates that “vary widely from region to region.” Many African nations are still struggling to improve social services and health conditions. In the meantime, existing conditions have major ramifications for residents, especially in terms of health and medical care. In fact, “most African countries have yet to develop comprehensive systems of social-welfare benefits,” although “South Africa and the North African countries of Egypt, Tunisia, and Algeria” are further along in development of their social-welfare systems (Encyclopedia Britannica Micropædia 2003, v. 1, 132).
Health Care The dearth of well-developed social-welfare systems is even more problematic given that “Health and sanitary conditions in Africa are generally poor, particularly outside the major metropolitan [centers] having doctors and hospitals.” The result is that “Africans in many parts of the continent suffer from starvation or malnutrition” and “the most prevalent diseases [of] malaria, dysentery, tuberculosis, whooping cough, typhoid fever, gonorrhea, and AIDS.” Adequate medical care is scarce. In fact, “South Africa, Réunion, Mauritius, Libya, and Algeria are perhaps the only countries in Africa that do not have a serious shortage of doctors.” Given the aforementioned conditions, it is not surprising that infant mortality rates are high and life expectancies are low. Infant mortality “in some countries (e.g., Ethiopia and Mali), reaches rates of more than 150 per 1,000 live births.” Life expectancy rates are equally dismaying: “as low as 40 years in the leastdeveloped countries or as high as 65 years in salubrious climates like those of Réunion and Mauritius” (132).
Euthanasia History People in parts of Africa, like those in the United States and elsewhere throughout the world, are grappling with euthanasia and other issues related to the end of life. The Dispatch, a newspaper based in South Africa, featured an article on March 21, 2001, that illustrated the fact that people are divided on the topic of euthanasia: “Fifty percent of South Africans polled in a survey believed voluntary euthanasia was acceptable, one of South Africa’s leading information companies, Research Surveys, has found. The sample of men and women was representative of the country’s various population groups” (Dispatch March 21, 2001). A subsequent Dispatch article, on May 17, 2001, reported on
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a speech given by Willem Landman, a member of the South African Law Commission, at a symposium on euthanasia at the World Congress of Family Doctors in Durban, South Africa. According to the article, Landman contended in his speech that “a large number of doctors in South Africa would be willing to perform euthanasia at the request of their patients once the controversial practice was [legalized] in the country.” The article also noted reservations expressed by a Cape Town doctor named Zandy Rosochacki: “He believed [legalizing] euthanasia in South Africa would be premature and difficult to put into practice—given circumstances where there was one doctor for every 40,000 people in certain rural areas. Unlike countries like the Netherlands and Australia, South Africa had not yet reached a stage where euthanasia could be legalized” (Dispatch May 17, 2001). If a Washington Post article regarding possible candidates to succeed Pope John Paul II as leader of the world’s Roman Catholic population is any indication, this openness toward euthanasia does not span the African continent. The article addressed the possibility of Cardinal Francis Arinze becoming “the first pope from Africa in 1,500 years” (Timberg 2005, A01). Cardinal Arinze’s status, the article noted, was partly a result of his efforts following a 1970s governmental decree that European and American priests had to leave the country. An archbishop at the time, Arinze is said to have risen to the challenge, recruiting Nigerians to serve the Catholic Church as new priests. The results of Arinze’s efforts are visible today, according to the article: Since the purge of foreign-born priests, church membership in the territory once overseen by Arinze has quintupled through a combination of conversion and the burgeoning size of Catholic families. Two out of every three residents of the area reportedly are Catholic (Timberg 2005, A01). The article also notes that despite the fact that “Arinze has become a controversial figure to many American Catholics because of his rigid views on matters of doctrine,” his conservative stances, and the conservative stances of the Catholic Church, “are not controversial . . . among Catholics in most African countries . . .” and concludes, “the Vatican’s teachings against . . . euthanasia . . . draw little dissent here” (Timberg 2005, A01).
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Relevance to the United States The people of Africa, like the people of the United States, have been polled about their opinions on euthanasia and other end-oflife issues. The people of Africa, also like the people of the United States, have widely divergent opinions on these issues. Although the aforesaid polling results and anecdotal reports indicate results that lean in one direction, the information about the degree of allegiance to Cardinal Francis Arinze, and his doctrines, seems to contradict that leaning to some extent. How can separate polls show such dissimilar results? The polling methodology is one factor that can make a difference. Many components of the overall polling strategy, including the sample size, the language used to ask the question, and the randomness of the respondents, can also make a difference in the results. In addition, organizations responsible for commissioning polls can put a positive or negative “spin” on the results. A news organization or other type of entity that is committed to studying the matter objectively can ask straightforward questions and present the results in an unbiased way. On the other hand, an organization that is trying to swing public opinion one way or the other can ask loaded questions and present the results selectively in a manner designed to further its agenda in the most effective manner possible.
Canada Canada is the second-largest country in the world in terms of area. Its capital is Ottawa. While “people of British and French descent comprise more than half the population,” the country is also home to “significant minorities of German, Italian, Ukrainian, Chinese, Dutch, American Indian, and Inuit origin.” Roman Catholics make up nearly half of the country’s population; “more than one-third [of Canadians] are Protestants” (Encyclopedia Britannica Micropædia 2003, v. 2, 785–786).
Health Care Canada divides “responsibility for social welfare and health care . . . between the federal and the [ten] provincial governments.” Health conditions are considered to be favorable. Most Canadians are covered by “the federal medical care insurance program, which provides coverage for medically required services
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rendered by a physician or surgeon. Provincial hospital insurance programs, funded in part by the federal government, cover almost all of the population.” Canada has a “high number of physicians and hospital beds per capita.” The country has “high life expectancy rates of 75 years for men and 81 years for women.” The life expectancy rates are buttressed by an infant mortality rate that “is about average for a Western industrialized country” (785–786).
Euthanasia History A Canadian woman named Sue Rodriguez is known for her fight to legalize assisted suicide in Canada. After she was diagnosed with amyotrophic lateral sclerosis (ALS), or Lou Gehrig’s disease, Rodriguez issued a public plea for the government to legalize physician-assisted suicide. She took her battle all the way to the Supreme Court, but she was unsuccessful in her efforts. Her plea resulted in the creation of a government committee which was charged with studying the issues of euthanasia and assisted suicide. The committee ultimately decided that Canada’s existing laws on these matters should stand (Yount 2000, 45). Sue Rodriguez lost her battle, but she still managed to choose the manner of her death: She “defied the Court ruling and eventually committed suicide with the assistance of an unnamed physician” (48–49). Irene McNeilly’s name is not as well known but she, too, has waged a war regarding euthanasia. As an article in Report/ Newsmagazine noted, “She is angry because of treatment her husband received in St. Therese Hospital in St. Paul, prior to his death [March 19, 2001]. It was not only ‘callous and degrading,’ she alleges, but possibly ended in euthanasia” (McLean 2001, 22). McNeilly’s husband, Dr. Keith McNeilly, suffered a stroke at the age of 79. During her husband’s subsequent hospital stay, Mrs. McNeilly was concerned when he was given morphine despite improving health and she alleged that a dose of morphine, given without her permission, resulted in his death. [She] lodged a complaint with the College of Physicians and Surgeons. Allan Sinclair, manager of health services with Lakeland Regional Health Authority which is also investigating, says he has no knowledge of any euthanasia ever practised in the
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region. The Elder Advocate of Alberta, Ruth Adria of Edmonton, says that if the case does prove to be euthanasia, it will not be the first she has seen documented; in fact, she has charges in process (22).
Relevance to the United States Throughout the United States, elected officials, doctors, and citizens have lamented the state of America’s healthcare system and called for change. One oft-mentioned option is a universal healthcare system. As our neighbor to the north, Canada provides us with a unique view of a universal healthcare system; however, in studying the system, we must be sure to study its drawbacks, as well. Although Canada’s system guarantees health care, the waiting times can be extremely long, especially for visits to specialists and for certain specialized procedures. For some Canadians, the wait proves too long and they choose to visit medical practitioners in the United States; such a decision is not made lightly because the expenses must be paid out of pocket. Canada’s system offers valuable insight to everyone concerned with reforming health care in the United States. In a country where so many people are uninsured, universal health care holds a great deal of appeal for many Americans. Whatever system the United States eventually chooses, we should be mindful of all aspects of the collective Canadian experience and the lessons that have resulted from it.
France Officially known as the French Republic, France is characterized by a population that, despite its diversity in terms of both ethnicity and religion, is united: “The French consider themselves a single race and a single nation, but they are actually amalgams of ethnic strains that overlapped during centuries of invasions and migrations.” In terms of religion, “About three-fourths of the French people belong to the Roman Catholic Church. Other religious groups of sizable numbers include Protestants of various denominations, Jews, and Muslims. A significant portion of the population is also atheist” (Encyclopedia Britannica Micropædia 2003, v. 4, 919–920).
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Health Care France’s birth rates and death rates are comparable with other European countries. The country’s social-welfare system “covers most employed persons” and “insured residents are . . . reimbursed for part or all of their medical costs.” Health conditions in France also “compare favorably with those of other western European countries,” and the country has a “relatively low incidence of infectious disease and an adequate supply of both medical personnel and hospital beds.” Finally, with an infant mortality rate that is “comparatively low for Europe,” the country has a life expectancy that is “high [at] 72 years for males and 80 years for females (919–920).
Euthanasia History Along with its national system of health care, France has “a welldeveloped hospice care program.” These factors are cited as one possible reason for a lack of greater urgency regarding end-of-life issues: “The high quality of health care coupled with an excellent hospice system for managing extreme pain may contribute to lack of official concern for the legalization of euthanasia and physicianassisted suicide” (Scherer and Simon 1999, 72–73). That lack of official concern changed when Vincent Humbert’s name became well known in France following a catastrophic automobile accident in 2000. The accident left him unable to “walk, see, speak, smell, or taste.” He was able to move his right thumb and he used that ability to write a book by indicating letters of the alphabet. The book, I Ask the Right to Die (Je Vous Demande le Droit de Mourir), spelled out his wish to die legally. When his request failed to yield official approval, his mother, Marie Humbert, agreed to help him commit suicide. She “injected an overdose of barbiturates into his intravenous drip, sending him into a coma”; he died two days later and his mother was arrested for her role in complying with his request (Horsburgh, Lerner, and Corbett 2003, 83–84). Although Vincent Humbert’s quest for suicide ultimately resulted in his mother assisting him, his case resonated after his death. An article in the Christian Science Monitor, regarding the global impact of the Terri Schiavo case, noted that Humbert’s case led to new legislation aimed at “clarifying doctors’ responsibilities in such circumstances”: Due to come into effect later this year, the law limits “unreasonable persistence” in treating the terminally
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ill, and specifies that “when medical acts appear useless, disproportionate, or serve no other purpose than the artificial support of life, they can be suspended or not undertaken.” The law has been welcomed, with some reservations, by activists on both sides of the euthanasia debate, though it is ambiguous about doctors’ right to give potentially fatal doses of painkillers. High doses are permitted to ease discomfort even if the doctor suspects they might kill the patient as a secondary effect, but not if they are intentionally deadly (Ford 2005). The charges against Marie Humbert were eventually dropped; however, she was not pleased with that outcome. As a newspaper account noted, “Marie Humbert said she felt cheated because she wanted to stand trial to defend her son Vincent’s oftstated wish to die after his debilitating injuries in a road accident in 2000. She wanted to campaign for a law allowing assisted suicide” (Reuters February 27, 2006).
Relevance for the United States The case of Vincent Humbert was dissimilar to Terri Schiavo’s case in terms of illness, circumstances, or manner of death. However, the cases were similar in some very important ways. First, both cases touched on end-of-life issues that many people prefer not to address, perhaps because they do not wish to think about the end of their own lives. Second, both cases involved family members with very strong feelings. These family members—and their actions—were central to the media attention that surrounded both cases. Third, both cases resulted in the death of the central figures in environments of controversy and legal wrangling: Terri Schiavo because her husband, Michael, emerged as the victor in his courtroom battle; Marie Humbert because she was unsuccessful in her attempt to gain official approval for her son’s assisted suicide and fulfilled her son’s wishes herself. Finally, both cases had resounding impacts; people on both sides of the ocean became more aware of end-of-life matters. Both cases spawned legislation, increased interest in legal documents to make provisions for end-of-life circumstances, and made their central figures household names in terms of issues related to the end of life.
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Germany Germany is officially known as the Federal Republic of Germany and its capital is Berlin. Although Roman Catholics comprise a majority of the population in many European countries, that is not the case in Germany. In fact, “Protestants substantially outnumber Roman Catholics in the population. Predominantly Roman Catholic districts are found in the Rhineland and Bavaria. Northern Germany is largely Protestant. The country also has a small number of Muslims and Eastern Orthodox Christians” (Encyclopedia Britannica Micropædia 2003, v. 5, 217–218).
Health Care With a social services system that includes benefits when a person falls ill, Germany has distinguished itself in terms of health conditions. “Sickness benefits pay for most medical attention [and] Germany’s health and sanitary conditions are among the best in the world.” Perhaps because “the rate of doctors per person is higher than that found in either France or the United Kingdom,” the “infant mortality rate is low, and life expectancy stands at 77 years” (217–218).
Euthanasia History Although all of the countries mentioned here have some sort of history with the concept of euthanasia, Germany’s history with it is singular. As head of the Nazi Party, Adolf Hitler wanted to remove everyone he considered defective from Germany; his goal was to create a master race. “The program started with mentally disabled children, then expanded to include mentally and physically disabled adults. The rationale behind the program was partly economic—a desire to spare the state the expense of caring for ‘useless’ people—and partly biological, stemming from a belief in eugenics, which claimed that only the healthy should reproduce” (Yount 2000, 10). An article in the International Herald Tribune on October 6, 2006, reported the discovery of a mass grave in Menden, Germany. The grave was found after a witness offered a tip. Authorities were treating the discovery as a murder investigation, despite the difficulties associated with collecting evidence after the passage of such a long interval. The article noted that authorities suspected that the “remains . . . are from child victims of Adolf Hitler’s euthanasia program, which killed people the Nazis considered worthless”:
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About 200,000 people, many of them children, who were deemed unfit were killed by doctors under the Nazis as part of a vast Europe-wide euthanasia program, according to the U.S. Holocaust Museum. According to Harald Jenner, a prominent German historian, as many as 8,000 minors died in facilities for the disabled between 1939 and 1945 under mostly unclear circumstances. Another estimated 70,000 disabled or mentally ill adults were deliberately killed under a secret Nazi program code-named T4 in specially established death camps in 1940–1941 (Associated Press 2006). Although some individuals and organizations cite these and other policies and practices from Nazi Germany as the ultimate threat in slippery slope arguments, author and physician Charles McKhann argues that this is an invalid application of these arguments. Arguing that “there was no slope at all,” McKhann cites the Nazi law, passed in 1933, regarding “Prevention of Hereditarily Ill Offspring,” which “provided compulsory sterilization for patients who were mentally retarded or who had serious genetic defects.” He notes that this policy was followed by others, including the “Children’s Action,” an effort by Hitler “to identify ‘all severe cases of idiocy, mongoloidism, microcephalic disorders, hydrocephaly, deformed extremities, and paralysis,’” so that the children who suffered these conditions could be “euthanized without parental knowledge or consent” (McKhann 1999, 185). McKhann continues his argument by explaining how the concept of euthanasia was corrupted by the Nazi party and their practices: The Nazi corruption of euthanasia bore no resemblance to the original meaning of the word, nor to its use today in the concept of assisted dying. They sought to whitewash and legitimize the process of eliminating “defective” members of society by deliberately misusing the word (186). Like many countries throughout the world, Germany is currently wrestling with issues related to the end of life. One recent development, according to Deutsch Welle, a German newspaper, focuses on living wills and the suspension of treatment:
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A federal court decided in 2003 that living wills are binding for doctors and caregivers, but life-sustaining measures can only be suspended if the illness is fatal. The main issue is whether patients whose condition isn’t necessarily fatal—largely those plagued by severe dementia or suspended in a persistent vegetative state—will be permitted to have treatment suspended (Hartl 2005).
Relevance to the United States As the excerpt from Deutsch Welle notes, Germany is struggling to address issues related to the end of life. Throughout the United States, end-of-life issues are being addressed by various organizations and in academic settings, as well as by legislative bodies, newspaper editorial boards, and people throughout the country. Although it is obvious that the United States is not alone in addressing these issues, news from other countries provides a valuable perspective, especially in terms of cultural nuances.
Japan Japan is a country in East Asia; Tokyo is the nation’s capital. Although the Japanese are a “single ethnic group,” citizens of Japan people follow a variety of religions: Shinto (an indigenous folk religion), various sects of Buddhism, and Christianity coexist. There are also a variety of “new religions,” of which the Soka-Gakkai, based on a sect of Buddhism, has one of the largest followings. No one religion is dominant, and each is affected by the others. Buddhism is classified into 12 major sects and almost 60 branches. A small proportion of the population is Christian (Encyclopedia Britannica Micropædia 2003, v. 6, 497).
Health Care With a “social-welfare system [that consists] of both public and private health and welfare programs, [Japan] covers virtually the entire population . . . with benefits for . . . sickness . . . and old age.” The country’s health conditions are indicative of its status as
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a developed country. At “78 years for men and 85 years for women,” life expectancy rates in Japan are “among the highest in the world” (498–499).
Euthanasia History “Until recently, death and dying were considered taboo or inappropriate subjects for discussion in Japan” (Scherer and Simon 1999, 85). However, it seems that mindset is beginning to change: “Now, spurred by recent cases of apparent euthanasia, Japan has begun grappling seriously with the difficult issue of ‘death with dignity,’ including legislation to make it possible” (Reuters April 27, 2006). One of the cases to which the aforementioned article alludes was that of a doctor who “confessed to helping a number of terminally ill patients die.” Radio host Eleanor Hall highlighted the case during a radio show focusing on world affairs; a reporter in Tokyo filled in some of the facts of the case, including the fact that “between 2000 and 2005 [the doctor] helped at least seven terminally ill cancer patients to end their lives by switching off or removing their respirators.” Although “a 1995 court ruling outlined the circumstances in which Japanese doctors can help their patients to die,” it seems those specific provisions may not have been met in these cases and that is the crux of the problem (Hall 2006). Medical personnel and family members facing difficult decisions like these in Japan will soon have additional help and resources, according to a newspaper article. The additional help will come in the form of “bioethics SWAT teams”: While the name may sound odd, the bioethics SWAT teams, says Atsushi Asai, a professor of bioethics at Kumamoto University’s Graduate School of Medicine, will fill a much-needed gap. Members will be on hand to respond specifically to doctors and family members unsure of how to deal with terminally ill patients (Konishi 2006). The bioethics SWAT teams will assist medical personnel and family members with addressing difficult issues by examining all relevant facets of each individual case. The article notes that team members will “analyze the situation from an ethical, legal and
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social viewpoint before dispensing advice.” Although the program is limited while it is in the early stages, organizers hope that it will result in additional resources: “While the research team is for now relying on subsidies from the Ministry of Health, Labor and Welfare, plans call for creating a nonprofit organization” to allow this effort to continue (Konishi).
Relevance to the United States For many people, end-of-life issues are purely academic; they are the subject of debate, discussion, and study. For others, they are at the heart of a difficult personal decision about the end of one’s own life or the life of a loved one. For hospitals, they often represent a quagmire of legal, ethical, and medical issues. Japan’s bioethics SWAT teams offer an innovative approach to addressing these issues. Their goal of assisting medical personnel and family members means that they will have to be mindful of the perspectives of these very separate constituencies. Their input may be most valuable—and most needed—in situations in which the medical personnel and family members have opposite views on a particular situation. Their commitment to analyzing each situation from various perspectives prior to offering input is important because end-of-life issues and decisions involve a variety of components, including medical concerns, cultural factors, religious beliefs, legal matters, and ethical issues. As various legislative bodies, individuals, organizations, and others throughout the United States work to address end-oflife issues from a variety of standpoints, family members continue to watch loved ones suffer and medical personnel continue to treat patients to the best of their ability. Is there any place in the American system for something like these bioethics SWAT teams? At this point, hospital ethics boards generally end up filling this role, but these boards are generally brought into the discussion when the matter has reached the crisis point. While some hospitals do offer some type of assistance prior to that point, many simply do not have the resources to do so. Although there would be constraints, such as healthcare privacy laws to address in the United States, such assistance might well be welcomed in many situations throughout the country.
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China Officially called the People’s Republic of China, China is “a multinational country, with a large number of ethnic and linguistic groups” and the capital is Beijing. The country’s large population has resulted in a controversial plan to limit future growth because the “huge population must subsist on a relatively limited area of agricultural land, raising the ever-present possibility of an inadequate food supply.” The plan is well known: China “rewards couples who have only one child and penalizes those who have more than two. Each one-child family is given preference in housing, medical care, and other social-welfare services” (Encyclopedia Britannica Micropædia 2003, v. 3, 229–230).
Health Care Medical care in China includes teams of medical personnel who travel to see patients in rural areas. Although such “house calls” are a thing of the past in many countries, this type of proactive care is making a tremendous difference in eliminating many diseases: Medical personnel in cities are encouraged to go into the country to serve people there; medical teams circulate regularly in rural areas. Among these are the socalled barefoot doctors, who are given intensive training for relatively short periods so that they may work in rural areas. Owing to this emphasis on medical care and sanitation, such diseases as cholera, plague, typhoid, and scarlet fever have been virtually eradicated. China’s new health problems are cardiovascular diseases and cancer. China’s life expectancy in the 1970s was about 60 years; by the 1990s, it had risen to 69 years for men and 72 years for women (229–230).
Euthanasia History Nine people from Xi’an City in China made news when they “jointly wrote to local media asking for euthanasia, or mercy killings,” according to an article in People’s Daily. The patients, who had uremia, cited “unbearable suffering and [an unwillingness] to burden their families any more” as reasons for their requests. The article explained what could be done for the patients: “China has so far no legalized euthanasia, that is, no
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institutions and persons are permitted by law to conduct euthanasia, otherwise legal punishment would follow. So what doctors can do is for the time being only to try their best to ease patients’ pains” (People’s Daily 2001).
Relevance to the United States As the People’s Daily article illustrates, doctors in China, like doctors in the United States, may receive requests from suffering patients who want to end their lives as a means of ending their suffering. Whether euthanasia or assisted suicide is legalized or not, this type of request is a weighty one for a patient to make and it has the potential to have a major impact on the doctor-patient relationship. Regardless of how the doctor actually responds, if the doctor is thoughtful, reasoned, compassionate, and respectful of the patient’s feelings and concerns, the doctor-patient relationship may survive— even if the response is not the one the patient was seeking. If, on the other hand, the doctor minimizes the patient’s condition or does not seem to give the request adequate consideration, the patient may decide to begin receiving care from a different physician—even if the response was the one he or she sought. For patients seeking a respite from their pain, fear, illness, and worry, the doctor’s compassion, understanding, and acknowledgement are necessary parts of endof-life care, regardless of whether the care is comfort care or care designed to provide the patient with choice regarding the end of life.
Belgium Belgium is officially known as the Kingdom of Belgium and Brussels is the capital. Belgium’s population, which consists of French, German, and Dutch speakers, is largely Roman Catholic.
Health Care As in many European countries, “social-welfare programs provide health insurance [covering almost the entire population]” of Belgium. Life expectancy rates are comparable to other European nations: “73 years for males and 80 for females” (Encyclopedia Britannica Micropædia 2003, v. 2, 61–62). When Belgium “partially [legalized] euthanasia in 2002,” safeguards were instituted; requests are “controlled by a commission that reviews patients’ and doctors’ declarations.” The safe-
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guards also include “a clause necessitating a long-term relationship between the doctor practicing euthanasia and the patient putting an end to his or her suffering. Consequently potential candidates need to reside in Belgium to be granted this right” (Expatica Magazine 2006). An article in The Economist offered additional clarification of Belgian law in this matter: Belgium permits only voluntary euthanasia. The patient must be adult and in a “futile medical condition of constant and unbearable physical or mental suffering that cannot be alleviated.” His request must be “voluntary, well considered, and repeated,” and all this confirmed by two doctors. [In 2004,] 347 acts of euthanasia were reported (The Economist 2005).
Relevance to the United States Like Oregon’s Death with Dignity Act, Belgian law regarding euthanasia includes safeguards. The people who craft such laws, whether in the United States or elsewhere, include such measures in the language of the legislation to reduce the potential for abuse as much as possible. Just as laws regarding euthanasia or assisted suicide engender debate, safeguards are also subject to debate. People who are opposed to euthanasia and assisted suicide often declare that the safeguards fall far short in terms of preventing abuse; those who favor end-of-life options sometimes declare the same safeguards as unnecessary obstacles or constraints to people who want to end their lives.
Colombia The Republic of Colombia, as Colombia is officially known, has Bogotá as its capital. Although Roman Catholicism, as the official religion, “is practiced by most Colombians,” Colombia has a small but growing Protestant community, and “some Indians continue to follow traditional religious beliefs” (Encyclopedia Britannica Micropædia, 2007, v. 3, 461).
Health Care Colombia’s “annual birth rate and its rate of natural increase are among the highest in Latin America,” but the country’s infant
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mortality rate is “also relatively high” (461). In addition, Colombia has other health-related problems, with “significant numbers of people [suffering] from malaria, dysentery, and other infectious diseases, and malnutrition”; these problems are compounded by a “shortage of trained medical personnel.” The country’s life expectancy rates are “66 years for men and 74 for women” (462).
Euthanasia History Given the country’s Roman Catholic history, it came as a surprise to some when “Colombia’s constitutional court accepted the practice of euthanasia in May 1997 for terminally ill patients who expressly ask for it” (Television New Zealand 2001). However, as an article in the San Diego Union Tribune on July 31, 2005, noted, legislators have expressed reluctance to develop a law following the constitutional court’s decision: The court urged Congress to codify the practice to prevent abuses. Lawmakers, apparently reluctant to take on such an emotionally charged debate in this predominantly Roman Catholic country, still haven’t done so (Housego 2005). Those who favor such a law, including Carlos Gaviria, argue that it would prevent abuse. Gaviria was the judge who wrote for the majority at the time of the constitutional court’s ruling. He subsequently ran for senate; in this role, he can propose legislation, rather than just make a recommendation about it. Regardless of the state of the law, anecdotal reports indicate that some patients have been able to find physicians willing to assist them in their efforts to end their lives. However, given the lack of records about the practice at this time, it is difficult to ascertain exactly how many patients have received this type of assistance (Housego 2005).
Relevance to the United States The situation in Colombia is an interesting one: Although the constitutional court accepts the practice of euthanasia, there is no law on the books about it. This dichotomy means that there are no procedures in place and no records are kept. Colombia’s situation is in stark contrast to Oregon’s, where the Death with Dignity Act con-
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tains a number of safeguards and reporting procedures. However, despite the lack of a law on the matter, anecdotal accounts of Colombia’s experience indicate that some people who wish to end their lives rather than endure additional suffering have found physicians willing to assist them in this endeavor—even in the face of such strong religious opposition. Anecdotal reports from the United States, too, indicate that although assisted suicide is illegal in every state but Oregon, some patients in other states are also able to find physicians who are willing to assist them.
References Associated Press. “Grave May Be Evidence of Euthanasia.” International Herald Tribune, October 6, 2006, http://www.iht.com/ articles/2006/10/06/news/germany.php (accessed October 21, 2006). Boseley, Sarah. “Most Doctors Help End Lives of Terminally Ill Patients, Says Study.” Guardian, October 14, 2006, http://www.guardian.co.uk/medicine/story/0,1922385,00.html (accessed October 21, 2006). Dispatch. “Half of SA for Mercy Killing.” March 21, 2001, http://www.dispatch.co.za/2001/03/21/southafrica/BKILLING .HTM (accessed October 22, 2006). Dispatch. “Many Doctors in SA Favour Mercy Killing.” May 17, 2001, http://www.dispatch.co.za/2001/05/17/southafrica/ CADOCTOR.HTM (accessed October 22, 2006). The Economist 2005. “The Art of Dying.” October 13, 59–59. “Africa.” Encyclopedia Britannica Micropædia. Vol. 1. Chicago: Britannica, 2003. “Australia.” Encyclopedia Britannica Micropædia. Vol. 1. Chicago: Britannica, 2003. “Belgium.” Encyclopedia Britannica Micropædia Vol. 2. Chicago: Britannica, 2003. “Canada.” Encyclopedia Britannica Micropædia Vol. 2. Chicago: Britannica, 2003. “China.” Encyclopedia Britannica Micropædia Vol. 3. Chicago: Britannica, 2003.
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“Colombia.” Encyclopedia Britannica Micropædia Vol. 3. Chicago: Britannica, 2003. “France.” Encyclopedia Britannica Micropædia Vol. 4. Chicago: Britannica, 2003. “Germany.” Encyclopedia Britannica Micropædia Vol. 5. Chicago: Britannica, 2003. “Japan.” Encyclopedia Britannica Micropædia Vol. 6. Chicago: Britannica, 2003. “The Netherlands.” Encyclopedia Britannica Micropædia Vol. 8. Chicago: Britannica, 2003. “United Kingdom.” Encyclopedia Britannica Micropædia Vol. 12. Chicago: Britannica, 2007. Expatica Magazine. “Belgium Keeps Tight Reins on Euthanasia Legislation.” November 9, 2006, http://www.expatica.com/ actual/article.asp?subchannel_id=48&story_id=34248 (accessed November 13, 2006). Foley, Kathleen, and Herbert Hendin. 2002. The Case against Assisted Suicide: For the Right to End-of-Life Care. Baltimore, MD: Johns Hopkins University Press. Ford, Peter. “World Divided on Ethics of Terri Schiavo Case.” Christian Science Monitor, March 25, 2005, http://www.csmonitor.com/2005/0325/p01s04-wogi.htm (accessed October 5, 2006). Hall, Eleanor. “Japanese Doctor Sparks Euthanasia Debate.” The World Today, March 31, 2006, http://www.abc.net.au/worldtoday/content/2006/s1605759 (accessed November 12, 2006). Hartl, Judith. “Germany Debates Physician-Assisted Death.” Deutsch Welle, March 24, 2005, http://www.dw-world.de/ dw/article/0,2144,1529079,00.html (accessed November 12, 2006). Horsburgh, Susan, Dietlind Lerner, and Bryce Corbett. “Her Son’s Last Wish.” People, November 13, 2003, 83–84. Housego, Kim. “Euthanasia Regularly Practiced in Colombia.” San Diego Union Tribune, July 31, 2005, http://www.signonsandiego.com/news/world/20050731–1013-colombia-euthanasia.html (accessed January 17, 2007).
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Konishi, Hiroshi. “Proposed ‘SWAT’ Teams to Provide Guidance on Bioethics.” Asahi Shimbun, October 9, 2006, http://www.asahi. com/english/Herald-asahi/TKY200610090098.html (accessed October 22, 2006). Le Fanu, James. “Second Opinion: A Legal Release.” Telegraph, September 10, 2006, http://www.telegraph.co.uk/health/ main.jhtml?xml=/health/ 2006/10/09/hlefanu09.xml (acccessed October 22, 2006). Light, Donald, Ph.D. 2003. Universal Healthcare: Lessons from the British Experience. American Journal of Public Health, January: vol. 93, issue 1, 25–30. Mathers, Colin D., Doris Ma Fat, Mie Inoue, Chalapati Rao, and Alan D. Lopez. 2005. “Counting the Dead and What They Died From: An Assessment of the Global Status of Cause of Death Data.” Bulletin of the World Health Organization. March (83): 171–177. McKhann, Charles F. 1999. A Time to Die: The Place for Physician Assistance. New Haven, CT: Yale University Press. McLean, Candis. “None Dare Call It Euthanasia.” Report/Newsmagazine (National Edition), May 28, 2001. People’s Daily. “9 Xi’an Patients Jointly Request for Euthanasia.” April 10, 2001, http://www.china.org.cn/english/2001/ Apr/10872.htm (accessed November 12, 2006). Reuters. “No Charges for Frenchwoman Who Helped Son Die.” SwissInfo, February 27, 2006, http://www.swissinfo.org/eng/ search/detail/No_charges_for_Frenchwoman_who_helped_son_ die.html?siteSect=881&sid=6509884&cKey=1141072535000 (accessed November 11, 2006). Reuters. “Ageing Japan Takes Up ‘Death with Dignity’ Debate.” Khaleej Times, April 27, 2006, http://www.khaleejtimes.com/ DisplayArticle.asp?xfile=data/todaysfeatures/2006/April/ todaysfeatures_April55.xml§ion=todaysfeatures (accessed November 12, 2006). Roque, Josephine. “Org. Calling for Euthanasia Option for the Clinically Depressed.” All Headline News, September 21, 2006, http://www.allheadlinenews.com/articles/7004941207 (accessed October 23, 2006).
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Scherer, Jennifer M., and Rita J. Simon. 1999. Euthanasia and the Right to Die. Lanham, MD: Rowman & Littlefield Publishers. Television New Zealand. “Mercy Killing around the World.” April 11, 2001, http://tvnz.co.nz/view/page/425822/36104 (accessed January 18, 2007). Timberg, Craig. “Nigeria’s Spiritual Rainmaker Is Eyed at Vatican.” Washington Post, April 17, 2005, http://www.washingtonpost.com/ wp-dyn/articles/A59514–2005Apr16.html (accessed November 11, 2006). Yount, Lisa. 2000. Physician-Assisted Suicide and Euthanasia. New York: Facts on File.
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4 Chronology
O
n many levels, euthanasia is a personal issue. When one is facing a terminal illness or considering the end-of-life issues of a loved one, thought is focused inward. The concept of euthanasia, however, does not exist in a vacuum. Due to the complexity of the issue, it is influenced by the religious, legal, and medical communities. It has ramifications for these constituencies, as well. The following chronology highlights issues related to euthanasia throughout history. Religious, legal, and medical milestones provide the framework. 1727 BCE The Babylonian Code of Hammurabi is developed to protect patients from physician error. 850 BCE Greek physicians are organized as members of a lay craft. 600–300 The term euthanatos, meaning good death, is coined in Ancient Greece. BCE Due to the development of scientific medicine, healing is no longer believed to occur as a result of magic. The Hippocratic Oath is likely written at some point during this period. 500 BCE A religious sect called the Pythagorean Brotherhood is created. Its members consider the best parts of the soul to be divine and eternal.
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Pythagoras dies. A Greek philosopher, he placed the highest value on the soul and believed in immortality. 429–347 Plato lives during this period. In addition to making BCE the claim, which was radical for the time, that individuals are responsible for their own health, he declares that thought is centered in the brain. 421 BCE Many scholars believe the Hippocratic Oath is written this year. 400 BCE Roman emperors create laws against infanticide. A common practice until this point, it was utilized for healthy and unhealthy male and female infants. 383–322 Aristotle, the son of a physician, lives during this BCE time. He declares that the body and soul cannot be separated. 341–270 Greek philosopher Epicurus states that death is a state of oblivion. BCE CE 129 This year marks the birth of Galen, the man known as the Father of Medicine. Telemachus, a monk who is committed to bringing gladiator battles to an end, stands between two gladiators and demands they stop in the name of Christ. The gladiators kill him and the shock is so great that the emperor makes the battles illegal. 533 The Council of Orleans, France, refuses funeral rites for anyone who kills him/herself upon being accused of a crime. 693 The Council of Toledo, Spain, determines that the penalty for attempting to take one’s own life will be excommunication. 875–925 Rhases, a Persian, employs his knowledge of chemicals to create medicines. 1100–1140 Sicily holds state examinations for people who want to practice medicine. 1199 Practitioners of medicine begin to form associations. 1240 The study and practice of medicine are governed by Holy Roman Emperor Frederick II. 1310 The era of modern surgery begins with a human dissection by Italian anatomist Mondino De Luzzi. 1516 Sir Thomas More’s Utopia provides a literary example of a society that sanctions voluntary euthanasia. 497 BCE
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1798 1799
1803 1824
1846
1861 1865 1869 1870
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Suicide, a term from the Latin for “to kill,” becomes part of the English lexicon. Geneva, Switzerland, abolishes the practice of defiling the corpses of people who took their own lives. Oratio de Euthanasia, a document which advocates “an easy death for the patient” is written by a physician named Paradys. English physician Edward Jenner introduces vaccinations. Sir Humphrey Davy, a British chemist, uses nitrous oxide (also known as laughing gas) as a form of anesthesia. Morphine, a narcotic painkiller made from opium, is developed by German chemist Frederich Serturner. The English Parliament decrees that people who commit suicide may be buried in a churchyard. The burials, however, must take place between 9 P.M. and midnight. William Morton uses ether during a surgical procedure at Massachusetts General Hospital. The American Medical Association (AMA) is founded. Louis Pasteur, a French scientist, introduces the germ theory of disease. Antiseptic surgery is introduced in England by Joseph Lister. The Oxford English Dictionary includes an entry for euthanasia. The government of France makes it illegal to discriminate against anyone, including suicide cases, in matters pertaining to burial. The X-ray process is inadvertently discovered by Wilhelm Röntgen of Germany. Mohr v. Williams, a Minnesota case, sets legal precedent regarding informed consent. The Ohio state legislature considers the first piece of legislation related to euthanasia in the history of the United States. The bill fails when only approximately one-quarter of the state legislators vote in favor of it. Russia suspends use of the Hippocratic Oath at the beginning of the Russian Revolution. The theory is
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1917 (cont.) that the absence of the oath allows doctors to remain loyal to Russia, rather than to the patient. 1920 Michigan resident Frank Roberts is convicted of murder. He placed arsenic within reach of his wife, who was ill. Roberts dies during his incarceration. In Germany, a piece by Karl Binding and Alfred Hoche is published. The topic is Lebensunwerten Leben (life that is not worthy of life). 1925 The case against Dr. Harold Blazer, who took the life of his daughter, an invalid for 30 years, is dismissed following the jury’s inability to reach a verdict. 1929 Life insurance undergoes a change following the stock market crash. Although suicide claims had previously resulted in full payment, the spate of suicides following the crash prompts many insurance companies to include noncontestability clauses in their policies. These clauses mandate a two-year waiting period for payments on suicide policies. 1930–1931 Dr. C. Killick Millard, an English physician, issues a “Plea for Legalization of Euthanasia” in a speech to the Society of the Officers of Health. 1935 The British Euthanasia Society is founded by Harold Laski, Bertrand Russell, George Bernard Shaw, and H. G. Wells. 1937 Senator John Comstock of Nebraska introduces the Voluntary Euthanasia Act. The legislation, which aims to legalize active euthanasia, never goes to a vote. Chicago’s Cook County Hospital opens the nation’s first blood bank. Blood banks are a key factor in making complex procedures, even surgeries, more routine. 1938 Unitarian minister Charles Potter establishes the Euthanasia Society in New York. This organization, which promotes passive euthanasia, is the first of its kind in the nation and the second in the world. 1939 The concept of mercy killing is developed. 1941 The Nazis murder approximately 100,000 (nonJewish) handicapped Germans. The Nazis refer to this as euthanasia. 1945 Streptomycin (an antibiotic) is developed.
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1950–1951 Euthanasia is denounced by the General Council of the Presbyterian Church. 1952 The Protestant Episcopal Church declares its official opposition to euthanasia. During a surgical procedure, an artificial heart/lung machine is used for the first time. 1954 Morals and Medicine, a book by Joseph Fletcher, introduces the concepts of patient autonomy and a “good death” to a broader spectrum of the public. 1955 Open-heart surgery is performed for the first time. Sir Alexander Fleming, a bacteriologist from Scotland, discovers penicillin in London, England. 1957 During a speech to the Seventh International Congress of Doctors at The Hague, Pope Pius XII declares, “Medical law can never permit the doctor or the patient to practice direct euthanasia.” He allows, however, that extraordinary care could be withdrawn in some cases. 1959 Herman Feifel’s book, The Meaning of Death, is published. The book brings issues related to death and dying to the forefront, especially in academia. The development of the sonogram, which makes it possible to view a fetus in utero, is announced. Dr. Hermann N. Sanders, who took the life of terminal cancer patient Abbie Borroto and included his actions in her medical chart, is prosecuted for first-degree murder. 1960–1969 During this period, neonatology becomes a medical subspecialty. Neonatal intensive care units are developed to provide highly specialized treatment for infants who would die without such care. 1960 The pacemaker is invented. 1961 The birth control pill is approved as a new form of contraception. In England, suicide and attempted suicide are no longer deemed criminal. Assisted suicide, however, remains illegal. 1965 Griswold v. Connecticut, a Supreme Court case regarding contraceptive use, sets a legal precedent in terms of right to privacy. 1967 The Euthanasia Education Fund, a tax-exempt partner
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1967 (cont.) of the Euthanasia Society of New York, is formed to educate the public about death and dying. In cooperation with Luis Kutner, an attorney from Chicago, the organization creates the first living will. Dr. Christiaan Barnard performs the first heart transplant. The Foundation of Thanatology is established. The organization is dedicated to improving care for the critically ill. 1968 Dr. Walter Sackett, a retired physician and member of the Florida House of Representatives, begins introducing legislation about living wills and other end-oflife issues. His efforts to pass these bills are unsuccessful. In London, England, Dame Cicely Saunders establishes the first modern hospice. 1969 Dr. Elizabeth Kübler Ross’s book, On Death and Dying, is published. The Hastings Center is established. This organization delves into issues of biomedical ethics. The Euthanasia Education Council is founded. Donald McKinney is its first president. The British House of Lords considers a bill on voluntary euthanasia. The bill passes without debate on its first reading but it is rejected on the second reading. 1970 More than 60,000 living wills are distributed by the Euthanasia Society. Georgetown University Medical School’s Kennedy Institute of Ethics is established. 1971 Bioethics enters the lexicon. 1972 More than 100,000 people in the United States request living will forms so they can document their wishes about end-of-life care. The U.S. Senate’s Special Committee on Aging meets to discuss “Death with Dignity: An Inquiry into Related Public Issues.” Long Island physician Vincent Montemaro is prosecuted after he euthanized Eugene Bauer, a 59year-old who suffered from terminal cancer.
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The National Conference of Catholic Bishops forms the National Right to Life Committee. In Roe v. Wade, the Supreme Court legalizes abortion. The American Hospital Association, which counts more than 90 percent of the nation’s hospitals among its membership, implements “A Patient’s Bill of Rights.” In the Netherlands, Dr. Gertruida Potsma, convicted of killing her terminally ill mother at the mother’s request, is sentenced to one month in jail and one year of probation. The sentence of incarceration for one month is suspended. The trial mobilizes Jaap and Klazien Sybrandy to establish the Netherlands Society for Voluntary Euthanasia. As a result of their efforts, a legal precedent is established to permit euthanasia in certain cases. New Haven, Connecticut, is the site of the first hospice in America. The American Medical Association’s National Conference Steering Committee issues new standards for CPR and emergency cardiac care. After ingesting a combination of alcohol and sedatives, a young woman named Karen Ann Quinlan goes into a coma. Derek Humphry helps his wife Jean die in Britain following her fight with cancer. California Governor Jerry Brown signs the state’s Natural Death Act into law. The Natural Death Act allows patients to set forth their wishes for care at the end of their lives. The document is tantamount to a living will. Switzerland’s Academy of Medical Sciences releases guidelines on caring for dying patients. The guidelines mandate personal support, care, and medical treatment. A physician in Amsterdam, the Netherlands, is tried for giving a patient a lethal dose of a drug. The physician is acquitted. Assisted suicide is considered a criminal act in New York State.
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1978 (cont.)
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An act of Congress (Public Law 95–622) establishes the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. The Commission is charged with examining the ethical and legal questions of current medical and research-oriented issues. The Veterans Administration declares that it is not permissible for physicians to issue do not resuscitate (DNR) orders for patients who are terminally ill. Jerry Falwell, a Baptist minister and evangelist, establishes the Moral Majority, an organization that focuses its attention on various issues, including abortion and euthanasia. The Hemlock Society is founded in California by Derek Humphry, Ann Wickett, and Gerald Larue. Dr. George B. Mair’s How to Die with Dignity is published by the Scottish chapter of EXIT, a right-todie organization. The World Federation of Right-to-Die Societies is founded. The Los Angeles County Medical Association and the Los Angeles County Bar Association form a committee which delivers physician guidelines for removing life support, in the absence of prior court approval, from patients who are terminally ill. The first AIDS case is diagnosed. Derek Humphry’s guide to self deliverance, Let Me Die before I Wake, is published. A layperson (i.e., not a doctor) is convicted of assisting a suicide in Rotterdam, the Netherlands. The case sets legal precedents for determining which cases will be subject to prosecution. The British chapter of EXIT publishes A Guide to Self-Deliverance. The Tax Equity and Fiscal Responsibility Act is passed in Congress. One provision divides medical conditions into “diagnostic-related groups.” The result is a change in Medicare policy limiting payments to predetermined amounts depending on the services rendered. Many cite the Tax Equity and Fiscal Responsibility Act, and the Medicare policy
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change, as a factor in premature hospital discharges of elderly patients. New York State’s Medical Society develops physician guidelines for withholding resuscitation if a terminally ill patient stops breathing or his/her heart fails. In the Netherlands, Queen Beatrix establishes the State Commission on Euthanasia. A physician charged with fulfilling a patient’s request for death is tried in the Alkmaar District Court of the Netherlands. The court finds that the patient was exercising her right to self-determination and declares that the doctor followed all protocols. The prosecutor appeals the court’s ruling. Two journalists in Paris release a manual which portrays suicide as a revolutionary act appropriate for general use. Sales of the manual, titled Suicide, Mode d’Emploi, reach nearly 50,000 within five months. Attempts to ban the manual prove unsuccessful. Nancy Cruzan, age 25, sustains critical injuries in an automobile accident. She falls into a coma and nutrients and hydration are administered by artificial means. Absent a living will, Nancy Cruzan’s parents engage in a protracted legal struggle to discontinue the artificial nutrition and hydration and allow their daughter to die. The Veterans Administration declares that patients have a right to die. The declaration allows doctors, with permission of the patient, to write orders that reject lifesaving steps when the patient is critically ill. In cases where the patient is unable to decide, the patient’s family may give such permission. The President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research determines that patients should have the option of refusing lifesaving measures when death is imminent. On March 7, the U.S. Department of Health and Human Services issues “Baby Doe” regulations scheduled to become effective March 22. The regulations
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1983 (cont.) mandate that every hospital which receives federal funding must post the following notice in all nurseries and maternity wards: “Discriminatory failure to feed and care for handicapped infants in this facility is prohibited by federal law.” On March 18, several national organizations, including the American Academy of Pediatrics, protest the Baby Doe regulations by filing a lawsuit against the Department of Health and Human Services and Secretary Margaret Heckler. On April 14, Judge Gerhard Gesell, declaring that the Baby Doe regulations violate federal law, rules that they must be amended. On October 8, Baby Jane Doe is born in New York. She has spina bifida and is hydrocephalic and microencephalic. The infant’s parents decline surgery that would provide her with approximately 20 years of life in a severely compromised state. Attorney Lawrence Washburn, acting on behalf of the infant, petitions the court to perform the surgery, alleging that the hospital is discriminating against a handicapped infant. The court rules in his favor and the surgery is performed. The Netherlands case (see 1982) from the Alkmaar District Court goes to the Amsterdam Court of Appeals. The Appeals Court, in a reversal of the lower court’s decision, convicts the physician but does not recommend punishment. The doctor files an appeal. Dr. Pieter Admiraal’s Justifiable Euthanasia: A Manual for the Medical Profession is released. The booklet provides doctors and pharmacists with drug dosages required to effectively hasten death. 1984 The U.S. Congress passes “Baby Doe” legislation, which requires that states that receive federal funds for child abuse prevention adopt rules aimed at preventing medical neglect of handicapped infants. The Royal Dutch Society for the Promotion of Medicine calls upon the Minister of Justice in the Netherlands to legalize euthanasia. The Netherlands Society for Voluntary Euthanasia assists the physician in the Alkmaar
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District Court case with appealing the most recent ruling. The Dutch Supreme Court subsequently overturns the decision handed down by the Amsterdam Court of Appeals; the case is referred to the Court of Appeals in The Hague. Karen Ann Quinlan dies. Attorneys Michael White and Robert Risely write the Humane and Dignified Death Act and attempt to put the issue before the voters in California. The act never makes it to the ballot because it is lacking the required number of signatures. In The Hague, the Netherlands, the court dismisses charges against the physician from the Alkmaar District Court. The justices reason that there are no norms of medical ethics that prohibit his actions. Dr. Peter Rosier is tried for murdering his wife, Patti, who was battling cancer. The jury is unanimous in its acquittal. Nancy Cruzan is diagnosed as being in a persistent vegetative state. France bans all books that provide information about how to commit suicide. An organization known as Americans against Human Suffering attempts to place an initiative legalizing euthanasia and physician-assisted death on the California ballot. The effort fails due to an insufficient number of signatures. A Tennessee police officer named Gary Dockery is shot in the head in the line of duty and lapses into a coma. His physicians view his chances of recovery as very slim. Dr. Jack Kevorkian builds the “mercitron,” a suicide machine. Senator John Danforth of Missouri introduces the Patient Self-Determination Act (PSDA) in the U.S. Senate. The Supreme Court of the United States accepts the Nancy Cruzan case. The case, Cruzan v. Director, Missouri Department of Health, is the Court’s first rightto-die case.
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In Law, Medicine, and Health Care, Dr. Steven Miles publishes research showing that courts are more likely to fulfill the wishes of men than women regarding life support. Congress passes the Patient Self-Determination Act, requiring all facilities that receive federal funds to make patients aware that they have the right to refuse medical treatment. The act also authorizes these facilities to offer living wills and powers of attorney prior to illness or injury. Effective in 1991, the act surpasses state laws regarding living wills. On June 4, Dr. Jack Kevorkian helps Janet Adkins commit suicide. Adkins, 54, suffered from Alzheimer’s disease. On June 25, the U.S. Supreme Court rules in Cruzan v. Director, Missouri Department of Health. The ruling is 5–4 in favor of Nancy Cruzan’s parents. Chief Justice William Rehnquist cites the Fourteenth Amendment in noting that people have the right to avoid unwanted medical treatment. Specific guidelines are left to the states. On December 3, Dr. Kevorkian is charged with the murder of Janet Adkins. Judge Gerald McNally listens to a tape Adkins made prior to her death and drops the charges. On December 14, Nancy Cruzan’s feeding tube is removed and she is transferred to hospice care. On December 18, nineteen right-to-life activists are arrested as they attempt to force reconnection of Nancy Cruzan’s feeding tube. On December 26, Nancy Cruzan dies. The Royal Dutch Medical Association and the Netherlands Ministry of Justice agree to require that all doctors disclose cases involving assisted dying. An article by Dr. Timothy Quill appears in the New England Journal of Medicine. In his article, Dr. Quill chronicles how he helped Patricia Diane Trumbull, a terminally ill patient, end her life. Although prosecutors charge him, the jury does not deliver an indictment. Prescription Medicine: The Goodness of Planned Death, by Dr. Jack Kevorkian, is published.
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Choice in Dying, a national right-to-die organization, is formed by the merger of Concern for Dying and the Society for the Right to Die. Nancy Cruzan’s parents establish the Cruzan Foundation. The organization’s mission is to help families in situations like the one they faced with their daughter. Derek Humphry’s book, Final Exit, is published. In addition to appearing on the New York Times best seller list for eighteen weeks, the book is a nonfiction best seller for 1991. The ballot in Washington State features a Death with Dignity initiative. With 1.3 million votes cast, the measure fails. Pennsylvania’s State House of Representatives votes in favor of allowing terminally ill people to forego treatment provided that they had signed a living will while still sound in mind and body. On October 23, Dr. Kevorkian helps Sherry Miller and Marjorie Wantz commit suicide. Miller, 43, suffered from multiple sclerosis, and Wantz, 58, suffered from abdominal and pelvic pain. On November 20, in a unanimous decision, the Michigan Board of Medicine suspends the medical license of Dr. Jack Kevorkian. On December 1, the Patient Self-Determination Act, passed by Congress in 1990, goes into effect. Florida Governor Lawton Chiles signs the state’s Health Care Advance Directives Act into law. Having received the required number of signatures, California’s Death with Dignity Act is placed on the ballot. It fails with a vote of 54 percent to 46 percent. Washington State’s Feeding Tube Bill (HB #1481) is approved. Under the bill, a patient in an irreversible coma may be removed from life support if the patient had a living will. On February 5, Dr. Kevorkian is indicted for murder in the deaths of Sherry Miller and Marjorie Wantz. The case is known as Michigan v. Kevorkian. On May 15, Dr. Kevorkian helps 52-year-old
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1992 (cont.) Susan Williams commit suicide. Williams suffered from multiple sclerosis. On June 5, the office of the Medical Examiner in Oakland County, Michigan, finds that Dr. Kevorkian’s actions in the death of Susan Williams constitute homicide. On July 21, Dr. Kevorkian is cleared of murder charges in the deaths of Marjorie Wantz and Sherry Miller. The prosecutor files an appeal. After being cleared of murder charges in the deaths of Marjorie Wantz and Sherry Miller, Dr. Kevorkian assists four other people with committing suicide in 1992. Their names and conditions are listed below. Lois Hawes lung cancer Catherine Andreyev breast cancer Marguerite Tate amyotrophic lateral sclerosis Marcella Lawrence heart disease, liver problems, emphysema, arthritis On November 24, the Michigan House of Representatives passes a measure declaring that assisted suicide is a felony carrying a four-year prison term. It will become law on March 30, 1993. Final Exit is banned in New Zealand, Australia, and France. The ban is lifted within the same year in Australia and New Zealand. 1993 Dr. Jack Kevorkian helps 12 people commit suicide during this year. Dr. Ali Khalili bone cancer Merian Frederick amyotrophic lateral sclerosis Jack Miller bone cancer Mary Biernat breast cancer Stanley Ball pancreatic cancer Elaine Goldblum multiple sclerosis Hugo Gale emphysema and heart problems Jonathan Grenz mouth and throat cancer Martha Ruwart duodenal and ovarian cancer
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Ronald Mansur Thomas Hyde
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bone and lung cancer amyotrophic lateral sclerosis Donald O’Keefe bone cancer On February 25, Michigan’s State Senate passes special legislation to make the ban on assisted suicide effective immediately. On March 1, the American Civil Liberties Union (ACLU) goes to court to challenge Michigan’s ban on assisted suicide. The Dutch Parliament passes a law guaranteeing that doctors will not be prosecuted for euthanasia if they follow the established guidelines. This is considered the first modern euthanasia law in the world. Three patients suffering from terminal illnesses, along with their doctors, go to court in Quill et al. v. New York to test the state’s ban on assisted suicide. The U.S. District Court in New York City rules against them, declaring that assisted suicide is illegal. Their appeal takes the case to the Second Circuit Court of Appeals. With Michigan’s temporary ban on assisted suicide nearing expiration, the state legislature votes to implement a permanent ban. The State Supreme Court declares the ban constitutional given the lack of a constitutional right to assisted suicide. Voters in Oregon approve Measure 16, the state’s Death with Dignity Act. It is the first law in the United States to explicitly allow assisted suicide. A temporary restraining order prevents it from taking effect. A judge later postpones it indefinitely pending a thorough analysis of constitutional issues. A Dutch-produced documentary, Death upon Request, is aired in the Netherlands. The subject is Cees van Wendel de Joode’s quest to end his life. At 63, he is fighting amyotrophic lateral sclerosis. On January 24, Compassion in Dying, an organization committed to making end-of-life choices available to terminally ill patients, brings a lawsuit to the U.S. District Court for Western Washington on behalf of three terminally ill patients and their physicians. The
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1994 (cont.) case, Compassion et al. v. Washington State, is based on their claim that existing law in Washington State interferes with people’s constitutional rights of liberty and equal protection under the Fourteenth Amendment. On May 3, in Compassion et al. v. Washington State, a federal judge rules that it is unconstitutional to deny a terminally ill, competent adult in Washington a physician’s aid in dying. 1995 The Journal of the American Medical Association (JAMA) reports findings on surveys about advance directives. Among the findings: In three out of four cases of elderly patients admitted to a New York Hospital, doctors were unaware of the existence of advance directives. In California, a survey of the files of Medicare patients with advance directives revealed that the directives were present in only 25 percent of the files. On March 9, the U.S. Ninth Circuit Court of Appeals overturns the ruling in Compassion et al. v. Washington State, declaring that it is not within a person’s constitutional rights to have a physician-assisted death. Dr. Jack Kevorkian assists five people with committing suicide. Reverend John Evans pulmonary fibrosis Nicholas Loving amyotrophic lateral sclerosis Erika Garcellano amyotrophic lateral sclerosis Esther Cohan multiple sclerosis and ulcers Patricia Cashman cancer On October 30, Dr. Kevorkian, five other physicians, and a psychologist form an organization called Physicians for Mercy. They draft guidelines for physicians who help terminally ill patients commit suicide. 1996 Gary Dockery, the police officer who slipped into a coma after being shot in the head in the line of duty (see 1988), emerges from the coma. He is able to communicate clearly. Dr. Jack Kevorkian is found not guilty in the 1993 deaths of Dr. Ali Khalili and Merian Frederick.
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He is tried again in the deaths of Marjorie Wantz and Sherry Miller (see 1991 and 1992). Dr. Kevorkian assists 19 people with committing suicide. Linda Henslee multiple sclerosis Austin Bastable multiple sclerosis Ruth Neuman multiple strokes Lona Jones malignant brain tumor Bette Lou Hamilton syringomyelia Shirley Cline cancer Rebecca Badger multiple sclerosis Elizabeth Mertz amyotrophic lateral sclerosis Judith Curren chronic fatigue, immune system dysfunction, fibromyalgia Louise Siebens amyotrophic lateral sclerosis Patricia Smith multiple sclerosis Pat DiGangi multiple sclerosis Loretta Peabody multiple sclerosis Jack Leatherman pancreatic cancer Isabel Correa a spinal cord disorder Richard Faw colon cancer Wallace Spolar multiple sclerosis Nancy de Soto amyotrophic lateral sclerosis Barbara Collins ovarian cancer On February 1, the New England Journal of Medicine publishes results of physician surveys regarding physician-assisted suicide in Oregon and Michigan. The results indicate that many doctors, in some cases and under specific conditions, support physician-assisted suicide. On March 6, following an en banc hearing, the U.S. Ninth Circuit Court of Appeals rules in Compassion et al. v. Washington State. The court, in a vote of 8 to 3, overturns the lower court’s ban on physician-assisted suicide. The decision is stayed pending appeal to the U.S. Supreme Court. On April 2, in Quill et al. v. Vacco (see 1994), the
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1996 (cont.) Second Circuit Court of Appeals reverses the earlier court’s ruling. The case is slated to go to the U.S. Supreme Court. (Note that the case is also known as Quill et al. v. New York or Quill et al. v. Koppell.) On May 14, Oakland County’s Circuit Court finds Kevorkian not guilty of breaking the Michigan Supreme Court’s 1994 ruling banning assisted suicide. On May 17, in Manhattan, New York, 72-yearold George Delury is sentenced to six months in jail for helping his wife, Myrna Lebov, commit suicide in 1995. Lebov, suffering from multiple sclerosis, was 52 at the time of her death. Delury aided her in her quest to die by mixing a drug concoction for her to take. On June 20, Dr. Maurice Generaux, a physician in Canada, is charged with assisting in the suicide of Aaron McGinn on April 10. McGinn, age 31, had been diagnosed as HIV positive. Generaux is the first doctor in Canada charged with “aiding a suicide.” The Rights of the Terminally Ill Act goes into effect in Australia’s Northern Territory. 1997 In response to a Congressional inquiry, the U.S. Drug Enforcement Administration (DEA) declares that “delivering, dispensing, or prescribing a controlled substance with the intent of assisting a suicide” is not a “legitimate medical purpose.” Congress passes a law prohibiting the use of federal funds in physician-assisted suicides. The legislation, known as the Assisted Suicide Funding Restriction Act of 1997, is signed by President Bill Clinton. The State Supreme Court in Florida rules that the state’s ban on assisted suicide is not a violation of the right to privacy under the state constitution. Dr. Kevorkian assists 30 people with committing suicide during this year. Elaine Louise Day amyotrophic lateral sclerosis Lisa Lansing Crohn’s disease Helen Livengood severe arthritis and problems related to the esophagus
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Albert (Buddy) Miley Janette Knowles
quadriplegic amyotrophic lateral sclerosis Heidi Aseltyne AIDS Delouise Bacher multiple sclerosis Janis Murphy chronic fatigue syndrome and fibromyalgia Dorinda Scheipsmeier multiple sclerosis Lynne Dawn Lenox multiple sclerosis Karen Shoffstall multiple sclerosis Janet Good pancreatic cancer Thomas Summerslee multiple sclerosis Carol Fox ovarian cancer Deborah Sickels multiple sclerosis Natverlal Thakore Parkinson’s disease Kari Miller multiple sclerosis John Zdanowicz amyotrophic lateral sclerosis Lois Caswell chronic pain syndrome Annette Blackman multiple sclerosis John O’Hara stroke, gout, kidney problems Nadia Foldes cancer Naomi Sachs osteoporosis Bernice Gross multiple sclerosis Martha Wichorek various ailments Rosalind Haas breast cancer Margaret Weilhart stroke, paralysis, blindness Cheri Trimble breast cancer Franz-Johann Long tentative diagnosis of bladder cancer Mary Langford breast and lung cancer On March 25, the Rights of the Terminally Ill Act in Australia’s Northern Territory is overturned by the passage of the Voluntary Euthanasia Laws Bill. On May 13, in a vote of 32 to 26, Oregon’s House of Representatives votes to place Measure 16 (the Death with Dignity Act) back on the ballot. On May 26, the Supreme Court of the United States overturns the decisions of the lower courts in
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1997 (cont.) Quill v. Vacco and Washington v. Glucksberg (as the Washington State case is now known). In this unanimous ruling, the Supreme Court upholds the constitutionality of state statutes which ban assisted suicide. The Court, however, allows that hastening death by increasing palliative care measures is not a prohibited action when the intent is to relieve pain and suffering. On June 10, echoing the sentiment of the state’s House of Representatives, Oregon’s Senate votes 20 to 10 to return Measure 16 to the voters. On October 27, Oregon’s Death with Dignity Act, passed in 1994, becomes effective. However, a measure to repeal it is slated to appear on the ballot in the upcoming election. On November 4, Oregon voters reject Measure 51, the ballot measure which would have repealed the state’s Death with Dignity Act (Measure 16). Colombia allows euthanasia under specific circumstances. By a vote of 234 to 89, the British Parliament votes against legalizing assisted suicide. 1998 The Health Services Commission in Oregon declares that it is permissible to utilize state funds for costs associated with physician-assisted suicide. Sixteen people take advantage of Oregon’s Death with Dignity Act and die by physician-assisted suicide this year. Michigan voters defeat Measure B, which would legalize physician-assisted suicide. Janet Reno, U.S. Attorney General, overturns the Drug Enforcement Administration’s 1997 declaration that “delivering, dispensing, or prescribing a controlled substance with the intent of assisting a suicide” is not a “legitimate medical purpose.” Dr. Kevorkian helps 18 people commit suicide this year. Nancy Rush lung cancer, emphysema, ulcers Carrie Hunter AIDS Jeremy Allen kidney cancer
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Muriel Clement
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advanced Parkinson’s disease Roosevelt Dawson quadriplegia William Connaughton fibromyalgia Patricia Greyham rheumatoid arthritis Waldo Herman lung cancer Mary Judith Kanner Huntington’s disease Shala Semonic amyotrophic lateral sclerosis Dixie Colleen Wilson amyotrophic lateral sclerosis Priscilla Hiles chronic arthritis, degenerative disk disease, sciatica, asthma Jack Schenbern prostate cancer Lucille Alderman heart disease and osteoarthritis Matthew Johnson quadriplegia Emma Kass lung cancer Joseph Tushkowski quadriplegia Thomas Youk amyotrophic lateral sclerosis On November 22, the CBS primetime program 60 Minutes shows footage of Dr. Jack Kevorkian helping Thomas Youk commit suicide. On November 24, Dr. Jack Kevorkian is charged in Michigan with murder in the death of Thomas Youk. Additional charges include violating the assisted suicide law and delivering a controlled substance without a license. Twenty-six people utilize Oregon’s Death with Dignity Act and die by physician-assisted suicide during this year. A bill to allow assisted suicide passes two committees of the California state legislature but lacks sufficient support to be put to a vote of the full Assembly. The Pain Relief Promotion Act of 1999, geared toward promoting aggressive pain management and prohibiting the use of controlled substances for assist-
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1999 (cont.) ed suicide and euthanasia, is introduced in Congress. It is approved in the U.S. House of Representatives. On April 13, Dr. Jack Kevorkian receives a prison sentence of 10 to 25 years for second-degree murder in the death of Thomas Youk. Kevorkian will be eligible for parole in six years. He plans to appeal. 2000 Maine voters defeat, by a vote of 51 percent to 49 percent, a ballot initiative that would legalize physicianassisted suicide. The State Senate in New Hampshire votes against legalizing physician-assisted suicide. A Hawaiian public access television station airs Final Exit, a video which demonstrates how to commit suicide using a plastic bag. The video was prepared by Derek Humphry of the Hemlock Society. A judge in Michigan denies Dr. Jack Kevorkian’s plea for early release. Kevorkian had cited poor health in making this request. Oregon Senator Ron Wyden threatens to filibuster the Pain Relief Promotion Act of 1999, which passed the U.S. House of Representatives in 1999. As a result, the act is never put to a Senate vote. The Voluntary Euthanasia Society of Scotland (VESS) changes its name to EXIT. 2001 U.S. Attorney General John Ashcroft restores the DEA’s 1997 declaration that it is not permissible for doctors to prescribe federally controlled drugs for euthanasia or assisted suicide. Ashcroft’s statement thwarts Oregon’s assisted suicide law and state officials secure a temporary restraining order to suspend the order pending judicial review. The New England Journal of Medicine features a report regarding sixty-nine of the cases in which Dr. Jack Kevorkian assisted people in committing suicide. The Journal analysis shows that seventeen were terminally ill. The other fifty-two were not terminally ill but their conditions had recently become worse. In five of those fifty-two cases, autopsies did not yield evidence of any disease. The Supreme Court in Alaska is unanimous in
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its rejection of a claim that Alaska’s law against assisted suicide violates constitutional rights. California’s state legislature approves legislation aimed at enhancing pain management for people at the end of their lives. On April 10, voluntary euthanasia is legalized in the Netherlands. The country is the first in the world to declare that euthanasia is legal. Hawaii’s House of Representatives approves a bill legalizing physician-assisted suicide. Known as Hawaii’s Death with Dignity Act, the bill fails in the State Senate by a vote of 14 to 11. On April 17, a federal judge rules that Attorney General John Ashcroft does not have the authority to foil the Oregon law which allows physician-assisted suicide. The federal government files an appeal with the Ninth Circuit Court of Appeals. On February 1, the new law in the Netherlands regarding voluntary euthanasia and physician-assisted suicide goes into effect. Although not illegal prior to this, such acts were permitted only under certain guidelines. Belgium approves a law similar to that of the Dutch. It allows voluntary euthanasia and physicianassisted suicide. On November 27, Toronto’s National Post prints results of a poll of Canadians regarding various issues, including physician-assisted suicide. The poll, conducted by Canadian polling firm COMPAS, shows that 55 percent of Canadian adults support physician-assisted suicide, while 36 percent oppose it. Representative Linda Lopez of Arizona’s House of Representatives sponsors a bill to legalize “aid in dying.” The bill fails within committee and never makes it to a full House vote. The Vermont Death with Dignity Act is introduced in Vermont’s state legislature. The bill never makes it to a vote. Oral arguments are held in the U.S. Ninth Circuit Court of Appeals regarding Attorney General John Ashcroft’s prohibition of the use of federally
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2003 (cont.) controlled drugs for assisted suicide. The case is known as Oregon v. Ashcroft. Hawaii’s Death with Dignity Act dies in committee. Oregon officials report that 129 people have been granted approval for physician-assisted suicide since 1998. Following a survey of its members, the Hemlock Society embraces a new course: The organization will become more proactive in the legislative arena. The goal is to provide people who are terminally ill and mentally competent with the opportunity to legally choose a peaceful death. The Hemlock Society’s new name is End-of-Life Choices. 2004 The Final Exit Network is formed following the change in the Hemlock Society’s name and mission. The Final Exit Network establishes a group of volunteers to help and support the dying. Hawaii’s Death with Dignity Act passes the state’s House Judiciary Committee, but the bill never makes it to a vote before the full House. Arizona Representative Lopez introduces a second bill regarding assisted suicide. Known as the Patient Comfort and Control Act, the bill fails. The Vermont Medical Association voices its opposition to legalizing physician-assisted suicide in Vermont. Disability rights groups join them in opposing such legislation. In Vermont, the chairs of the House and Senate Health and Welfare Committees announce that there will be no action on bills to legalize physician-assisted suicide. Legislation to legalize physician-assisted suicide is introduced in Wyoming. On May 26, the U.S. Ninth Circuit Court of Appeals upholds the lower court’s ruling in Oregon v. Ashcroft. On November 9, Attorney General John Ashcroft submits his resignation to President George W. Bush. Prior to leaving office, Ashcroft appeals the decision of the U.S. Ninth Circuit Court of Appeals in Ashcroft v. Oregon.
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The U.S. Supreme Court agrees to hear Gonzales v. Oregon (formerly known as Oregon v. Ashcroft). On March 2, Charles Cullen, a nurse who pled guilty in the deaths of twenty-nine patients, is sentenced to eleven consecutive life terms. Cullen had worked in nine hospitals and a nursing home throughout New Jersey and Pennsylvania. He told authorities that he may have killed more people than the twenty-nine for which he was convicted. On March 31, Terry Schiavo dies at the age of 41 after spending years in what many doctors termed a persistent vegetative state (PVS). Her death follows a protracted legal battle between her husband, Michael, and her parents, Robert and Mary Schindler, regarding Michael Schindler’s decision to remove life support, including a feeding tube and hydration. On April 30, Donald Herbert, a firefighter from Buffalo, New York, awakens and speaks after spending close to ten years in a coma. Herbert had fallen into the coma after a burning roof fell on him in the line of duty and he was deprived of oxygen. On October 14, Charles Foti, Attorney General of Louisiana, investigates allegations that staff at Memorial Medical Center euthanized patients following Hurricane Katrina. The allegations center on patients who were elderly and seriously ill. In Vermont’s House of Representatives, Representatives William Aswad, Malcolm Severance, and David Zuckerman introduce House Bill 168, Vermont’s Death with Dignity Act. The bill is sent to the Human Services Committee. Assembly members Lloyd Levine and Patty Berg of the California State Assembly introduce Bill 651, the California Compassionate Choices Act. Compassion and Choices, an organization dedicated to providing patients with end-of-life choices, is created as the result of a merger between Compassion in Dying and End-of-Life Choices. The organization is headquartered in Denver, Colorado, and Portland, Oregon. A new version of Hawaii’s Death with Dignity
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2005 (cont.) Act is introduced in the state legislature but the bill dies in committee and never makes it to a full vote. Arizona’s state legislature considers two bills legalizing assisted suicide. HB 2313 is similar to Oregon’s Death with Dignity Act, while HB 2311 is similar to the 2004 Patient Comfort and Control Act. Both bills fail. The state legislature of Wisconsin considers a Death with Dignity bill introduced by Representatives Frank Boyle and Fred Risser. A Swiss hospital declares that representatives of EXIT, a right-to-die organization with a local chapter, will be allowed into hospital wards. EXIT is legally permitted to help terminally ill people in Switzerland commit suicide. However, there are certain conditions: It is the patient’s stated wish to die, the patient is suffering from an incurable disease or faces imminent death, and the patient administers the fatal overdose of barbiturates. If the assisting person has “selfish motives” in assisting the suicide, he or she can be prosecuted for providing assistance. A pharmaceutical company announces that “euthanasia kits” will be made available in pharmacies in Belgium. 2006 The U.S. Supreme Court, by a vote of 6 to 3, rules that Oregon’s physician-assisted suicide law stands. Rejecting the position of former Attorney General John Ashcroft, the Court rules that the attorney general does not have the authority to override the Oregon law allowing physician-assisted suicide. In Rhode Island’s General Assembly, Representative Edith Ajello introduces the Rhode Island Death with Dignity Act (HB 7428). After failing in committee, the bill never makes it to the floor for a full vote. State Senator Pat Thibaudeau introduces Washington’s Death with Dignity Act (Senate Bill 6843). The bill remains in the Senate Committee on Health and Long-Term Care. On February 21, Donald Herbert, the Buffalo firefighter who emerged from a ten-year coma in April 2005, dies after contracting pneumonia.
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On May 2, the U.S. Court of Appeals in Washington rules that terminally ill patients have the right to receive experimental drugs prior to official approval of the drugs by the U.S. Food and Drug Administration. On May 22, Michigan’s Department of Corrections receives a request from Dr. Jack Kevorkian for commutation of his prison sentence of 15 to 20 years for second-degree murder in the death of Thomas Youk. He bases his request on failing health. On July 18, a doctor and two nurses are arrested for allegedly euthanizing patients in a hospital in New Orleans, Louisiana, following the devastation wrought by Hurricane Katrina. Australia’s Suicide Materials Offenses Act is effective. Under this act, it is criminal to discuss euthanasia or assisted suicide or provide advice on these matters on the Internet or via telephone, e-mail, or fax. Books, postal mail, and meetings are not included. On May 12, the British House of Lords votes 148 to 100 against legalizing physician-assisted suicide. Dr. Jack Kevorkian is released from prison in June. California representatives Patty Berg and Lloyd Levine place a bill before their colleagues in California’s state legislature to legalize assisted suicide. Additional people may have received Dr. Jack Kevorkian’s assistance in committing suicide. Dr. Kevorkian reportedly kept some of the cases private.
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5 Biographical Sketches
T
he following people have participated—or are participating— in the issues of euthanasia or physician-assisted suicide in some way. Some continue to make an impact on this issue at the present time; others are deceased but their legacies are important to the study of this topic. Some of these names will be recognizable because of their influence on end-of-life issues in the areas of public policy, religion, research, or ethics. Others will be familiar because their names are associated with some sort of milestone in the realm of end-of-life issues.
Janet Adkins (1936–1990) Janet Adkins was a teacher who lived a full and active life in Portland, Oregon, with her husband and their three sons. When she was diagnosed with Alzheimer’s disease, she was informed that she would soon be unable to care for herself. She sought counseling and determined that she would rather die than live the life that lay before her. Her early efforts to obtain aid in dying from three Oregon physicians were unsuccessful, but when she learned of Dr. Jack Kevorkian through media reports, she contacted him. He examined her medical records and decided to assist her in her quest to die. In June 1990, Janet Adkins’ husband accompanied her to Michigan. Dr. Kevorkian chose a campsite outside of Royal Oak,
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Michigan, as the location to assist her in her effort to die. Dr. Kevorkian’s method required Adkins to flip a switch to trigger the release of thiopental to induce sleep. Subsequently, with the use of a timer, potassium chloride was administered to stop Adkins’ heart. Despite Kevorkian’s efforts to streamline the process, there were unforeseen glitches: He was missing some necessary components for the machine when he arrived. During his attempts to remediate the problem, some of the necessary medication was spilled. As a result, Adkins waited while Dr. Kevorkian addressed the situation. Although her death was delayed briefly by these problems, Janet Adkins will forever be known as the first person to die by using Dr. Jack Kevorkian’s “suicide machine,” which he called the “mercitron.” Her death, on June 4, 1990, was reported internationally and it spurred a spate of legislation regarding end-of-life issues. Dr. Kevorkian was subsequently charged with murder in Adkins’ death, but the case ended in an acquittal.
Dr. Pieter Admiraal (1929–) Dr. Pieter Admiraal is known for his efforts since the early 1970s to promote euthanasia as an option in the Netherlands. In addition to his advocacy efforts, Dr. Admiraal has practiced physicianassisted suicide; in fact, he is considered to be one of the most experienced physicians in the world in practicing physician-assisted suicide. An anesthesiologist, Dr. Admiraal served at the Reinier de Graf Hospital in Delft for thirty years before retiring in 1995. His efforts to promote euthanasia and physician-assisted suicide include the publication of a 1977 guide that outlines the dosages required for drugs to be lethal. He followed this guide up in 1987 with a compilation of lethal dosage information for the Royal Dutch Society for the Advancement of Pharmacy. He has also written numerous pieces addressing the issue of physician effectiveness in various physician-assisted suicide scenarios. In addition, Dr. Admiraal has spoken about physician-assisted suicide in various locations throughout the world. Dr. Admiraal is known for expressing the view that euthanasia should be included as one of the options available to patients at the end of their lives as a way of helping them maintain their autonomy as they face end-of-life issues.
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Kevin Andrews (1955–) In Australia’s Northern Territory, euthanasia was legalized for a period of nine months: July 1996 through March 1997. The law which made euthanasia legal for this period was known as the Rights of the Terminally Ill Act (ROTI). Marshall Perron had sponsored the legislation. In 1996, Kevin Andrews introduced the Euthanasia Laws Bill of 1996 aimed at repealing the Rights of the Terminally Ill Act. Andrews’ bill was passed and the ROTI was repealed. A barrister, Andrews was elected to Australia’s House of Representatives in 1991,and served as the Minister of Aging for nearly two years. Andrews has collaborated on articles and books on several subjects, including issues related to biomedical ethics.
Dr. Margaret Pabst Battin Margaret Pabst Battin, Ph.D., has authored and edited books, journal articles, and papers on various subjects, including those related to end-of-life issues. The books include Ethical Issues in Suicide, Suicide: The Philosophical Issues, The Case for Physician-Assisted Dying: The Right to Excellent End-of-Life Care and Patient Choice, and Ending Life: Ethics and the Way We Die. Dr. Battin is a professor of Philosophy and adjunct professor of Internal Medicine, Division of Medical Ethics, at the University of Utah. In addition to a Ph.D. in Philosophy from the University of California at Irvine (1976), Dr. Battin holds a Master’s of Fine Arts degree, also from the University of California at Irvine (1973), and a bachelor’s degree from Bryn Mawr College (1963).
Pope Benedict XVI (1927–) As the leader of the world’s Roman Catholic population, Pope Benedict XVI, by his words and actions, influences Catholic opinion on various matters, including euthanasia, physician-assisted suicide, and other issues related to the end of life. In his role as leader of the church, he also sets policy for Roman Catholic institutions such as hospitals and nursing homes that play a role in end-of-life care. Pope Benedict XVI has both influenced Roman
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Catholics and established policy by stressing the sanctity of life from birth until death. Pope Benedict XVI, formerly known as Cardinal Joseph Ratzinger, was born in Germany in 1927. He was ordained as a priest in the Roman Catholic Church in 1951, obtaining his doctorate in theology two years later. He subsequently began teaching at the university level and participated in Vatican II as a theological advisor to the Archbishop of Cologne, Cardinal Joseph Frings. Father Ratzinger was later named an archbishop and then a cardinal. He served as Prefect of the Congregation for the Doctrine of the Faith and later as a leader of the College of Cardinals. He was elected by his fellow cardinals to serve as pope, following the death of Pope John Paul II in April 2005.
Dr. Daniel Callahan (1930–) Daniel Callahan has studied numerous issues related to bioethics, including population, aging, abortion, euthanasia, and physicianassisted suicide. His seminal works in these and other areas of bioethics have earned him a reputation as an expert on issues related to medical ethics. In addition to a Ph.D. from Harvard University (1965), Dr. Callahan’s educational background includes a master’s degree from Georgetown University (1957) and a bachelor’s degree from Yale University (1952). Dr. Callahan cofounded the Hastings Center in 1969 and was its president for more than 20 years. He also was director of its international program. His work in academia has included serving as a Fellow in Yale University’s Institution for Social and Policy Studies, Senior Research Fellow in Yale’s Department of Philosophy, Senior Lecturer at Harvard Medical School, and Visiting Fellow at Harvard’s Center for Population and Development Studies. In addition, Dr. Callahan has served as a board member, consultant, or advisor for various organizations, including the Medical Ethics Committee of the American College of Physicians, the U.S. Centers for Disease Control and Prevention, and the Center for Philosophy and Public Policy. He was a special consultant to the Presidential Commission on Population Growth and the American Future in the early 1970s. Dr. Callahan is the author, coauthor, or editor of numerous
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books, including Medicine and the Market: Equity v. Choice (with Angela Wasunna), A World Growing Old (with Ruud ter Meulen and Eva Topinková), The Troubled Dream of Life: In Search of a Peaceful Death, What Kind of Life: The Limits of Medical Progress, and Setting Limits: Medical Goals in an Aging Society.
Diane Coleman Diane Coleman is the founder of Not Dead Yet. Founded in 1996, this organization is dedicated to opposing assisted suicide and euthanasia. In her capacity as founder, she has appeared on numerous television and radio programs at the national, regional, and local levels. Coleman is a person with disabilities and she adds that perspective to her work, as well as to her service as a board member for disability-related organizations. She has written articles on topics related to disabilities, and she speaks on such topics, as well as on topics related to health care. Coleman is an adjunct member of the faculty of University of Illinois at Chicago, where she has cotaught courses at the graduate level addressing issues of disability and medical ethics. Coleman earned her law degree and Master’s in Business Administration at the University of California, Los Angeles (1981). After practicing law for several years, she became codirector of the Technology Access Center of Middle Tennessee and Policy Analyst for the Tennessee Technology Access Project. She is currently serving as the executive director of the Progress Center for Independent Living in Illinois, an organization which advocates for people with disabilities.
Nancy Cruzan (1957–1990) At the age of 25, Nancy Cruzan was in an automobile accident that resulted in extensive injuries, oxygen deprivation, and permanent brain damage. Her deep coma would eventually be determined to be a persistent vegetative state. Her family talked to her, provided stimulation, and made her as comfortable as possible as they worked to help her come out of the coma. However, after four years, they began to believe that she might never come out of the
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coma. At that point, her family declared that she would not have wanted to live that life. Due to the fact that she was not on a ventilator or other form of life support, it was determined that removing the feeding tube was the only way to bring about the end of her life. Her parents stated that they, on their daughter’s behalf, wanted the tube to be removed. Administrators at the rehabilitation facility where she lived resisted this decision and Nancy Cruzan’s parents took their case to court. Nancy Cruzan did not have any written directives regarding her end-of-life wishes. In the absence of such directives, the court ruled that the state’s interest in maintaining sanctity of life outweighed the family’s concerns about Nancy Cruzan’s quality of life. The Cruzans disagreed and appealed the verdict; the case went to the U.S. Supreme Court. The Court, in Cruzan v. Director, Missouri Department of Health, ruled in favor of the Cruzans, citing the right to die as a constitutionally protected liberty interest. There was a caveat, however, that such a right to die was not absolute. The court declared that there were limitations unless proof existed regarding the person’s wishes and that it was incumbent on the states to provide guidelines to determine what was acceptable as proof. The Cruzans went back to the state court in Missouri to offer proof of what their daughter’s wishes might have been; testimony from friends was found by the state court to constitute sufficient proof. Nancy Cruzan’s feeding tube was subsequently removed on December 14, 1990 and she died on December 26, 1990.
Dr. Kathleen Foley After earning her degree in medicine at Cornell University Medical College, Dr. Kathleen Foley completed her residency, as well as a fellowship, at the New York Hospital/Cornell Medical Center. She is board certified in Neurology with clinical expertise in Cancer Pain and Supportive Care. Her work has included extensive study about pain, palliative care, and issues related to the end of life. An attending neurologist in the Pain and Palliative Care Service at Memorial Sloan-Kettering Cancer Center in New York City, Dr. Foley has served as the chair of the Society of Memorial Sloan-Kettering Cancer Center in Pain Research. She has also
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served as a professor of Neurology, Neuroscience, and Clinical Pharmacology at Weill Medical College of Cornell University. Dr. Foley has chaired two advisory panels for the World Health Organization’s Cancer Unit; the panels developed guidelines for managing cancer pain and establishing initiatives in palliative care. Dr. Foley’s other experience has included testifying before the Senate Judiciary Committee, managing the Project on Death in America (PDIA), and writing extensively. She has written or cowritten several books, including The Case against Assisted Suicide: For the Right to End-of-Life Care; Palliative Care for Infants, Children, and Adolescents: a Practical Handbook; and Describing Death in America: What We Need to Know.
Dr. Faye Girsh Dr. Faye Girsh earned her doctorate at Harvard University. She has worked as a clinical and forensic psychologist and taught at Morehouse College and the University of Chicago. She has an extensive background with the right-to-die movement, including serving as president of the Hemlock Society, vice president and president of End-of-Life Choices, senior advisor for the Final Exit Network, and member of the board of directors of various organizations, including Americans for Death with Dignity, ERGO, and the World Federation of Right to Die Societies. In recognition of her dedication to right-to-die issues, Dr. Girsh received the Hemlock Society’s Lifetime Achievement Award. Dr. Girsh has made television appearances, written extensively, and spoken internationally about right-to-die issues. She remains active in the right-to-die movement.
Dr. Herbert Hendin (1926–) Dr. Herbert Hendin is a professor of psychiatry and behavioral sciences at New York Medical College. He previously served as medical director of the American Foundation for Suicide Prevention. As a result of his extensive study of suicide and assisted suicide in the United States and the Netherlands, Dr. Hendin is considered an expert on these subjects. He has testified before the
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Subcommittee on the Constitution of the Judiciary Committee of the U.S. House of Representatives. In addition, Dr. Hendin has written extensively on the aforementioned subjects. Among the books he has written or collaborated on are The Case against Assisted Suicide: For the Right to Endof-Life Care; Seduced by Death: Doctors, Patients and Assisted Suicide; and Suicide in America.
Vincent Humbert (1981–2003) An active, vibrant 22-year-old Frenchman, Vincent Humbert was injured in an automobile accident in 2000. In addition to depriving him of his ability to walk, the accident deprived him of his sight, speech, and senses of smell and taste. He used his ability to move his right thumb to painstakingly indicate letters so that he could spell out his wish to die legally in a book entitled Je Vous Demande le Droit de Mourir (I Ask the Right to Die). He was frustrated by the fact that his request was not granted. His mother, Marie Humbert, agreed to help him commit suicide. Subsequent to her actions assisting him in this quest, she was arrested. Although the charges against Marie Humbert were eventually dropped, she was frustrated that she did not have the opportunity to stand trial, defend her son’s wishes, and advocate for other people to gain the right to die.
Derek Humphry (1930–) Born in England, Derek Humphry began his newspaper career as a messenger for the Yorkshire Post and quickly worked his way into a position as a reporter for the Bristol Evening World. He was drafted into the British Army and served for two years. Afterward, he worked as a reporter for the Manchester Evening News, and then at the London Daily Mail. He later accepted a position as an editor. When Humphry’s wife, Jean, was diagnosed with inoperable bone cancer, he helped her commit suicide. He later married Ann Wickett and they moved to the United States, where Humphry worked again as a reporter, this time at the Los Angeles Times. In 1978, Humphry published Jean’s Way, a book in which he recounted his role in helping his first wife commit suicide. The
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book received mixed reactions: praise from those who supported his actions in assisting Jean with committing suicide and criticism from those who questioned the legality and correctness of his actions. Among the critics were prosecutors in London; however, after a lengthy investigation, the prosecutors decided against charging him with a crime. As a result of the publicity surrounding this case, Humphry began to receive requests from others who wanted his assistance in committing suicide. These requests prompted him and his wife, Ann Wickett, along with Gerald Larue and Richard Scott to form the Hemlock Society. This organization was dedicated to helping people explore suicide as an option when facing terminal illness, advocating for legislation to legalize assisted suicide, and providing support to people who had decided to end their lives. Humphry’s later books include Let Me Die Before I Wake, The Right to Die, Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide, Dying with Dignity: Understanding Euthanasia, Lawful Exit: The Limits of Freedom for Help in Dying, and The Good Euthanasia Guide 2004: Where, What, and Who in Choices in Dying.
Pope John Paul II (1920–2005) During his papacy, Pope John Paul II served as the leader of Roman Catholics throughout the world. In this capacity, he had unparalleled influence on the opinions of Roman Catholics. His policies governed Roman Catholic institutions, including hospitals and nursing homes, throughout the world. Born Karol Wojtyla in Krakow, Poland, Pope John Paul II was ordained to the priesthood in the Roman Catholic Church in 1946. During his papacy, which began in 1978, Pope John Paul II traveled more than any of his predecessors as he spread the message of Catholicism throughout the world. As the pope, he placed special emphasis on the sanctity of life; in this way, he addressed various issues including abortion and euthanasia. One of his encyclicals, issued in 1980, addressed euthanasia. In this document, he denounced euthanasia and declared that there is spiritual value in suffering. Pope John Paul II’s encyclical became more meaningful for many Roman Catholics when he lived the message that he had preached in it. When he was diagnosed with Parkinson’s disease,
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he continued to spread the message of Catholicism; as his health declined, he remained dedicated to that message. His death, in April 2005, was mourned by Roman Catholics and others throughout the world who cited his suffering as a testament to his beliefs in the sanctity of life.
Yale Kamisar (1929–) Although Yale Kamisar is most known for his expertise in criminal procedure and related areas, he is also considered an expert on issues related to physician-assisted suicide and euthanasia. Kamisar has written extensively on a variety of issues; his writings on end-of-life issues include papers, articles, and chapters for books. He has also collaborated on books regarding constitutional law and constitutional rights After graduating from New York University, Yale Kamisar earned his law degree at Columbia Law School. As a law school professor, he has instructed students at the University of Michigan Law School, the University of San Diego School of Law, and the University of Minnesota Law School.
Dr. Jack Kevorkian (1928–) Dr. Jack Kevorkian’s name is what comes to mind for many people in the United States if the topic of euthanasia or physicianassisted suicide is raised. His renown in this area is a result of the assistance he gave to people who wished to commit suicide. By Dr. Kevorkian’s own count, he assisted approximately 130 people in that endeavor. Dr. Kevorkian devised a machine to facilitate the process of assisting people in committing suicide. The “mercitron” incorporated a mechanism that enabled the patient to flip a switch that would prompt the machine to begin administering a drug cocktail that would end life. Although he was arrested and faced criminal charges in three of the cases in which he assisted people in committing suicide, he was acquitted each time. That changed, however, when he was arrested and charged with first-degree murder in the death of Thomas Youk (see biographical information for Thomas Youk).
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Dr. Kevorkian’s motives were controversial and unclear. In addition to questions of legality, there were issues raised about the fact that some of the people he assisted in committing suicide were later determined to not actually suffer from a terminal illness. He also was criticized for not having a long-term doctor-patient relationship with any of them; rather, he got to know them briefly when they reached out to him to request his assistance in committing suicide. Some people in the medical and legal communities argued that some of these people might not have chosen suicide if they had received adequate medical and/or other treatment.
Dr. Elisabeth Kübler Ross (1926–2004) Dr. Elisabeth Kübler Ross was known for her work, including writing numerous books, about death, dying, grief, and grieving. Dr. Kübler Ross was born in Zurich, Switzerland, in 1926. She attended medical school at the University of Zurich. After graduating in 1957, she moved to the United States and began her career. From the beginning, Dr. Kübler Ross was struck by the way terminally ill people were treated and she sought to improve that treatment by offering insight into their experience. Her first book, On Death and Dying, provided insight into the five stages of the dying process and insight into how death impacts everyone affected by it. Although some now denounce these stages as unscientific and declare that the stages are not universally experienced by everyone who is terminally ill, the book and the research by Dr. Kübler Ross remain required reading for many people studying for careers as doctors, nurses, psychiatrists, psychologists, or other professions in which they may come in contact with the terminally ill. In addition to On Death and Dying, Dr. Kübler Ross wrote several other books, including The Tunnel and the Light, AIDS: The Ultimate Challenge, Living with Death and Dying, and On Grief and Grieving.
Luis Kutner (1908–1993) Luis Kutner, an attorney who practiced law in Chicago, Illinois, is credited with proposing that living will documents be used as a means of allowing people to express their wishes regarding end-
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of-life care. He published “Due Process of Euthanasia: The Living Will, a Proposal” in the Indiana Law Review in 1969. The paper was widely considered to be a milestone regarding the legal side of issues related to euthanasia and other matters dealing with the end of life. Kutner was motivated by his belief that people who wished to have assistance in committing suicide were denied legal rights and protections necessary to safeguard their wish to die. Those who agreed to assist them, he believed, should also be protected. He posited that his proposed living will document would enable adults who were mentally competent and healthy to put their wishes in writing so that there would be no question about what kind of care the person wanted at the end of life. Living wills are now common and the term has become part of our lexicon. Kutner is also known for his role in cofounding Amnesty International.
Barbara Coombs Lee Barbara Coombs Lee is a physician assistant and family nurse practitioner, as well as an attorney. She is committed to providing end-of-life choices. She works to do that in her role as president of Compassion and Choices, an organization which was created as a result of a merger between Compassion in Dying and End-of-Life Choices. Prior to the merger of the organizations, she had served as president and chief executive officer of Compassion in Dying. In addition to practicing as a private attorney, Lee has served as a counsel to the State Senate of Oregon and as an executive in the field of managed care. She was a chief petitioner regarding the Oregon Death with Dignity Act.
Rita Marker (1940–) A practicing attorney, Rita Marker has served as director of the International Task Force on Euthanasia and Assisted Suicide since the organization was founded in 1987. Marker previously served as an adjunct professor of Political Science and Ethics at the University of Steubenville, Ohio. She has written numerous articles and spoken on issues related to bioethics and human
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rights throughout the world. Marker’s other advocacy efforts include offering testimony to the Subcommittee on the Constitution, Civil Rights, and Property Rights of the U.S. Senate Judiciary Committee. Marker wrote Deadly Compassion. In this book, she examined the topic of euthanasia in terms of the suicide of Ann Humphry and argued against the legalization of euthanasia. She also contributed to Contemporary Perspectives on Rational Suicide.
Dr. Philip Nitschke (1947–) When the Rights of the Terminally Ill Act was introduced for Australia’s Northern Territory, Dr. Philip Nitschke made headlines by stating that he would be willing to assist patients in committing suicide. Soon after, he developed a device he called a “deliverance machine.” This piece of equipment included a computer which required patients to repeatedly confirm their wish to die before the drugs to end life were administered. Dr. Nitschke assisted four people in ending their lives under the Rights of the Terminally Ill Act. The act, which was in effect for nine months, was repealed under the Euthanasia Laws Bill of 1996, proposed by Kevin Andrews. Dr. Nitschke subsequently founded EXIT International. Members of EXIT International advocate for new legislation to legalize euthanasia and help people obtain information regarding options available to them at the end of their lives. As part of his work with EXIT International, Dr. Nitschke conducts workshops throughout Australia and New Zealand to provide people with information on relevant legal issues and how they can control their own deaths.
Dr. Edmund Pellegrino (1920–) Dr. Edmund Pellegrino is known for his opposition to euthanasia and physician-assisted suicide. He was especially vocal on the subject when the Journal of the American Medical Association (JAMA) printed an intern’s anonymous letter purportedly relating his experience in assisting in the death of a terminally ill patient. The letter, “It’s Over, Debbie,” was published in JAMA on January 8, 1988.
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A professor emeritus of Medicine and Medical Ethics at the Center for Clinical Medical Ethics at Georgetown University Medical Center, Dr. Pellegrino also previously served as the director of the Kennedy Institute of Ethics at Georgetown. Dr. Pellegrino’s educational background includes a bachelor’s degree from St. John’s University. He earned his medical degree at New York University. His résumé includes extensive writing in philosophy and ethics, as well as medical science. In addition, he has authored or coauthored numerous books, including Transcultural Dimensions in Medical Ethics; Jewish and Catholic Bioethics: An Ecumenical Dialogue; and Health, Disease, and Illness: Concepts in Medicine. Dr. Pellegrino currently serves as a senior fellow of the Center for Bioethics and Human Dignity, an organization dedicated to exploring and expanding the Christian role in issues of bioethics.
Dr. Gertruida Postma In the early 1970s, Dr. Gertruida Postma of the Netherlands administered a lethal injection to her mother, who was dying. She was tried and found guilty; her sentence consisted of a one-month suspended sentence and a year of probation. Jaap Sybrandy, a social worker, and his wife, Klazien, subsequently formed the Netherlands Society for Voluntary Euthanasia because they were inspired by the story surrounding Dr. Potsma and her mother. As a result of their efforts, a legal precedent was established to allow euthanasia in the Netherlands under certain conditions.
Dr. Timothy Quill (1949–) Dr. Timothy Quill is director of the Palliative Care Program at the University of Rochester Medical Center in Rochester, New York. He is also a professor of medicine at the University of Rochester School of Medicine and Dentistry. In addition to numerous articles about end-of-life care, Dr. Quill has written or edited several books, including Death and Dignity: Making Choices and Taking Charge, A Midwife through the Dying Process: Stories of Healing and Hard Choices at the End of Life, Caring for Patients at the End of Life: Facing an Uncertain Future
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Together, Physician Guide to End-of-Life Care, and The Case for PhysicianAssisted Dying: The Case for Palliative Care and Patient Choice. Dr. Quill is the physician referenced in Quill v. Vacco, a case that originated in New York State and went to the U.S. Supreme Court. Dr. Quill had prescribed medication for a leukemia patient to help her sleep, even though he knew there was a possibility that she would take them to end her life. She did just that. He wrote about this experience in the New England Journal of Medicine and ultimately appeared as a plaintiff before the Supreme Court in Quill v. Vacco (McKhann 1999, 84). Dr. Quill co-edited Physician-Assisted Dying: The Case for Palliative Care and Patient Choice with Margaret Pabst Battin, Ph.D. In the introduction to this book, Drs. Quill and Battin write that the central question in this issue is not whether people would prefer “access to palliative care and hospice or access to physicianassisted death” (2004, 1). They pose the central question as “What would you prefer, access to excellent palliative care and hospice by themselves or access to excellent hospice and palliative care plus legal access to a physician-assisted death as a last resort if your suffering becomes intolerable and you wish an earlier, easier death?” (Quill and Battin 2004, 1).
Karen Ann Quinlan (1954–1985) Karen Ann Quinlan fell into a coma on April 15, 1975, at the age of 21, after consuming drugs and alcohol. She was admitted to a New Jersey hospital where she was monitored for several months. When doctors declared that she had sustained irreversible brain damage and was in a persistent vegetative state, her parents stated that it was their wish, on her behalf, to have their daughter taken off the respirator. Although hospital officials initially agreed with the decision made by Quinlan’s parents, they later decided that they could not allow her to be removed from the respirator. Mr. and Mrs. Quinlan responded by taking their battle to court. During the intervening period, Quinlan’s nurse weaned her from the respirator and the court battle became moot. Quinlan remained in a persistent vegetative state for eight years; she died in 1985 of pneumonia. Karen Ann Quinlan’s case resonated for years after her death. Numerous pieces of legislation addressing end-of-life issues were
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proposed throughout the country, hospitals created ethics committees to address thorny end-of-life issues, and requests for living wills increased dramatically.
Dr. James Rachels (1941–2003) During his professional career, Dr. James Rachels wrote extensively on morality, moral philosophy, and ethics; some of his writings focused on euthanasia and other end-of-life issues. His books include The End of Life: Euthanasia and Morality. His article “Active and Passive Euthanasia” was published extensively, including in one of his own books of essays. Born in 1941, Dr. Rachels earned his bachelor’s degree at Mercer University (1962) and his Ph.D. at the University of North Carolina at Chapel Hill (1967). During his teaching career, he taught students at the University of Richmond, New York University, the University of Miami, Duke University, and the University of Alabama at Birmingham.
Dame Cicely Saunders (1919–2005) Dame Cicely Saunders worked as a nurse and later returned for additional education to enable her to work as a physician. She combined her training with compassion and a bold philosophy about the dying process when she opened the first modern hospice, St. Christopher’s, outside London, England, in 1967. Later she toured the United States to share her insight, experience, and ideas about providing comfort care for people who are terminally ill. At St. Christopher’s, Dame Saunders implemented a philosophy that united medical care for the patient with spiritual care for the patient and the patient’s family. Her goal was to incorporate compassion into every action and respect for the patient’s dignity while providing comfort, care, and adequate pain relief to the terminally ill. Through her implementation of this type of care, Dame Saunders provided a new alternative for people who faced terminal illnesses. In recognition of her efforts and dedication to the hospice movement, the title of Dame was bestowed on her in 1980. Today, Dame Saunders is known as the founder of the modern hospice movement and she is remembered for her dedi-
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cation to humanizing and personalizing the dying process as much as possible.
Terri Schindler Schiavo (1963–2005) When Terri Schindler Schiavo collapsed in 1990, she suffered cardiac arrest and slipped into a state that some physicians determined was a persistent vegetative state. She was 26 years old and she did not have advance directives. In the absence of such a document, her husband, Michael, was responsible for decisions regarding her care. At some point later, Michael Schiavo began to have disagreements with his wife’s parents, Robert and Mary Schindler, regarding her care. Michael Schiavo argued that his wife would not have wanted to be kept alive in the manner in which she was living. Citing conversations with his wife, he stated his intention to have her feeding tube removed. His in-laws disagreed and a legal battle ensued. Michael Schiavo’s decision ultimately prevailed and Terri Schiavo’s feeding tube was removed. She died on March 31, 2005. The case spawned a great deal of media attention and debate, as well as increased interest in the concept of advance directives.
Wesley J. Smith (1949–) Wesley J. Smith is an author, a senior fellow at the Discovery Institute, an attorney for the International Task Force on Euthanasia and Assisted Suicide, and a special consultant for the Center for Bioethics and Culture. Smith wrote Forced Exit: The Slippery Slope from Assisted Suicide to Legalized Murder; it was rereleased in 2006 under the title Forced Exit: Euthanasia, Assisted Suicide, and the New Duty to Die. He also wrote Culture of Death: The Assault on Medical Ethics in America. In addition to books, Smith has written opinion pieces for newspapers throughout the world on end-of-life issues and other topics. He has offered commentary on television and radio in the United States and in other countries throughout the world. Smith has testified before government committees at both the federal and state levels on end-of-life issues. In the introduction to his book, Forced Exit: The Slippery Slope from Assisted Suicide to Legalized
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Murder, Smith writes about a dear friend who chose to end her life. He explains that the experience motivated him to crusade against euthanasia, including writing this book.
Joni Eareckson Tada (1950–) Joni Eareckson Tada suffered an accident while diving in the Chesapeake Bay in 1967. The accident left her a quadriplegic; she has used a wheelchair since then. Although she initially hoped for death, she began to believe more deeply in her religion. Her belief gave her the comfort to begin to live her life, rather than trying to withdraw from it. In addition to a career as an accomplished painter, Tada has been an author and collaborator of numerous books. Her books include Joni, which recounts her story, as well as A Step Further: Growing Closer to God through Hurt and Hardship, Heaven, and Ordinary People, Extraordinary Faith. Joni was made into a movie. In 1979 Tada founded Joni and Friends (JAF), an organization dedicated to promoting Christianity within the disability community. She travels extensively to share her story and her ministry. Tada speaks extensively about the obstacles she has faced to share the notion that it is possible for people to live with disabilities. She uses anecdotes from her own life to illustrate her point that people might suffer from depression as a result of their health issues but that the depression can be treated rather than leading people to turn to assisted suicide as a means of escaping those health issues.
Thomas Youk (1946–1998) Thomas Youk was suffering from amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease, and the disease was worsening when he contacted Dr. Jack Kevorkian and asked for the doctor’s assistance in ending his life. Dr. Kevorkian agreed to assist the 52-year-old man and decided to record the process, from Youk’s request through his actual death, on videotape. In a departure from his normal procedure, Dr. Kevorkian actually administered the injection. Dr. Kevorkian then sent the videotape, including the part showing his
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actions in administering the injection, to 60 Minutes, a newsmagazine on the CBS network. CBS aired the videotape and Dr. Jack Kevorkian was arrested and charged with first-degree murder in the death of Thomas Youk. Prosecutors, citing the fact that Dr. Kevorkian actually administered the injection, tried him on the charge of first-degree murder. The jury found him guilty of murder in the second degree and Dr. Kevorkian was sentenced to 10 to 25 years in prison.
References McKhann, Charles F. 1999. A Time to Die: The Place for Physician Assistance. New Haven, CT: Yale University Press. Quill, Timothy E., and Margaret P. Battin. 2004. Physician-Assisted Dying: The Case for Palliative Care and Patient Choice. Baltimore, MD: Johns Hopkins University Press.
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6 Data and Documents
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elevant statistics and other data, as well as germane facts and documents, can be useful in gaining a thorough understanding of any complex issue. End-of-life issues are no different. The data and other materials in this chapter will provide researchers with greater insight into the questions and debate that surround end-of-life issues. The information in this chapter is presented in three sections: Facts and Data Documents Quotations Each section is then further divided into medical-bioethical, spiritual-social-cultural, and legal-political subsections.
Facts and Data Although there are many subjective components to arguments surrounding end-of-life issues, there are also facts and statistics that help frame the issue and provide context. Books, articles, Web sites, and other sources provide a combination of objective data and subjective components, including religious beliefs, ethical concerns, and issues about protection of rights. This publication presents the objective data to facilitate research and greater understanding of these issues.
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Meaning of the Word Euthanasia, according to The Merriam-Webster Dictionary, means mercy killing. It is from the Greek words eu, meaning good, and thanatos, meaning death.
A Common Thread The American Cancer Society estimates that 570,280 people in the United States died of cancer in 2005 (2005). The Amyotrophic Lateral Sclerosis division of the Muscular Dystrophy Association reports that approximately 35,000 people in the United States currently suffer from amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s disease), a disease which causes paralysis and usually results in death within five years of diagnosis (1999). The Alzheimer’s Association estimates that 5.1 million Americans suffer from Alzheimer’s disease in 2007 (2007). The Centers for Disease Control and Prevention (CDC) estimates that between 1,039,000 and 1,185,000 people in the United States had HIV/AIDS as of the end of 2003 (2005). What is the common thread? It is that people suffering from these diseases are most likely to commit suicide or request assistance in dying. What are the particular factors, though, that motivate some terminally ill people to end their lives or request assistance in doing so? In his book Angels of Death: Exploring the Euthanasia Underground, Roger S. Magnusson (2002) examines the motivations of some AIDS patients who sought the option of assisted suicide. Of the thirty-five patients interviewed, twenty-one cited “intolerable/unresolved/ chronic pain or physical discomfort”; seventeen said they were “tired of fighting/‘over it’/[exhausted and hopeless]”; thirteen cited “fear of the process of dying/not wanting to suffer as others have suffered/fear of suffering when dying”; eight reported “severe deterioration in quality of life/lack of quality of life/unable to enjoy life”; eight said they did “not want to be a burden” (75–76).
Elderly Suicide in America According to the American Association of Suicidology (AAS), while elderly people accounted for 12.4 percent of the population
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in 2003, they represented 16.7 percent of suicides. In addition, AAS says people age 80 years and older are most likely to successfully complete their suicide attempts. The American Association of Suicidology stresses that poor health is merely one of the factors in elderly suicide attempts. The AAS cites other issues that might contribute toward a suicide attempt in an elderly person, including a loved one’s death, isolation and loneliness, and life change such as retirement or widowhood (American Association of Suicidology 2006). Author Eric Marcus (1996) addresses this higher success rate, as well as the rationale behind some elderly suicides, in his book Why Suicide? He notes: Elderly people are more likely to complete a suicide than those under 65 because when they decide to take their lives, they’re very serious about it. Generally, these are not people making a cry for help or attempting to get back at a boyfriend or girlfriend. They want to die. They choose more lethal methods. And they get it right the first time. Many of them live alone, so even if their suicide attempt is a cry for help, they’re far less likely to be found in time to be saved (78). The cry for help component of many of these attempts is critical, according to the American Foundation for Suicide Prevention (AFSP). The organization cites a link between suicide and mental illness, declaring that depression is often a factor in cases of people who contemplate suicide while suffering from an illness that is serious or terminal. Such depression, the organization stresses, is treatable (2004). It must be noted that the phenomenon of suicide among people who are ill is definitely not limited to the elderly. Statistical information, however, often does not provide a differentiation between those who commit suicide while suffering from a terminal illness and those who are not suffering from such an illness at the time of suicide. Statistical information about suicide among the elderly provides us with valuable insight into the issue and provides a foundation for further research into suicide among younger people who are suffering from serious or terminal illness.
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The Hospice Option As people with terminal illnesses approach the end of their lives, their options are not limited to euthanasia or dying in the sterility of a hospital or without medical support at home. Dame Cicely Saunders founded the modern hospice movement in London, England, in 1968. One of the many benefits of hospice care is that all caregivers are trained to provide the patient, as well as family members, with necessary support, including spiritual and psychological support. The patient’s pain is a focus in the sense that all caregivers are specially trained to provide relief from pain. Many hospice facilities throughout the United States provide patients with the choice between home care and care within the hospice facility. This choice makes the patient feel more in control of his or her care and provides some level of comfort in the midst of the stress and anxiety surrounding a terminal illness. In The Case against Assisted Suicide: For the Right to End-of-Life Care, edited by Kathleen Foley, M.D., and Herbert Hendin, M.D. (2002), Saunders explains why hospice care can be offered at home. “Hospice is a complex set of attitudes and skills, not a building. Much of this care and treatment can be accomplished at home with the support of teams so well developed in the United States . . . ” (287). For Saunders, it is important to provide people who are facing the end of their lives with choices like this. In her piece in The Case against Assisted Suicide: For the Right to End-of-Life Care, she also says it is important that everyone provide support to the dying: Physicians, others on the multiprofessional team, family members, and other intimate caregivers are not the only ones who should feel the responsibility to give comprehensive palliative care that seeks to understand and address the many needs dying patients have; society as a whole should feel that responsibility. The strength of the whole hospice and palliative care movement has been its roots in the societies from which it has originated (286).
Spiritual-Social-Cultural End-of-life issues do not exist in a vacuum. External issues and forces influence these matters and provide a context for them.
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Some of these issues and forces must be acknowledged in researching or discussing matters related to end-of-life decisions.
The Context of Religion For many people, whether they are facing an end-of-life decision or merely conducting research, religion provides a context. For some people, this context is borne of deeply held beliefs which provide a framework to consider the intricacies of the issue. For others, this context may simply be a starting point from which to begin exploring the issue. In Euthanasia and the Right to Die, authors Jennifer M. Scherer and Rita J. Simon (1999) explain one of the primary reasons for the opposition many religions share toward euthanasia: In almost every religion, suicide is considered a crime against God, because the supreme power that grants life also determines when it should be terminated. The timing and manner of one’s death is determined solely by God, so suicide is not a morally or ethically sanctioned option in any situation. The belief is that human life is a gift from God and should be highly regarded, irrespective of the circumstances of that life. Existence in any capacity is thought to be superior to not living at all, as the human body is a conduit for spiritual reflection and moral contemplation (22). It is important to remember that this opposition is not universal, especially when the subject is what is termed rational suicide. The term is generally taken to mean that there are circumstances in which “death is clearly preferable to continued suffering.” In other words, there are circumstances in which death is considered a rational choice (McKhann 1999, 7). “With its tradition as a sanctuary for the religiously persecuted, the United States now harbors a wide range of structured religions; some accept rational suicide, others openly oppose it, and still others are neutral on the subject” (60). The Roman Catholic Church is well known for its opposition to suicide and any other activity that interferes with the sanctity of life, including euthanasia. However, suicide was not always as stigmatized as it has been in modern times. In his book A Time to
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Die: The Place for Physician Assistance, Charles F. McKhann, M.D., writes: In the early days of Christianity, the penalty for suicide was relatively mild, a delay for the damaged soul to reach the afterlife. But as the concept of the sanctity of life strengthened, suicide became more of an abomination, and the penalties decreed by the church became more severe. It became a cardinal sin: the suicide was refused Christian burial, the body was desecrated, and the family publicly humiliated. If the suicide left a fortune, the church seized it and rendered the family destitute (59–60). Moreover, the church’s position on other end-of-life issues was the subject of debate for a time, as well. The controversy began in 1957 with a statement from Pope Pius XII to an international conference of physicians regarding patient choice when it comes to medical treatment. It continued in 1970 with Cardinal Jean Villot’s statement, also at an international conference, that physicians were not always obligated to “prolong life at all costs.” A Declaration on Euthanasia, issued by the Vatican in 1980, quelled much of the controversy by stating in no uncertain terms that the Roman Catholic Church disapproved of euthanasia and assisted suicide. During his papacy, Pope John Paul II reinforced the Declaration on Euthanasia (Scherer and Simon 1999, 24). Judaism also regards the power to take life as resting solely with God. Every moment of a person’s life, indeed, every breath, is considered sacred. As a result, euthanasia and assisted suicide are considered anathema even though they are not specifically addressed in the Talmud. Passive euthanasia, however, is allowed given certain conditions: The Talmud implies that the physician does not have to do everything possible to keep the terminally ill patient alive. Removing artificial means that are not keeping a patient from dying, such as a feeding tube, is not considered a positive or direct action, in that no element, such as a lethal dose of morphine, is introduced to cause death. Thus, while there is an obligation to prolong nat-
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ural life, there is no legal obligation to prolong life artificially (24-25). In addition to the Roman Catholic and Jewish faiths, “Christian Science, Jehovah’s Witnesses, the Eastern Orthodox churches, the United Pentecostal Church, the Mormon Church, the Church of the Nazarene, and the Episcopal, Lutheran, and Southern Baptist churches all have doctrinal proscriptions against suicide. Islam also opposes suicide for any reason” (McKhann 1999, 61). However, the influence of any religion in this area is not absolute and one author asserts that it may be weakening. Nicholas A. Christakis wrote “Managing Death: The Growing Acceptance of Euthanasia in Contemporary American Society,” an essay which appears in Must We Suffer Our Way to Death? In this essay, Christakis contends that, because our society is governed by secular influences, euthanasia is becoming more accepted in some ways. Citing “elimination of school prayer, falling church attendance, and the waning of religious influence over everyday life” as evidence of this secularization, Christakis asserts, “With respect to euthanasia, this trend has found expression in the desacralization of death and healing. In a secular and humanistic society, euthanasia becomes more permissible” (Hamel and DuBose 1996, 36). Although many churches have expressed opposition, others have not taken a position. In addition to the United Church of Christ and the Presbyterian Church, these neutral churches include the Adventists, many Baptist churches, the Christian Reformed Church of North America, the Church of Christ, and the Pentecostal Church of God (McKhann 1999, 61). Amidst this opposition from some churches and neutrality from others, the Unitarian Universalist Association stands in “support for a right to self-determination in the dying process and freedom from prosecution for physicians who perform the procedure” (Scherer and Simon 1999, 25).
Media and Technology Media coverage is one example of how the contemporary age provides people with access to a broader spectrum of information regarding end-of-life issues. News is easily transmitted to national and international outlets for dissemination to readers and viewers throughout the United States and the world. The result is that people in their living rooms can learn about the latest breast
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cancer drug, a new piece of legislation about euthanasia, or a physician who has been accused of illegally assisting in the suicide of a patient. Our modern age offers myriad other ways to explore end-of-life issues, as well. From searching the Internet for relevant sites to watching a DVD of a movie that addresses euthanasia, people interested in this topic have more learning and research options available to them than people in previous generations did. The cases in which Dr. Jack Kevorkian assisted people in committing suicide are a prime example of how modern media coverage provides the general public with greater access to information regarding end-of-life issues. News coverage of these cases enabled people throughout the United States and the world to monitor Dr. Kevorkian’s activities and his efforts to legalize assisted suicide. This coverage peaked on November 22, 1998, when 60 Minutes, a news magazine on the CBS television network, aired a videotape showing Dr. Kevorkian “administering a lethal injection” to Thomas Youk, a Michigan resident who had requested Dr. Kevorkian’s assistance in ending his life because he suffered from Lou Gehrig’s disease (Magnusson 2002, 31). When jurors found Dr. Jack Kevorkian guilty of seconddegree murder on March 26, 1999, Judge Jessica Cooper addressed Dr. Kevorkian in the courtroom. Additional news coverage focused on her words: This trial was not about the political or moral correctness of euthanasia. It was about you, sir. It was about lawlessness. You had the audacity to go on national television, show the world what you did and dare the legal system to stop you. Well, sir, consider yourself stopped (31). Media coverage also provided people around the world with the opportunity to follow the situation surrounding Terri Schiavo. In a compromised neurological state since 1990, Schiavo was the subject of legal conflicts between her husband, Michael, and parents, Robert and Mary Schindler. In 2000, Michael Schiavo won his legal battle to withdraw life support; the Schindler family appealed, however, and several years of legal wrangling ensued. The result was that Terri Schiavo’s feeding tube was removed on March 18, 2005, and she died on March 31, 2005. This case led to worldwide debate about end-of-life issues.
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Technology played a key role in that debate. The increasing popularity of weblogs, or blogs, meant that anyone with a computer and an opinion could post their thoughts on the Internet to share an opinion and invite debate. For the family of Terri Schiavo, technology provided an opportunity to tell their side of the story. The family established a foundation and a Web site, www.terrisfight.org, to share their experiences and advocate for people facing similar situations. Technology provided a similar opportunity for Michael Schiavo. He founded TerriPAC and established a Web site for the organization at www.terripac.com, with the goal of working to restore personal freedoms and individual rights. In addition to learning about the stances of advocacy organizations, researchers and others who wish to learn more about end-of-life issues, or simply keep up with news coverage of them, can do so easily by visiting sites on the Internet.
Health Care Today From Congressional committees to city councils and from national health care advocacy organizations to local hospitals, health care in the United States is the topic of frequent examination and analysis. It is relevant here simply because end-of-life issues, by their very nature, touch upon many of the topics that have been so thoroughly studied. Economic factors are among the most closely studied facets of healthcare issues. Skyrocketing health care costs have had an enormous impact on health care in the United States, including how health care is delivered, how the health insurance industry is run, and the way tax dollars are allocated. The relevance to endof-life issues is emerging in ways that cause concern for those examining these issues. For example, questionable practices by some managed care companies, insurers, and insurance brokers are giving rise to concerns about economics being a major factor in end-of-life decisions. In addition, for the large segment of the population which is uninsured or underinsured, access to health care is limited. For people with insurance obstacles, end-of-life decisions are extremely limited; in some cases, the result amounts to involuntary euthanasia, or death by neglect. Just as health insurance costs can be a drain on the budget of an individual or family, Medicaid costs can be a burdensome com-
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ponent of a state’s budget. This type of budgetary quagmire is described in Physician-Assisted Death: In all state budgets, Medicaid is the second largest budget item after education. Persons over 85, in fact, use four times as much money to cover a hospitalization [as] those under 85. There will be fewer individuals “in the middle” to bear the burden of caring for the young and the elderly. Already the phenomenon of the elderly (75 to 85 years of age) caring for the “old old” (those over 85) has begun (Humber, Almeder, and Kasting 1994, 116). What then is the answer? Although some tout Canada’s healthcare system as a model, authors Jennifer M. Scherer and Rita J. Simon (1999) point out the existence of problems there, as well: While Canada is able to provide health care for all its citizens at a lower cost than is feasible in the United States, its medical system is frequently backlogged; individuals wait months or years for surgical procedures, and state-of-the-art technology is not as widely used and applied (48).
How Do Physicians Feel? It is difficult to get a precise idea of where physicians stand on the issue of physician-assisted suicide. There are several reasons for this and they generally mirror the problems that plague pollsters on other issues. 1. Many polls or surveys are done on a state-by-state basis, often in response to the introduction of new legislation or some other precipitating factor. For example, when Oregon’s Death with Dignity Act was proposed, physicians in that state were surveyed about their feelings on the issue as it related to the proposed act. 2. Different surveys approach the issue differently. Some examine attitudes while others ask about past experiences. Some limit questions to this particular topic while others include questions about end-of-life issues in a sur-
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vey that touches on a host of issues. These disparities make it more difficult to compare one survey to another. 3. Many physicians are somewhat hesitant to speak frankly on the subject. One survey of 1,902 physicians throughout the United States, conducted in 1998, found that 3.3 percent of responding physicians had “written at least one ‘lethal prescription’” and 4.7 percent had “provided [a] lethal injection” in one or more cases. While 11 percent indicated that they would “prescribe medication to assist a patient to suicide” even if such action was illegal, the affirmative responses jumped to 36 percent if such action was legal. Similarly, while 7 percent declared that they would be willing to administer a lethal injection if such action was illegal, the affirmative responses increased to 24 percent if such an action were legal (Magnusson 2002, 40). In another survey, conducted in 1996, 2,761 Oregon physicians shared their views about prescribing “a lethal dose of medication to assist a suicide if it were legal.” Forty-six percent of the respondents indicated that they would be willing to do so and 52 percent indicated that they would not (41). A 1996 survey of Michigan physicians generated 1,119 responses. Of these physicians, 35 percent indicated that they would assist a patient in committing suicide if it were legal—22 percent said they would take part in “either physician-assisted suicide or active euthanasia” while 13 percent said they would not assist in active euthanasia but would assist in physician-assisted suicide— and 52 percent said that would not be a party to either (41). A 1995 survey of Oregon physicians examined their attitudes toward assisted suicide. Of the respondents, 60 percent said “assisted suicide should be legal in some cases” and 66 percent said it “would be ethical in some cases”; conversely, 33 percent said “assisted suicide was immoral,” 34 percent said it “violated professional ethics,” and 30 percent said it “violated personal beliefs” (Scherer and Simon 1999, 10).
Legal-Political There have been many legal and political developments in the areas of euthanasia and assisted suicide within the past decade. Many of these developments are listed below. To facilitate research
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and understanding, the list is divided into sections: developments within the United States and developments elsewhere. These sections include subsections separating legal developments from political developments. (Please note that this section is simply meant to provide an overview of these issues; for additional specifics regarding timing of the highlights, please turn to the chronology in Chapter 4.)
United States Legal Developments. In May 1997, the Supreme Court ruled unanimously in Quill v. Vacco and Washington v. Glucksberg that state statutes banning assisted suicide were constitutional. However, the Court allowed that hastening death by increasing palliative care measures is not prohibited when the intent is the relief of pain and suffering. Dr. Jack Kevorkian’s string of assisting patients with committing suicide came to a halt when a Michigan jury found him guilty of murder in the death of Thomas Youk. His prison sentence was ten to twenty-five years, with the possibility of parole in six years. He subsequently requested commutation of his prison sentence based on failing health; his request was denied. In March 2005, Terri Schiavo died at the age of 41. Her death followed several years in a persistent vegetative state and an extensive legal battle between her husband, Michael, and her parents, Robert and Mary Schindler, regarding Michael Schindler’s decision to remove life support, including a feeding tube and hydration. Political Developments. In 1997, Congress passed a law prohibiting the use of federal funds in physician-assisted suicides. The legislation, known as the Assisted Suicide Funding Restriction Act of 1997, was signed by President Bill Clinton. In 1997, shortly before Oregon’s Death with Dignity Act was slated to become effective, Oregon’s House of Representatives and Senate voted to return it to the voters by placing it back on the ballot as Measure 51, which would have repealed the state’s Death with Dignity Act. Voters stuck with their original position, though, and defeated Measure 51. The state’s Health Services Commission subsequently declared that state funds could be utilized for costs associated with physician-assisted suicide. The Pain Relief Promotion Act of 1999, geared toward promoting aggressive pain management and prohibiting the use of
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controlled substances for assisted suicide and euthanasia, was passed by the U.S. House of Representatives, but as a result of Oregon Senator Ron Wyden’s threat to filibuster it, the act was never put to a Senate vote.
Outside the United States Political Developments. In 1997, the British Parliament voted against legalizing assisted suicide. Although the Rights of the Terminally Ill (ROTI) Act in Australia’s Northern Territory had made euthanasia possible for a time, the act was ultimately overturned by the passage of the Voluntary Euthanasia Laws Bill in 1997. The legalization of euthanasia in 2001 was a milestone for the right-to-die movement in the Netherlands. The law took effect in 2002. Focus on Oregon—Politically and Personally. In the midst of these national and international developments, much of the attention surrounding right-to-die issues in the United States has been focused on the State of Oregon. Oregon’s Death with Dignity Act, on the ballot in November 1994, passed by a narrow margin and made history. Former Oregon Governor Barbara Roberts, writing in the foreword of Compassion in Dying: Stories of Dignity and Choice, explains the history of the state’s law and her very personal interest in it. She notes that her late husband, State Senator Frank Roberts, had been involved in examining end-of-life issues since the 1980s. His interest in the issue led to sponsorship of bills and championing of “the rights of individuals to have options on end-of-life matters.” Roberts goes on to say: So why did Frank introduce all this legislation? He did so because he passionately and compassionately believed adults had the knowledge, ability, wisdom— and the right—to decide their own fate. And perhaps, looking back, he may have had some premonition of what was to come for him at the end of his own life. Frank died a prolonged and difficult cancer death. In the last weeks of his life he spoke often and wistfully of his proposed aid-in-dying legislation. But he did not live to see the Oregon measure reach the ballot or to celebrate the passage of Oregon’s Death with Dignity Act in 1994 (Lee 2003, viii).
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Regardless of where people stand on right-to-die issues, it seems that the late Frank Roberts, state senator and later cancer patient, helped bring these issues into a realm where people were more comfortable discussing, debating, researching, and ultimately deciding them. As his wife remarks, “In the final months of Frank’s life, when I was Governor of Oregon and he was still serving as a State Senator, we spoke openly and publicly about his impending death. I believe our openness encouraged greater public discussion among all Oregonians about death and dying” (viii).
Documents The debate surrounding end-of-life issues, including the changing relationships between doctors, patients, and institutions, has included a number of landmark documents. The following documents and excerpts are a mere fraction of the documents that have helped shape this debate.
Medical-Bioethical Hippocratic Oath For centuries, doctors have been asked or required to declare an oath to uphold a standard of care and ethics developed primarily for the benefit of the patient. Many scholars believe the original Hippocratic Oath was written circa 421 BCE. Various organizations have developed alternative oaths over the years to keep pace with changing medical practices and mores. The Hippocratic Oath, however, remains the most well-known. The Hippocratic Oath I swear by Apollo the physician, by Aesculapius, Hygeia and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment the following oath: To consider dear to me as my parents him who taught me this art; to live in common with him and if necessary to share my goods with him; to look upon his children as my own brothers, to teach them this art if they so desire without fee or written promise; to
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impart to my sons and the sons of the master who taught me and the disciples who have enrolled themselves and have agreed to the rules of the profession, but to these alone, the precepts and the instruction. I will prescribe regiment for the good of my patients according to my ability and my judgment and never to harm anyone. To please no one will I prescribe a deadly drug, nor give advice which may cause his death. Nor will I give a woman a pessary to procure abortion. But I will preserve the purity of my life and my art. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners (specialists in this art). In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction, and especially from the pleasures of love or with women or men, be they free or slaves. All that may come to my knowledge in the exercise of my profession or outside of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal. If I keep this oath faithfully, may I enjoy my life and practice of my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot. Source: William R. Hensyl, ed., Stedman’s Concise Medical Dictionary (New York: Prentice Hall, 1987), 343.
International Codes of Medical Ethics This international code was adopted by the World Medical Association in 1949; it was amended in 1968, 1983, and 1994. Duties of Physicians in General ALL PHYSICIANS SHALL always maintain the highest standards of professional conduct. ALL PHYSICIANS SHALL not permit motives of profit to influence the free and independent exercise of professional judgment on behalf of patients. ALL PHYSICIANS SHALL, in all types of medical practice, be dedicated to providing competent
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medical service in full technical and moral independence, with compassion and respect for human dignity. ALL PHYSICIANS SHALL deal honestly with patients and colleagues, and strive to expose those physicians deficient in character or competence, or who engage in fraud or deception. The following practices are deemed to be unethical conduct: a. Self-advertising by physicians, unless permitted by the laws of the country and the Code of Ethics of the national medical association. b. Paying or receiving any fee or any other consideration solely to procure the referral of a patient or for prescribing or referring a patient to any source. A PHYSICIAN SHALL respect the rights of patients, colleagues, and of other health professionals, and shall safeguard patient confidences. A PHYSICIAN SHALL act only in the patient’s interest when providing medical care which might have the effect of weakening the physical and medical condition of the patient. A PHYSICIAN SHALL use great caution in divulging discoveries or new techniques or treatment through non-professional channels. A PHYSICIAN SHALL certify only that which he has personally verified. Duties of the Physician to the Sick A PHYSICIAN SHALL always bear in mind the obligation of preserving human life. A PHYSICIAN SHALL owe his patients complete loyalty and all the resources of his science. Whenever an examination or treatment is beyond the physician’s capacity, he should summon another physician who has the necessary ability. A PHYSICIAN SHALL preserve absolute confidentiality on all he knows about his patient, even after the patient has died. A PHYSICIAN SHALL give emergency care as a humanitarian duty unless he is assured that others are willing and able to give such care.
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Duties of the Physician to Each Other A PHYSICIAN SHALL behave toward his colleagues as he would have them behave toward him. A PHYSICIAN SHALL NOT entice patients from his colleagues. A PHYSICIAN SHALL observe the principles of the Declaration of Geneva approved by the World Medical Association. Source: “International Code of Medical Ethics” (World Medical Association: Stockholm, Sweden, 1994).
Declaration of Geneva AT THE TIME OF BEING ADMITTED AS A MEMBER OF THE MEDICAL PROFESSION: I SOLEMNLY PLEDGE to consecrate my life to the service of humanity; I WILL GIVE to my teachers the respect and gratitude that is their due; I WILL PRACTISE my profession with conscience and dignity; THE HEALTH OF MY PATIENT will be my first consideration; I WILL RESPECT the secrets that are confided in me, even after the patient has died; I WILL MAINTAIN by all the means in my power, the honour and the noble traditions of the medical profession; MY COLLEAGUES will be my sisters and brothers; I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient; I WILL MAINTAIN the utmost respect for human life; I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat; I MAKE THESE PROMISES solemnly, freely and upon my honour. Source: 173rd Council Session, Divonne-les-
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Bains, France, “Declaration of Geneva,” World Medical Journal 52 (2006): 29.
Spiritual-Social-Cultural Documents Related to Religion These documents provide a chronological overview of the issues raised and defined by several religious groups regarding euthanasia and end-of-life issues. Missouri Synod of the Lutheran Church To Affirm the Sacredness of Human Life A resolution of the Missouri Synod of the Lutheran Church adopted in 1977. WHEREAS, Life is a gift from God and comes into being by an act that shares in the creative powers of God himself; and WHEREAS, Scripture teaches that suffering has a purposes [sic] of God; and WHEREAS, Life and death belong in the realm of God’s providence; and WHEREAS, Scripture teaches that suffering has a positive purpose and value in God’s economy and is not to be avoided at all costs (2 Cor. 1:5–7; 2 Cor. 4:7–11; Heb. 12:5–11; Rom. 8:16–18, 28, 35–39; Phil. 3:10; Col. 1:24); and WHEREAS, We sing of the positive purpose of suffering in our worship (TLH, 523, 528, 533, et al); and WHEREAS, The Commission on Theology and Church Relations (CTCR) and its Social Concerns Committee (SCC) currently have a study in progress regarding the question of euthanasia; and WHEREAS, The willful taking of the life of one human being by another is contrary to the Word and the will of God (Ex. 20:13); therefore be it RESOLVED, That the Synod affirm that human life is sacred and finds meaning and purpose in seeking and following God’s will, not in self-centered pleasure, a concern for convenience, or a desire for comfort; and be it further
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RESOLVED, That the Synod affirm the positive benefits of suffering, so that God’s children may be comforted in Christ Jesus and have their sights focused more firmly on eternal values; and be it further RESOLVED, That the Synod unequivocally declare that the practice known as euthanasia, namely, inducing death, is contrary to God’s will and cannot be condoned or justified; and be it finally RESOLVED, The CTCR and the SCC be urged to complete their study as soon as possible. The report, issued in October 1979, affirmed this stance. Source: Lutheran Church–Missouri Synod, “Resolution 3-30: ‘To Affirm the Sacredness of Human Life,’” 1977 Convention Proceedings, 138.
Roman Catholic Church The following is an excerpt form the Roman Catholic Church’s landmark Declaration on Euthanasia. It was prepared by the Sacred Congregation for the Doctrine of the Faith and issued in 1980. Declaration on Euthanasia Introduction The rights and values pertaining to the human person occupy an important place among the questions discussed today. In this regard, the Second Vatican Ecumenical Council solemnly reaffirmed the lofty dignity of the human person, and in a special way his or her right to life. The Council therefore condemned crimes against life “such as any type of murder, genocide, abortion, euthanasia, or willful suicide” (Pastoral Constitution GAUDIUM ET SPES, no. 27). More recently, the Sacred Congregation for the Doctrine of the Faith has reminded all the faithful of Catholic teaching on procured abortion. The Congregation now considers it opportune to set forth the Church’s teaching on euthanasia. It is indeed true that, in this sphere of teaching, the recent popes have explained the principles, and these retain their full force; but the progress of medical
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science in recent years has brought to the fore new aspects of the question of euthanasia, and these aspects call for further elucidation on the ethical level. In modern society, in which even the fundamental values of human life are often called into question, cultural change exercises an influence upon the way of looking at suffering and death; moreover, medicine has increased its capacity to cure and to prolong life in particular circumstances, which sometime give rise to moral problems. Thus people living in this situation experience no little anxiety about the meaning of advanced old age and death. They also begin to wonder whether they have the right to obtain for themselves or their fellow men an “easy death,” which would shorten suffering and which seems to them more in harmony with human dignity. I. The Value of Human Life Human life is the basis of all goods, and is the necessary source and condition of every human activity and of all society. Most people regard life as something sacred and hold that no one may dispose of it at will, but believers see in life something greater, namely, a gift of God’s love, which they are called upon to preserve and make fruitful. And it is this latter consideration that gives rise to the following consequences: No one can make an attempt on the life of an innocent person without opposing God’s love for that person, without violating a fundamental right, and therefore without committing a crime of the utmost gravity. Everyone has the duty to lead his or her life in accordance with God’s plan. That life is entrusted to the individual as a good that must bear fruit already here on earth, but that finds its full perfection only in eternal life. Intentionally causing one’s own death, or suicide, is therefore equally as wrong as murder; such an action on the part of a person is to be considered as a rejection of God’s sovereignty and loving plan. Furthermore, suicide is also often a refusal
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of love for self, the denial of a natural instinct to live, a flight from the various duties of justice and charity owed to one’s neighbor, to various communities or to the whole of society—although, as is generally recognized, at times there are psychological factors present that can diminish responsibility or even completely remove it. However, one must clearly distinguish suicide from that sacrifice of one’s life whereby for a higher cause, such as God’s glory, the salvation of souls or the service of one’s brethren, a person offers his or her own life or puts it in danger (cf. Jn. 15:14). II. Euthanasia In order that the question of euthanasia can be properly dealt with, it is first necessary to define the words used. Etymologically speaking, in ancient times euthanasia meant an easy death without severe suffering. Today one no longer thinks of this original meaning of the word, but rather of some intervention of medicine whereby the suffering of sickness or of the final agony are reduced, sometimes also with the danger of suppressing life prematurely. Ultimately, the word euthanasia is used in a more particular sense to mean “mercy killing,” for the purpose of putting an end to extreme suffering, or saving abnormal babies, the mentally ill or the incurably sick from the prolongation, perhaps for many years, of a miserable life, which could impose too heavy a burden on their families or on society. It is, therefore, necessary to state clearly in what sense the word is used in the present document. By euthanasia is understood an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated. Euthanasia’s terms of reference, therefore, are to be found in the intention of the will and in the methods used. It is necessary to state firmly once more that nothing and no one can in any way permit the killing of an innocent human being, whether a fetus or an embryo, an infant or an adult, an old person or one suffering
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from an incurable disease, or a person who is dying. Furthermore, no one is permitted to ask for this act of killing, either for himself or herself or for another person entrusted to his or her care, nor can he or she consent to it, either explicitly or implicitly, nor can any authority legitimately recommend or permit such an action. For it is a question of the violation of the divine law, an offense against the dignity of the human person, a crime against life, and an attack on humanity. It may happen that, by reason of prolonged and barely tolerable pain, for deeply personal or other reasons, people may be led to believe that they can legitimately ask for death or obtain it for others. Although in these cases the guilt of the individual may be reduced or completely absent, nevertheless the error of judgment into which the conscience falls, perhaps in good faith, does not change the nature of this act of killing, which will always be in itself something to be rejected. The pleas of gravely ill people who sometimes ask for death are not to be understood as implying a true desire for euthanasia; in fact, it is almost always a case of an anguished plea for help and love. What a sick person needs, besides medical care, is love, the human and supernatural warmth with which the sick person can and ought to be surrounded by all those close to him or her, parents and children, doctors and nurses. III. The Meaning of Suffering for Christians and the Use of Painkillers Death does not always come in dramatic circumstances after barely tolerable sufferings. Nor do we have to think only of extreme cases. Numerous testimonies which confirm one another lead one to the conclusion that nature itself has made provision to render more bearable at the moment of death separations that would be terribly painful to a person in full health. Hence it is that a prolonged illness, advanced old age, or a state of loneliness or neglect can bring about psychological conditions that facilitate the acceptance of death. Nevertheless the fact remains that death, often preceded or accompanied by severe and prolonged suffering, is something which naturally causes people anguish.
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Physical suffering is certainly an unavoidable element of the human condition; on the biological level, it constitutes a warning of which no one denies the usefulness; but, since it affects the human psychological makeup, it often exceeds its own biological usefulness and so can become so severe as to cause the desire to remove it at any cost. According to Christian teaching, however, suffering, especially suffering during the last moments of life, has a special place in God’s saving plan; it is in fact a sharing in Christ’s passion and a union with the redeeming sacrifice which He offered in obedience to the Father’s will. Therefore, one must not be surprised if some Christians prefer to moderate their use of painkillers, in order to accept voluntarily at least a part of their sufferings and thus associate themselves with the sufferings of Christ crucified (cf. Mt. 27:34). Nevertheless it would be imprudent to impose a heroic way of acting as a general rule. On the contrary, human and Christian prudence suggest for the majority of sick people the use of medicines capable of alleviating or suppressing pain, even though these may cause, as a secondary effect, semi-consciousness and reduced lucidity. As for those who are not in a state to express themselves, one can reasonably presume that they wish to take these painkillers, and have them administered according to the doctor’s advice. But the intensive use of painkillers is not without difficulties, because the phenomenon of habituation generally makes it necessary to increase their dosage in order to maintain their efficacy. At this point it is fitting to recall a declaration by Pius XII, which retains its full force; in answer to a group of doctors who had put the question: “Is the suppression of pain and consciousness by the use of narcotics . . . permitted by religion and morality to the doctor and the patient (even at the approach of death and if one foresees that the use of narcotics will shorten life)?” the Pope said: “If no other means exist, and if, in the given circumstances, this does not prevent the carrying out of other religious and moral duties: Yes.” In this case, of course, death is in no
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way intended or sought, even if the risk of it is reasonably taken; the intention is simply to relieve pain effectively, using for this purpose painkillers available to medicine. However, painkillers that cause unconsciousness need special consideration. For a person not only has to be able to satisfy his or her moral duties and family obligations; he or she also has to prepare himself or herself with full consciousness for meeting Christ. Thus Pius XII warns: “It is not right to deprive the dying person of consciousness without a serious reason.” IV. Due Proportion in the Use of Remedies Today it is very important to protect, at the time of death, both the dignity of the human person and the Christian concept of life, against a technological attitude that threatens to become an abuse. Thus some people speak of a “right to die,” which is an expression that does not mean the right to procure death either by one’s own hand or by means of someone else, as one pleases, but rather the right to die peacefully with human and Christian dignity. From this point of view, the use of therapeutic means can sometimes pose problems. In numerous cases, the complexity of the situation can be such as to cause doubts about the way ethical principles should be applied. In the final analysis, it pertains to the conscience either of the sick person, or of those qualified to speak in the sick person’s name, or of the doctors, to decide, in the light of moral obligations and of the various aspects of the case. Everyone has the duty to care for his or her own health or to seek such care from others. Those whose task it is to care for the sick must do so conscientiously and administer the remedies that seem necessary or useful. However, is it necessary in all circumstances to have recourse to all possible remedies? In the past, moralists replied that one is never obliged to use “extraordinary” means. This reply, which as a principle, still holds good, is perhaps less clear today, by reason of the imprecision of the term and the rapid progress made in the treatment of sickness. Thus some
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people prefer to speak of “proportionate” and “disproportionate” means. In any case, it will be possible to make a correct judgment as to the means by studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources. In order to facilitate the application of these general principles, the following clarifications can be added: • If there are no other sufficient remedies, it is permitted, with the patient’s consent, to have recourse to the means provided by the most advanced medical techniques, even if these remedies are still at the experimental stage and are not without a certain risk. By accepting them, the patient can even show generosity in the service of humanity. • It is also permitted, with the patient’s consent, to interrupt these means, where the results fall short of expectation. But for such a decision to be made, account will have to be taken of the reasonable wishes of the patient and the patient’s family, as also of the advice of the doctors who are specially competent in the matter. The latter may in particular judge that the investment in instruments and personnel is disproportionate to the results foreseen; they may also judge that the techniques applied impose on the patient strain or suffering out of proportion with the benefits which he or she may gain from such techniques. • It is also permissible to make do with the normal means that medicine can offer. Therefore one cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. Such a refusal is not the equivalent of suicide; on the contrary, it should be considered as an acceptance of the human condition, or a wish to
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avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community. • When inevitable death is imminent in spite of the means used, it is permitted in conscience to take the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted. In such circumstances the doctor has no reason to reproach himself with failing to help the person in danger. Conclusion The norms contained in the present Declaration are inspired by a profound desire to service people in accordance with the plan of the Creator. Life is a gift of God, and on the other hand death is unavoidable; it is necessary, therefore, that we, without in any way hastening the hour of death, should be able to accept it with full responsibility and dignity. It is true that death marks the end of our earthly existence, but at the same time it opens the door to immortal life. Therefore, all must prepare themselves for this event in the light of human values, and Christians even more so in the light of faith. As for those who work in the medical profession, they ought to neglect no means of making all their skill available to the sick and dying; but they should also remember how much more necessary it is to provide them with the comfort of boundless kindness and heartfelt charity. Such service to people is also service to Christ the Lord, who said: “As you did it to one of the least of these my brethren, you did it to me” (Mt. 25:40). Source: “The Vatican’s Declaration on Euthanasia” (Rome, 1980).
Unitarian Universalist This 1988 resolution is a reaffirmation of the support of Unitarian Universalists for living wills and commitment to “self-determination in dying.”
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The Right to Die with Dignity Unitarian Universalist General Assembly, 1988 Guided by our belief as Unitarian Universalists that human life has inherent dignity, which may be compromised when life is extended beyond the will or ability of a person to sustain that dignity; and believing that it is every person’s inviolable right to determine in advance the course of action to be taken in the event that there is no reasonable expectation of recovery from extreme physical or mental disability, and . . . WHEREAS, prolongation may cause unnecessary suffering and/or loss of dignity while providing little or nothing of benefit to the individual; and WHEREAS, differences exist among people over religious, moral and legal implications of administering aid-in-dying when an individual of sound mind has voluntarily asked for such aid; and WHEREAS, obstacles exist within our society against providing support for an individual’s declared wish to die; and WHEREAS, many counselors, clergy and healthcare personnel value prolongation of life regardless of the quality of life or will to live; and THEREFORE BE IT RESOLVED: That the Unitarian Universalist Association calls upon its congregations and individual Unitarian Universalists to examine attitudes and practices in our society relative to the ending of life, as well as those in other countries and cultures; and BE IT FURTHER RESOLVED: That Unitarian Universalists reaffirm their support for the Living Will, as declared in a 1978 resolution of the General Assembly, declare support for the Durable Power of Attorney for Health Care, and seek assurance that both instruments will be honored. BE IT FURTHER RESOLVED: That Unitarian Universalists advocate the right to self-determination in dying, and the release from civil or criminal penalties of those who, under proper safeguards, act to honor the right of terminally ill patients to select the time of their own deaths; and
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BE IT FURTHER RESOLVED: That Unitarian Universalists advocate safeguards against abuses by those who would hasten death contrary to an individual’s desires; and BE IT FINALLY RESOLVED: That Unitarian Universalists, acting through their congregations, memorial societies, and appropriate organizations, inform and petition legislators to support legislation that will create legal protection for the right to die with dignity, in accordance with one’s own choice. Source: General Assembly of Unitarian Universalists, 1988 Proceedings, 74.
Documents Related to Individuals and Organizations Arthur and Cynthia Koestler died on March 1, 1983. He was 77 and she was 55. Arthur Koestler was perhaps best known for his writing, including a novel, Darkness at Noon. However, he was also the president of the Voluntary Euthanasia Society in London. He suffered from Parkinson’s disease and what he termed “the slowkilling variety of leukemia (CCL).” When he wrote his “Suicide Note” (excerpts below) ten months before taking his own life, he clearly thought Cynthia would survive him. However, as the footnote indicates, his wife Cynthia took her own life that day as well. A Suicide Note Arthur Koestler, June 1982 To Whom It May Concern. The purpose of this note is to make it unmistakably clear that I intend to commit suicide by taking an overdose of drugs without the knowledge or aid of any other person. Should this attempt fail and I survive it in a physically or mentally impaired state, in which I can no longer control what is done to me, or communicate my wishes, I hereby request that I be allowed to die in my own home and not be resuscitated or be kept alive by artificial means. I further request that my wife, or physician, or any friend present, should invoke habeus
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corpus against any attempt to remove me forcibly from my house to hospital. What makes it nevertheless hard to take this final step is the reflection of the pain it is bound to inflict on my few surviving friends, above all my wife Cynthia. It is to her that I owe the relative peace and happiness that I enjoyed in the last period of my life—and never before. Source: George Mikes, Arthur Koestler: The Story of a Friendship (London: André Deutsch, 1983), 78, 79. Footnote Cynthia Koestler I should have liked to finish my account of working for Arthur—a story which began when our paths happened to cross in 1949. However, I cannot live without Arthur, despite certain inner resources. Source: Harold Harris, Stranger on the Square, by Arthur and Cynthia Koestler (New York: Random House, 1984), preface.
American Association of Retired Persons (AARP) The AARP’s National Legislative Council issued the following statement in 1997. After careful consideration, our National Legislative Council recommends to the Board of Directors of the AARP that it not take a position on physician-assisted suicide. The Council concluded that this intensely personal issue is one about which each individual should make his or her own decision. Source: Marjorie B. Zucker, The Right to Die Debate (Westport, CT: Greenwood Press, 1999), 264.
Legal-Political Many people in the right-to-die movement hope that the U.S. Constitution will ultimately determine whether or not individuals in the United States have a right to die. The reason for this is that constitutional rights provide greater legal protection than rights resulting from case law. Consequently, those in favor of euthana-
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sia work toward this protection while those who oppose euthanasia work to ensure that euthanasia is not deemed a constitutional right. The following excerpts from the U.S. Constitution are provided to help clarify the legal arguments that arise in these cases. The Constitution of the United States Preamble We the people of the United States, in order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defense, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this CONSTITUTION for the United States of America. A Bill of Rights of the United States of America Effective December 15, 1791 Article IV Security from Unwarranted Search and Seizure The right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no Warrants shall issue, but upon probable cause, supported by Oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized. Article V Life, Liberty and Property No person shall be held to answer for a capital, or otherwise infamous crime, unless on a presentment or indictment of a Grand Jury, except in cases arising in the land or naval forces, or in the Militia, when in actual service in time of War or public danger; nor shall any person be subject for the same offense to be twice put in jeopardy of life or limb; nor shall be compelled in any criminal case to be a witness against himself, nor be deprived of life, liberty, or property, without due process of law; nor shall private property be taken for public use, without just compensation. Article XIV Citizenship, Congressional Apportionment, Insurrection, Public Debt
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Section 1. All persons born or naturalized in the United States, and subject to the jurisdiction thereof, are citizens of the United States and of the State wherein they reside. No state shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United States; nor shall any State deprive any person of life, liberty or property, without due process of law; nor deny any person within its jurisdiction the equal protection of the laws. Source: United States Constitution, 1791.
Oregon Death with Dignity Act Oregon’s Death with Dignity Act was approved by the voters in 1994. It went into effect in 1997. The entire text of the act is available on the state Web site at http://oregon.gov/DHS/ph/pas/ ors.shtml. The following excerpts provide highlights of the act. The Oregon Death with Dignity Act Oregon Revised Statutes (General Provisions) (Section 1) Note: The division headings, subdivision headings and leadlines for 127.800 to 127.890, 127.895 and 127.897 were enacted as part of Ballot Measure 16 (1994) and were not provided by Legislative Counsel. 127.800 §1.01. Definitions. The following words and phrases, whenever used in ORS 127.800 to 127.897, have the following meanings: (1) “Adult” means an individual who is 18 years of age or older. (2) “Attending physician” means the physician who has primary responsibility for the care of the patient and treatment of the patient’s terminal disease. (3) “Capable” means that in the opinion of a court or in the opinion of the patient’s attending physician or consulting physician, psychiatrist or psychologist, a patient has the ability to make and communicate health care decisions to health care providers, including communication through persons familiar with the patient’s manner of communicating if those persons are available.
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(4) “Consulting physician” means a physician who is qualified by specialty or experience to make a professional diagnosis and prognosis regarding the patient’s disease. (5) “Counseling” means one or more consultations as necessary between a state licensed psychiatrist or psychologist and a patient for the purpose of determining that the patient is capable and not suffering from a psychiatric or psychological disorder or depression causing impaired judgment. (6) “Health care provider” means a person licensed, certified or otherwise authorized or permitted by the law of this state to administer health care or dispense medication in the ordinary course of business or practice of a profession, and includes a health care facility. (7) “Informed decision” means a decision by a qualified patient, to request and obtain a prescription to end his or her life in a humane and dignified manner, that is based on an appreciation of the relevant facts and after being fully informed by the attending physician of: (a) His or her medical diagnosis; (b) His or her prognosis; (c) The potential risks associated with taking the medication to be prescribed; (d) The probable result of taking the medication to be prescribed; and (e) The feasible alternatives, including, but not limited to, comfort care, hospice care and pain control. (8) “Medically confirmed” means the medical opinion of the attending physician has been confirmed by a consulting physician who has examined the patient and the patient’s relevant medical records. (9) “Patient” means a person who is under the care of a physician. (10) “Physician” means a doctor of medicine or osteopathy licensed to practice medicine by the Board of Medical Examiners for the State of Oregon. (11) “Qualified patient” means a capable adult who is a resident of Oregon and has satisfied the requirements of ORS 127.800 to 127.897 in order to
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obtain a prescription for medication to end his or her life in a humane and dignified manner. (12) “Terminal disease” means an incurable and irreversible disease that has been medically confirmed and will, within reasonable medical judgment, produce death within six months. [1995 c.3 §1.01; 1999 c.423 §1] (Written Request for Medication to End One’s Life in a Humane and Dignified Manner) (Section 2) 127.805 §2.01. Who may initiate a written request for medication. (1) An adult who is capable, is a resident of Oregon, and has been determined by the attending physician and consulting physician to be suffering from a terminal disease, and who has voluntarily expressed his or her wish to die, may make a written request for medication for the purpose of ending his or her life in a humane and dignified manner in accordance with ORS 127.800 to 127.897. (2) No person shall qualify under the provisions of ORS 127.800 to 127.897 solely because of age or disability. [1995 c.3 §2.01; 1999 c.423 §2] 127.840 §3.06. Written and oral requests. In order to receive a prescription for medication to end his or her life in a humane and dignified manner, a qualified patient shall have made an oral request and a written request, and reiterate the oral request to his or her attending physician no less than fifteen (15) days after making the initial oral request. At the time the qualified patient makes his or her second oral request, the attending physician shall offer the patient an opportunity to rescind the request. [1995c.3 §3.06] 127.845 §3.07. Right to rescind request. A patient may rescind his or her request at any time and in any manner without regard to his or her mental state. No prescription for medication under ORS 127.800 to 127.897 may be written without the attending physician offering the qualified patient an opportunity to rescind the request. [1995 c.3 §3.07] 127.850 §3.08. Waiting periods. No less than fifteen (15) days shall elapse between the patient’s initial oral request and the writing of a prescription under
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ORS 127.800 to 127.897. No less than 48 hours shall elapse between the patient’s written request and the writing of a prescription under ORS 127.800 to 127.897. [1995 c.3§3.08] 127.860 §3.10. Residency requirement. Only requests made by Oregon residents under ORS 127.800 to 127.897 shall be granted. Factors demonstrating Oregon residency include but are not limited to: (1) Possession of an Oregon driver license; (2) Registration to vote in Oregon; (3) Evidence that the person owns or leases property in Oregon; or (4) Filing of an Oregon tax return for the most recent tax year. [1995 c.3 §3.10; 1999 c.423 §8] 127.865 §3.11. Reporting requirements. (1)(a) The Department of Human Services shall annually review a sample of records maintained pursuant to ORS 127.800 to 127.897. (b) The department shall require any health care provider upon dispensing medication pursuant to ORS 127.800 to 127.897 to file a copy of the dispensing record with the department. (2) The department shall make rules to facilitate the collection of information regarding compliance with ORS 127.800 to 127.897. Except as otherwise required by law, the information collected shall not be a public record and may not be made available for inspection by the public. (3) The department shall generate and make available to the public an annual statistical report of information collected under subsection (2) of this section. [1995 c.3 §3.11; 1999 c.423 §9; 2001 c.104 §40] 127.880 §3.14. Construction of Act. Nothing in ORS 127.800 to 127.897 shall be construed to authorize a physician or any other person to end a patient’s life by lethal injection, mercy killing or active euthanasia. Actions taken in accordance with ORS 127.800 to 127.897 shall not, for any purpose, constitute suicide, assisted suicide, mercy killing or homicide, under the law. [1995 c.3 §3.14] Source: State of Oregon, Department of Human
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Services, “Legislative Statutes,” http://oregon.gov/ DHS/ph/pas/docs/statute.pdf.
Supreme Court Opinions Quill v. Vacco and Washington v. Glucksberg are landmark cases regarding end-of-life issues. The U.S. Supreme Court decided these cases on June 26, 1997. Chief Justice William Rehnquist, writing for the majority, in Vacco v. Quill: The Court of Appeals . . . concluded that some terminally ill people—those who are on life-support systems—are treated differently than those who are not, in that the former may “hasten death” by ending treatment, but the latter may not “hasten death” through physician-assisted suicide. . . Unlike the Court of Appeals, we think the distinction between assisting suicide and withdrawing life-sustaining treatment . . . is both important and logical; it is certainly rational . . . For all these reasons, we disagree with respondents’ claim that the distinction between refusing lifesaving medical treatment and assisted suicide is “arbitrary” and “irrational.” Source: Marjorie B. Zucker, The Right to Die Debate Westport, CT: Greenwood Press, 1999), 288. Chief Justice William Rehnquist, writing for the majority, in Washington v. Glucksberg: To hold for respondents, we would have to reverse centuries of legal doctrine and practice, and strike down the considered policy choice of almost every State . . . . . . That many of the rights and liberties protected by the Due Process Clause are sound in personal autonomy does not warrant the sweeping conclusion that any and all important, intimate, and personal decisions are so protected . . . Source: Marjorie B. Zucker, The Right to Die Debate. (Westport, CT: Greenwood Press, 1999), 289.
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Quotations Throughout the ongoing debate over euthanasia and physicianassisted suicide, many people on both sides of the issue have made statements that frame the issue in useful or significant ways. This section features quotations from both sides of the issue. Quotations that further the right-to-die argument are listed first; quotations that refute the right-to-die argument are listed next. All of the quotations are grouped according to whether they are medical-bioethical, spiritual-social-cultural, or legal-political.
In Favor of Euthanasia or Physician-Assisted Suicide Medical-Bioethical. Author David Rothman offers a stark view of the way end-of-life issues were addressed as recently as the 1960s: Issues of life and death remained relatively obscure in the 1960s, largely because doctors, inside the closed world of the intensive care units, turned off the machines when they believed the patient’s death was imminent and irreversible . . . The intensive care units were a private domain, whatever the formal definition of death, and doctors exercised their discretion. Source: David J. Rothman, Strangers at the Bedside (New York: Basic Books, 1991), 160. Charles F. McKhann, M.D., notes that he became interested in physician-assisted dying following the death of his own father: A physician himself, he died in 1988 at the age of eighty-nine, with widespread intra-abdominal cancer. In the process, he was kept alive for more than a month when his outlook was clearly hopeless. At one point, he asked whether I thought he was on his deathbed. When I said that he probably was, he replied, “That’s what I think, too, and I wish they would just let me go.” Even his two physician sons, one of whom is on the staff of the same hospital, were unable, or too timid and
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conflicted, to influence the decision making so that he might be allowed to die sooner. Source: Charles F. McKhann, A Time to Die: The Place for Physician Assistance (New Haven, CT: Yale University Press, 1999), 1, 2. Nancy Dickey, former chair of the American Medical Association’s Council on Ethical and Judicial Affairs, argues that decisions on end-of-life issues are unique to each person: We would all draw a different line at which we wouldn’t want to live any longer. We have a strong recognition in this country that you are the master of your body. If we begin to deny the freedom of an individual to participate or not in medical care, we could become a medical police state. Source: Quoted in Donald Cox, Hemlock’s Cup (Buffalo, NY: Prometheus Books, 1993), 79. Dr. Timothy Quill describes a situation in which he felt that medical care did more harm than good for an elderly, ailing patient: The bones in his chest were so frail that they fractured easily. His heart compressions were accompanied by a sickening crunch of broken ribs . . . I left the room profoundly disturbed. I felt that not only had we violated this dying man, but I too had been violated by being forced to act in a way I found both personally and professionally intolerable. How could we repeatedly brutalize this poor man in the name of extending life? Could this possibly be what the Hippocratic Oath intended? Source: Timothy Quill, Death and Dignity: Making Choices and Taking Charge (New York: W. W. Norton, 1993), 35–36. Dr. Willem Kolff, founder of the artificial heart program, speaks about the unique end-of-life issues and decisions facing Barney Clark, the first person to receive an artificial heart. Dr. Kolff and his colleagues gave Clark a key which empowered him with the option of turning off the machine that sustained his life:
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If the man suffers and feels it isn’t worth it any more, he has a key that he can apply . . . I think it is entirely legitimate that this man whose life has been extended should have the right to cut it off if he doesn’t want it, if life ceases to be enjoyable . . . The operation won’t be a success unless he is happy. This has always been our criteria—to restore happiness. Source: “Commercial Appeal,” as cited in James Rachels, The End of Life (Oxford, England: Oxford University Press, 1986), 79. Although many end-of-life issues, including assisted suicide, are commonly associated with physicians, patient care is the domain of nurses during the hours that fall between visits from a physician. The result is that nurses, de facto, face many of these end-of-life issues during the course of caring for the patient. One nurse, speaking as part of a study which surveyed critical care nurses on euthanasia and assisted suicide, gave voice to the frustration that can arise: I have experienced tremendous frustration and anger with physicians who either stress the possibility of a good prognosis, giving false hope—or place their belief system above that of their patients. The physician spends 5 to 10 minutes each day with the patient and then leaves me to carry out his orders and deal with the patient and his/her family for 8 to 12 hours. I’m left with the dilemma of carrying out orders that I believe—and sometimes know—are not in the patient’s best interest or what the patient or family has expressed as their desires. Source: David A. Asch, “The Role of Critical Care Nurses in Euthanasia and Assisted Suicide,” New England Journal of Medicine 334 (1996): 1374. A euthanasia law was passed in the Netherlands in 1993. Dr. Herbert Cohen offers a reason for the existence of the Dutch law: We need a counterweight for the enormous technology of present medicine. We are talking mostly about older people who, in other times, would have died from their
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condition. If we can keep people alive but give them a life that is no life, we must be consistent and give them the choice to end it. Source: Quoted in Marlise Simons, “Dutch Move to Enact Law Making Euthanasia Easier,” New York Times (February 9, 1993): 1, 9.
Spiritual-Social-Cultural In the case of an individual who is unable to make end-of-life decisions, those decisions fall to family members or other loved ones. Such was the case with Nancy Cruzan following an automobile accident when doctors declared she would remain in a persistent vegetative state for the remainder of her days. Her family felt that they knew exactly what Cruzan would have chosen and that their decision was merely to implement her choice: How do you make the best decision? The answer was, we didn’t make the decision—our loved one made the decision . . . Chances are—if you haven’t already—you will probably make some sort of treatment decision for yourself or a loved one someday. Source: Christy Cruzan White, in “Taking the ‘Right to Die’ Issue to the Supreme Court,” a presentation to the Hospice of Boulder (CO) County, March 10, 1996. The medical community, like the rest of society, is divided over end-of-life issues. This quote offers one possible reason for physician opposition: Our modern doctor is the sworn enemy of death, a specialist waging a battle in the medical arena. To lose a patient is to fail. All effort is organized and centered around the science of saving lives. In this all-out war, the human needs of the individual patient or family may often be forgotten or ignored. Source: Judith Ahronheim and Doron Weber, Final Passages: Positive Choices for the Dying and their Loved Ones (New York: Simon & Schuster, 1992), 18.
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In addition to the patient’s illness, there are always other issues, such as family concerns, that enter into the doctor-patient relationship and become factors in the end-of-life decision-making process. This quote cites cultural background as another issue of this type: Every step of the medical decision-making process is affected by both the patient’s and the physician’s cultural background. In the emotionality of life-and-death decisions, cultural beliefs are likely to be perceived as absolute beliefs about what is right and wrong . . . Source: Lillian Burke, as quoted in Donald Irish, et al., eds., Ethnic Variations in Dying, Death and Grief (Washington, DC: Taylor and Francis 1993), 170. Sogyal Rinpoche, a Tibetan meditation master, argues that a modern intensive care unit is not conducive to a peaceful death: . . . Being in an intensive care unit will make a peaceful death very difficult, and hardly allows for spiritual practice at the moment of death. As the person is dying, there is no privacy: they are hooked up to monitors, and attempts to resuscitate them will be made when they stop breathing or their heart fails . . . our state of mind at death is all-important. If we die in a positive frame of mind, we can improve our next birth . . . And if we are upset and distressed, it may have a detrimental effect, even though we may have used our lives well . . . To use life-support mechanisms when a person has no chance of recovery is pointless. It is far better to let them die naturally in a peaceful atmosphere and perform positive actions on their behalf. When the life-support machinery is in place, but there is no hope, it is not a crime to stop it, since there is no way in which the person can survive, and you are only holding on to their life artificially. Source: Sogyal Rinpoche, The Tibetan Book of Living and Dying (San Francisco: Harper, 1992), 185, 224, 372. Communication can be a major obstacle for people who face end-of-life issues themselves or on behalf of family members or friends:
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[The hospital was like a] foreign land where we often did not speak the language. Source: Christy Cruzan White, in “Taking the ‘Right to Die’ Issue to the Supreme Court,” a presentation at the Hospice of Boulder (CO) County, March 10, 1996. Dr. Timothy Quill, a physician and former hospice medical director, addresses patient concerns about death: Those who have witnessed difficult deaths of patients in hospice programs are not reassured by the glib assertion that we always know how to make death tolerable, and they fear that physicians will abandon them if their course becomes difficult or overwhelming in the face of comfort care. In fact, there is no empirical evidence that all physical suffering associated with incurable illness can be effectively relieved. Source: Timothy Quill, Death and Dignity: Making Choices and Taking Charge (New York: W. W. Norton, 1993), 106, 166. Author Gavin Fairbairn offers a distinction between euthanasia and suicide: In an act of euthanasia, steps are taken to allow a person who is dying to die a death that he wishes to die, in preference to a death he wishes to avoid. In an act of suicide, a person arranges his death to avoid a life that he does not wish to live, or in order to die a death that he wishes to die. Source: Gavin J. Fairbairn, Contemplating Suicide (New York: Routledge, 1995), 123.
Legal-Political In a case before the Supreme Court of the State of Kansas in 1960, Justice Alfred Schroeder ruled on the issue of informed consent: Anglo-American law starts with the premise of thorough-going self-determination. It follows that each
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man is considered to be master of his own body, and he may, if he be of sound mind, expressly prohibit the performance of life-saving surgery, or other medical treatment. Source: Natanson v. Kline, 186 Kan. 393, 350 P.2d 1093 (1960). In Compassion and Dying et al. v. Washington State, Judge Barbara Rothstein ruled that a state law known as “Promoting a Suicide Attempt” (RCW 9A.36.060) was unconstitutional: The liberty interest protected by the Fourteenth Amendment is the freedom to make choices according to one’s individual conscience about those matters which are essential to personal autonomy and basic human dignity. There is no more profoundly personal decision, nor one which is closer to the heart of personal liberty, than the choice which a terminally ill person makes to end his or her suffering and hasten an inevitable death. From a constitutional perspective, the court does not believe that a distinction can be drawn between refusing life-sustaining medical treatment and physician-assisted suicide by an uncoerced, mentally competent, terminally ill adult. Source: Barbara Rothstein, Compassion in Dying et al. v. Washington State (850 F. Supp. 3 May 1994). Marshall Perron, speaking before the Northern Australia Legislative Assembly, introduced the “Rights of the Terminally Ill” bill with an impassioned statement about suffering at the end of life: This is not a political issue; it is a human rights issue . . . Through the laws in place today, society has made an assessment for all of us that our quality of life, no matter how wretched, miserable or painful, is never so bad that any of us will be allowed to put an end to it. I am not prepared to allow society to make that decision for me or for those I love . . . If we as legislators wring our hands and turn our backs, we are compelling suffering citizens to beg their loved ones to take the law into their own hands by whatever means they have available
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because current laws forbid the medical profession to do what is humane. Source: Marshall Perron, excerpted from the First Reading Speech he presented at the Northern Territory Legislative Assembly meeting, February 22, 1995. The U.S. Supreme Court addressed numerous end-of-life issues in its decision in the case of Nancy Cruzan; several quotes from the decision are included below: The 14th Amendment provides that no state shall “deprive any person of life, liberty, or property without due process of law.” . . . But determining that a person has a liberty interest under the Due Process clause does not end the inquiry; whether respondent’s constitutional rights have been violated must be determined by balancing his liberty interests against the relevant state interests. Source: William Rehnquist, excerpted from U.S. Supreme Court Majority Opinions in Cruzan v. Director, Missouri Department of Health (June 25, 1990). As the court notes, the liberty interest in refusing medical treatment flows from decisions involving the state’s invasions into the body. Because our notions of liberty are inextricably entwined with our idea of physical freedom and self-determination, the Court has often deemed state incursions into the body repugnant to the interests protected by the Due Process clause [of the Fifth Amendment]. Source: Sandra Day O’Connor, excerpted from U.S. Supreme Court Majority Opinions in Cruzan v. Director, Missouri Department of Health (June 25, 1990). The various opinions in this case portray quite clearly the difficult, indeed agonizing, questions that are presented by the constantly increasing power of science to keep the human body alive for longer than any reasonable person would want to inhabit it. Source: Antonin Scalia, excerpted from U.S. Supreme Court Majority Opinions in Cruzan v. Director, Missouri Department of Health (June 25, 1990).
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Justice William Brennan dissented, citing procedural obstacles in the affirming decisions. His opinion, however, was essentially a pro decision: Because I believe that Nancy Cruzan has a fundamental right to be free of unwanted artificial nutrition and hydration, which right is not outweighed by any interests of the state, and because I find that the improperly biased procedural obstacles imposed by the Missouri Supreme Court impermissibly burden that right, I respectfully dissent. Nancy Cruzan is entitled to choose to die with dignity. Source: William Brennan Jr., excerpted from U.S. Supreme Court Majority Opinions in Cruzan v. Director, Missouri Department of Health (June 25, 1990).
Opposed to Euthanasia or Physician-Assisted Suicide Medical-Bioethical Dr. David Karnofsky, a cancer specialist, addresses the idea of whether the physician’s role should be determined by the patient’s wishes: The physician who treasures his patient’s life, without trying to judge its value to the patient, his family, or to his community, in the end will make fewer mistakes, will learn more about the disease he is treating, and will have the satisfaction of giving his best efforts against difficult odds. Source: Derek Humphry and Ann Wickett, The Right to Die (Eugene, OR: The Hemlock Society, 1990), 76. Although medical technology allows physicians, in many cases, to predict when death is imminent, many argue that intangibles such as family support and personality cannot be discounted: At best, confidence in predicting death is possible only in the last few hours. Patients with the same stage of
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disease but with different family settings, personalities, and “things to live for” actually do live for strikingly varied periods of time. Source: President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Deciding to Forego Life-Sustaining Treatment: A Report on the Ethical, Medical and Legal Issues in Treatment Decisions (Washington, DC: U.S. Government Printing Office, 1983), 25–26. Semantics play a role in end-of-life decision-making processes. This quote addresses the notion of futility and the fact that it may have different meanings for different people or constituencies: In many cases, disagreements over [medical] futility are actually debates over the prudent allocation of limited health care resources. Terming an intervention “futile” may allow people to deny that value judgments and trade-offs are being made or that the cost of trying to save some lives is too high. Source: Ann Alpers and Bernard Lo, “When Is CPR Futile?” Journal of the American Medical Association 273 (1995): 158. Right-to-die issues stir passion in many people; many physicians are among the most passionate: The very soul of medicine is on trial. For this is not one of those peripheral issues about which pluralism and relativism can be tolerated. . . . This issue touches medicine at its very moral center; if this moral center collapses, if physicians become killers or are even merely licensed to kill, the profession—and, therewith, each physician—will never again be worthy of trust and respect as healer and comforter of life in all its frailty. Source: Willard Gaylin, Leon Kass, Edmund Pellegrino, and Mark Siegler, “Doctors Must Not Kill,” Journal of the American Medical Association 259 (1998), 2139, 2140.
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Former U.S. Surgeon General Dr. C. Everett Koop is among those who have spoken out with passion on the issue: We are pulling the plug on a great medical history. If you ask your doctor to be both the killer and the healer, then when you get sick you won’t know which doctor is approaching your bed. Source: Donald Cox, Hemlock’s Cup (Buffalo, NY: Prometheus Books, 1993), 209. Medicine has changed in many ways over the past several decades. Author David Rothman asserts that many, if not most, of these changes have created a greater chasm between physicians and their patients: Practically every development in medicine in the postWorld War II period distanced the physician and the hospital from the patient and the community, disrupting personal connections and severing bonds of trust. Whatever the index—whether ties of friendship, religion, ethnicity, or intellectual activity—the results highlight a sharp division between the lay world and the medical world. By the 1960s the two had moved so far apart that one could have asked a lay audience about the last time they spoke to a physician and had their clothes on, and they would have been unable to remember an occasion. Source: David J. Rothman, Strangers at the Bedside (New York: Basic Books, 1991), 127. Although end-of-life decisions are often associated with physicians, nurses are often the de facto decision makers: In general, nurses are expected to obey a written “No Code” order which follows hospital policy. However, neither the physician’s orders nor the agency’s policies protect the nurse from legal and ethical accountability for her actions . . . Often the nurse’s implementation of professional legal and ethical duties may be hampered by the legal privilege and conventional ethical rights of the physician who is considered to have ultimate
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accountability for patient care or by institutional limits on the nurse’s authority to act. Source: “Nurses Speak Out: Does a Terminal Patient Have the Right to Die?” Good Housekeeping (May 1984).
Spiritual-Social-Cultural Fr. Gerald Kelly, a Jesuit priest, declares that human life is inviolable: . . . Innocent human life is absolutely inviolable. By reason of this principle, we exclude all direct killing of the innocent, e.g., by . . . “mercy killing.” Source: Gerald Kelly, “The Duty of Using Artificial Means of Preserving Life,” Theological Studies II, 1950, as cited in James Rachels, The End of Life: Euthanasia and Morality (Oxford, England: Oxford University Press, 1986), 69. Depression can afflict the elderly just as it can people in other age groups. Some argue that elderly people who seek a way to end their lives do so more as a result of depression than a desire to escape from an illness: . . . A very large proportion of the elderly men and women who kill themselves do it because they suffer from quite remediable depression . . . I have more than once seen a suicidal old person emerge from depression . . . When such men or women return to a less despondent version of reality, their loneliness seems . . . less stark and their pain more bearable because life has become interesting again and they realize that there are people who need them. Source: Sherwin Nuland, How We Die: Reflections on Life’s Final Chapter (New York: Alfred A. Knopf, 1993), 152. Dame Cicely Saunders, the founder of the modern hospice movement, summarizes the theory behind hospice: You matter because of who you are. You matter to the last moment of your life, and we will do all we can not
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only to help you die peacefully, but also to live until you die. Source: Cicely Saunders, as quoted in Larry Beresford, The Hospice Handbook (Boston: Little, Brown, 1993), vi.
Legal-Political This excerpt from a ruling in Cruzan v. Director, Missouri Department of Health is unequivocal in stating that life, not its quality, is the overriding interest of the state: The State’s interest is not in quality of life . . .were quality of life at issue, all manner of handicaps might find the State to terminate their lives. Instead the State’s interest is in life; that interest is unqualified. Source: Cruzan v. Director, Missouri Department of Health, 109 S. Ct. 3240 (1989). U.S. Supreme Court Justice John Paul Stevens, dissenting in Cruzan v. Director, Missouri Department of Health, addresses the patient’s best interests and the constitutional right to be free of unwanted treatment: The portion of this Court’s opinion that considers the merits of this case is similarly unsatisfactory. It, too, fails to respect the best interests of the patient. It, too, relies on what is tantamount to a waiver rationale: the dying patient’s best interests are put to one side and the entire inquiry is focused on her prior expressions of intent. An innocent person’s constitutional right to be free from unwanted medical treatment is thereby categorically limited to those patients who had the foresight to make an unambiguous statement of their wishes while competent. Source: John Paul Stevens, in United States Supreme Court Minority Opinions on Cruzan v. Director, Missouri Department of Health (June 25, 1990). The court has traditionally upheld the highest standard of life in cases of infants or young children deemed incompetent due
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to youth or lack of maturity. This standard holds even when the parents choose to end life. Such was the case with Robert and Pamela Mueller, who had decided to withhold nutrition from their children because the children were conjoined (Siamese) twins who could not be separated surgically. The parents’ decision was overturned when an anonymous complaint was filed and the State of Illinois assumed custody of the children: Perhaps the most important practical lesson of [the case] is the reminder that non-treatment of handicapped infants is subject to criminal prosecution. Causing the death of an infant by intentional withholding of food or necessary medical treatments by a parent, or by a physician who has undertaken to treat the infant, may constitute a series of crimes ranging from murder and manslaughter to conspiracy and child abuse. Source: John A. Robertson, “Involuntary Euthanasia of Defective Newborns: A Legal Analysis,” Stanford Law Review 27 (1975): 213.
References (Please note the sources cited for each document, excerpt, and quotation provided above are not repeated here.) ABC News. “Dying ‘Dr. Death’ Has Second Thoughts about Assisting Suicides.” May 26, 2006, http://abcnews.go.com/US/ LegalCenter/story?id=2008364&page=1&CMP=OTC-RSS Feeds0312 (accessed June 7, 2007). Alzheimer’s Association. “Statistics about Alzheimer’s Disease.” 2007, http://www.alz.org/AboutAD/statistics.asp, (accessed June 7, 2007). American Association of Suicidology. “Elderly Suicide Fact Sheet.” 2006, http://www.suicidology.org/associations/ 1045/files/Elderly.pdf, (accessed June 7, 2007). American Association of Suicidology. “Suicide in the U.S.A.” 2004, http://www.suicidology.org/associations/1045/files/ suicideintheus.pdf (accessed June 7, 2007).
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American Cancer Society. “Cancer Facts and Figures 2005: Estimated Cancer Deaths for Selected Cancer Sites by State, 2005.” 2005, http://www.cancer.org/downloads/stt/ Estimated_Cancer_Deaths_for_Selected_Cancer_Sites_by_State,_ US,_2005.pdf (accessed June 7, 2007). American Foundation for Suicide Prevention. “Facts and Figures.” 2004, http://www.afsp.org/index.cfm? fuseaction=home.viewpage&page_id=050FEA9F-B064-4092B1135C3A70DE1FDA (accessed June 7, 2007). Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. “What Have We Learned from HIV/AIDS Surveillance?” http://www.cdc.gov/hiv/topics/ surveillance/basic.htm (accessed June 7, 2007). Compassion and Choices. “Learn about Us: Timeline.” http://www.compassionandchoices.org/aboutus/timeline.php (accessed June 7, 2007). Death with Dignity National Center. “Chronology of Assisted Dying.” http://www.deathwithdignity.org/historyfacts/ chronology.asp (accessed June 7, 2007). Fans of Fieger. “Chronology of Dr. Jack Kevorkian’s Life and Assisted Suicide Campaign.” http://www.fansoffieger.com/ chronology.htm (accessed June 7, 2007). Foley, Kathleen, and Herbert Hendin. 2002. The Case against Assisted Suicide: For the Right to End-of-Life Care. Baltimore; MD: Johns Hopkins University Press. Hamel, Ronald P., and Edwin R. DuBose. 1996. Must We Suffer Our Way to Death? Dallas, TX: Southern Methodist University Press. Humber, James M., Robert Almeder, and Gregg Kasting, eds. 1994. Physician-Assisted Death. Totowa, NJ: Humana Press. Lee, Barbara Coombs. 2003. Compassion in Dying: Stories of Dignity and Choice. Troutdale, OR: NewSage Press. Longwood University, Greenwood Library. “Doctor-Assisted Suicide: A Chronology.” http://www.longwood.edu/library/ suichron.htm (accessed June 7, 2007). Mackle, Bob. “MDA Researchers Find Dietary Supplement Promising in Lou Gehrig’s Disease.” Muscular Dystrophy Association Public Information, Muscular Dystrophy Association Public Information, March 3, 1999, http://www.mda.org/news/ 990303alscreat.html (accessed June 7, 2007).
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Magnusson, Roger S. 2002. Angels of Death: Exploring the Euthanasia Underground. New Haven, CT: Yale University Press. Marcus, Eric. 1996. Why Suicide? New York: HarperSanFrancisco. McKhann, Charles F. 1999. A Time to Die: The Place for Physician Assistance. New Haven, CT: Yale University Press. The Merriam-Webster Dictionary. 1998. Springfield, MA: MerriamWebster. Nightingale Alliance. “U.S. Historical Perspective and Current Trends.” http://www.nightingalealliance.org/cgi-bin/home. pl?article=204 (accessed June 7, 2007). Roig-Franzia, Manuel, and Ceci Connolly. “La. Investigates Allegations of Euthanasia at Hospital.” Washington Post, October 15, 2005, A03. Scherer, Jennifer M., and Rita J. Simon. 1999. Euthanasia and the Right to Die. Lanham, MD: Rowman & Littlefield Publishers. South Australian Voluntary Euthanasia Society (SAVES). “The Death of Compassion: How They Killed the Rights of the Terminally Ill.” http://www.saves.asn.au/resources/ collection/col14.htm (accessed June 7, 2007). Terri Schindler Schiavo Foundation. “Terri’s Story: Timeline.” http://www.terrisfight.org/mainlinks.php?tablesingle=main_ terri_story&id=1 (accessed June 7, 2007).
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7 Directory of Organizations
Organizations in the United States
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any organizations in the United States and throughout the world are involved in euthanasia and end-of-life issues in some way. Some of them exist to address the issue, while others focus on numerous issues including euthanasia. This directory, which includes organizations based in the United States and throughout the world, provides contact information, a synopsis of the organization, highlights of the organization’s Web site, and relevant publications. Aging with Dignity P.O. Box 1661 Tallahassee, Florida 32302 Phone: (888) 594-7437 Web site: http://www.agingwithdignity.org E-mail:
[email protected] A national nonprofit organization founded in 1996, Aging with Dignity is known for its distribution of a document called “Five Wishes.” The organization describes Five Wishes as an easy-tounderstand living will that helps seriously ill people and their families deal with the medical, personal, spiritual, and emotional issues of their illnesses.
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The Web site offers updates on recent projects, ways to get involved in the organization’s efforts, resources for individuals or families facing end-of-life issues, and links to other organizations. Aging with Dignity offers Five Wishes, as well as a Five Wishes video and a guide called “Next Steps.” The organization also offers a resource guide for family caregivers. Aid in Dying Communication Project P.O. Box 570 Mill Valley, California 94942 Phone: (415) 596-4257 Web site: http://www.aidindying.org/ E-mail:
[email protected] The Aid in Dying Communication Project is geared toward helping clinical personnel with understanding the concerns of patients who are seriously ill, helping them communicate more effectively with patients who may request a “hastened death” and/or assistance in dying, and helping them respond to such a request with compassion. The Web site outlines the philosophy, objectives, and services of the Aid in Dying Communication Project. The organization offers educational and consulting services to various constituencies, including health professionals and ethics committees. American Association of Suicidology (AAS) 5221 Wisconsin Avenue, NW Washington, DC 20015 Phone: (202) 237-2280 Fax: (202) 237-2282 Web site: http://www.suicidology.org E-mail:
[email protected] The American Association of Suicidology (AAS), a nonprofit organization, was founded in 1968 by Edwin S. Schneidman, Ph.D. The organization’s Web site notes that the goal of AAS is to understand and prevent suicide. To that end, the American Association of Suicidology offers a variety of resources for both volunteers and professionals. The Web site provides general information and statistics about suicide, as well as an overview of the organization’s aims and services. In addition to an online bookstore, the site features information specifically geared toward various constituencies, including survivors, friends and loved ones, and researchers.
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AAS publishes a journal called Suicide and Life-Threatening Behavior and two newsletters. Surviving Suicide, which is published quarterly, is for people who have lost a loved one to suicide. Newslink is the American Association of Suicidology’s official newsletter and keeps members up-to-date on the organization’s activities. American Chronic Pain Association (ACPA) P.O. Box 850 Rocklin, California 95677 Phone: (800) 533-3231 Fax: (916) 632-3208 Web site: http://www.theacpa.org/ E-mail:
[email protected] The American Chronic Pain Association (ACPA), founded in 1980, is a nonprofit organization. ACPA works to increase awareness, especially in the healthcare field and among policy makers, about the issues associated with chronic pain. The organization provides individuals suffering from chronic pain with the support and educational resources necessary to lead a fulfilling life, despite the pain. ACPA’s Web site includes resources for people living with chronic pain, as well as for their families and caregivers. In addition, the site highlights resources and updates available for professionals and caregivers and offers a forum, in the form of a message board, for people living with pain. ACPA offers numerous publications, including a newsletter called the ACPA Chronicle, a workbook titled From Patient to Person—First Steps, and the ACPA Family Manual. In addition, a Facilitator Guide is available to help a person with pain start a selfhelp group. American Counseling Association 5999 Stevenson Avenue Alexandria, Virginia 22304 Phone: (800) 347-6647 Fax: (800) 473-2329 Web site: http://www.counseling.org The American Counseling Association, a not-for-profit organization, was founded in 1952 to grow and enhance the counseling profession. The organization’s updated Code of Ethics, revised
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over a three-year period, was released at the end of 2005. The 2005 version of the Code of Ethics includes information regarding endof-life issues. American Counseling Association members are required to abide by the Code of Ethics and thus shape the manner in which they address end-of-life issues with clients. The Web site features a section for ACA members, including professional publications, practice guidelines, and benefits and services of membership. In addition, the Web site offers features for the public, including a search tool for finding a counselor, dealing with trauma, and coping with various issues. American Counseling Association publications include journals and newsletters for people in counseling professions. The quarterly Journal of Counseling and Development and the monthly Legal and Regulatory Compliance newsletter are two examples. Both publications are geared toward counselors and other mental health professionals. American Foundation for Suicide Prevention (AFSP) 120 Wall Street, 22nd Floor New York, New York 10005 Phone: (888) 333-AFSP or (212) 363-3500 Fax: (212) 363-6237 Web site: http://www.afsp.org E-mail:
[email protected] The American Foundation for Suicide Prevention (AFSP) was founded in 1987 by a group of people committed to finding a means to fund research to make meaningful progress in preventing suicide. The original group consisted of experts on suicide, business professionals, community leaders, and survivors. Today, the AFSP is a not-for-profit organization dedicated to research and education with the goal of understanding and preventing suicide. The Web site provides an overview of the organization, information about suicide prevention, opportunities for involvement and advocacy, and educational resources. In addition, the site offers an overview of the American Foundation for Suicide Prevention’s grants and includes the necessary information for applicants. The American Foundation for Suicide Prevention publishes a quarterly newsletter, Lifesavers.
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American Life League (ALL) P.O. Box 1350 Stafford, Virginia 22555 Phone: (540) 659-4171 Fax: (540) 659-2586 Web site: http://www.all.org E-mail:
[email protected] Founded in 1979, American Life League addresses a range of issues including abortion, euthanasia, birth control, and bioethics. ALL is a nonprofit organization whose activities include grassroots involvement, public policy, youth outreach, and education. The Web site includes extensive information on each issue ALL addresses, guidelines for getting involved, and links to news in the form of press releases, a blog, and newsletters. Newsletters include the Communique, a weekly publication providing an overview of ALL activities and issues, and the Rock for Life Report highlighting ALL’s youth outreach activities. American Medical Association (AMA) 515 North State Street Chicago, Illinois 60610 Phone: (800) 621-8335 Web site: http://www.ama-assn.org/ Dr. Nathan Smith Davis founded the American Medical Association in 1847. Today, the AMA brings physicians together to address issues within their profession, as well as issues pertaining to public health. The Web site includes clear language outlining the American Medical Association’s opposition to euthanasia. The site also provides a search tool for patients to find a physician and access news and professional resources in the areas of medical ethics, public health, and legal issues. AMA Voice is a bimonthly publication aimed at keeping physicians informed about the association’s activities. American Medical News, a newspaper for physicians, is published weekly (48 weeks per year). The Archives journals cover medical specialty areas; some of the journals are published on a bimonthly basis while others are published monthly. The Journal of the American Medical Association (JAMA) is the most renowned of AMA’s publications. JAMA is published weekly (48 weeks per year).
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American Psychological Association (APA) Public Interest Directorate 750 First Street, NE Washington, DC 20002-4242 Phone: (202) 336-6050 Web site: http://www.apa.org/pi/eol/homepage.html E-mail:
[email protected] The Public Interest Directorate of the American Psychological Association (APA) is concerned with human welfare and social justice, including end-of-life issues and care. The APA is the largest association of psychologists in the world. The Directorate’s Web page on end-of-life issues and care outlines activities and offers fact sheets on relevant issues. The site also offers resources, including a synopsis of tasks and decisions and information about the role of psychology in this realm. Publications specific to end-of-life issues and care include fact sheets and similar useful documents. American Society of Law, Medicine & Ethics (ASLME) 765 Commonwealth Avenue, Suite 1634 Boston, Massachusetts 02215 Phone: (617) 262-4990 Fax: (617) 437-7596 Web site: http://www.aslme.org/ E-mail:
[email protected] Founded in 1911, the American Society of Law, Medicine & Ethics is a nonprofit educational organization. ASLME sponsors conferences on relevant topics and maintains a library. In addition to links for membership and conference information, the organization’s Web site highlights research topics and offers a special section for members, including a member forum. ASLME publishes two journals for members. The Journal of Law, Medicine & Ethics is a peer-reviewed journal for health care professionals. The American Journal of Law & Medicine examines various issues, including health law and legal and ethical matters, related to the practice of medicine.
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Americans for Better Care of the Dying (ABCD) 1700 Diagonal Road, Suite 635 Alexandria, Virginia 22314 Phone: (703) 647-8505 Fax: (703) 837-1233 Web site: http://www.abcd-caring.org E-mail:
[email protected] Americans for Better Care of the Dying (ABCD), founded in 1997, is dedicated to ensuring that people in the United States have good care available to them at the end of their lives. The organization focuses on fundamental reform efforts to meet its goals of establishing momentum for reform, finding the best systems and means of providing care, and implementing public policy based on existing evidence. The ABCD Web site features links to pages on news and events, information on existing laws and legislative activity, and online publications and references. The print ABCD Exchange newsletter is published several times per year. Americans United for Life (AUL) 310 South Peoria, Suite 300 Chicago, Illinois 60607 Phone: (312) 492-7234 Fax: (312) 492-7235 Web site: http://www.unitedforlife.org/ E-mail:
[email protected] Founded in 1971, Americans United for Life is a nonprofit, public interest bioethics law firm. The organization employs a multipronged approach of legislative, judicial, and educational efforts in its quest to preserve human life. This organization addresses various issues, including abortion, human cloning, and stem cell research, as well as euthanasia and assisted suicide. The Web site includes an extensive listing of AUL’s activities as well as summaries of the organization’s stance on issues, with links to various supporting documents. In addition, the site provides model legislation and policy guides. AUL has published several books and studies, including Defending Life 2006: A State-by-State Legal Guide to Abortion, Bioethics, and the End of Life. The organization’s AUL Momentum highlights current events in the areas of abortion and euthanasia.
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Association for Death Education and Counseling (ADEC) 60 Revere Drive, Suite 500 Northbrook, Illinois 60062 Phone: (847) 509-0403 Fax: (847) 480-9282 Web site: http://www.adec.org The Association for Death Education and Counseling (ADEC) is dedicated to ensuring the highest standards in death education, grief counseling, care for the dying, and research in issues related to death and dying. The Web site provides an overview of the organization, professional resources, information about the annual conference and other educational events, resources for people who are coping with loss, and information about certifications in Thanatology (the study of death and dying). In addition to a quarterly newsletter, The Forum, a cookbook, Morsels and Memories, and CDs which address grief in children and adolescents, ADEC publishes Omega: The Journal of Death and Dying, The Journal of Trauma and Loss, Mortality Journal, Living with Loss, and The Thanatology Newsletter. Center for Christian Bioethics Coleman Pavilion, 11121 S Loma Linda University Loma Linda, California 92350 Phone: (909) 558-4956 Fax: (909) 558-0336 Web site: http://www.llu.edu/llu/bioethics/ E-mail:
[email protected] The Center for Christian Bioethics is headquartered at Loma Linda University, which is operated by the Seventh-day Adventist Church. In addition to conducting bioethics Grand Rounds on a monthly basis at Loma Linda University Medical Center, the center hosts seminars and conferences dealing with bioethical issues in the areas of medicine, law, and ministry. The Web site provides a link for ordering videos of bioethics Grand Rounds and a listing of bioethics resources. In addition, there is a link to the online Ethics Library, which includes back issues of the center’s ethics newsletter, transcripts of selected lectureships, and various reports and conference materials.
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The Center for Christian Bioethics publishes a quarterly newsletter, Update. Children’s Hospice International (CHI) 901 North Pitt Street, Suite 230 Alexandria, Virginia 22314 Phone: (800) 2-4-CHILD Fax: (703) 684-0226 Web site: http://www.chionline.org/ E-mail:
[email protected] Children’s Hospice International (CHI) works to make hospice an integral component of the range of pediatric services available to terminally ill children and their families. The organization also increases awareness of the fact that children have special needs in terms of hospice care. The Web site includes an in-depth explanation about the Children’s Hospice International Program for All-Inclusive Care for Children and their Families (CHI PACC). The site also includes an extensive list of available resources and news updates. CHI publications include books relevant to children facing end-of-life issues, Palliative Pain & Symptom Management for Children & Adolescents and Approaching Grief. Citizens United Resisting Euthanasia (CURE) 303 Truman Street Berkeley Springs, West Virginia 25411 Phone: (304) 258-5433 Web site: http://mysite.verizon.net/cureltd/index.html E-mail:
[email protected] Citizens United Resisting Euthanasia, founded in 1981, provides a means for patient advocates to work together in opposition to euthanasia. Describing itself as the oldest network devoted solely to combating euthanasia, CURE vigorously defends patients’ rights to lifesaving treatments. The Web site outlines the organization’s mission and goals and includes news, educational resources, and links to other organizations. CURE publications include brochures about various issues relevant to euthanasia, numerous reports, and other documents.
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Compassion and Choices P.O. Box 101810 Denver, Colorado 80250-1810 Phone: (800) 247-7421 Fax: (303) 639-1224 Web site: http://www.compassionandchoices.org/ E-mail:
[email protected] Compassion and Choices was created when two organizations, Compassion in Dying and End-of-Life Choices, joined forces. This nonprofit entity champions choice and care at the end of life by focusing on relevant issues in Congress, as well as in the courts and state legislatures. The Web site outlines the organization’s numerous services, highlights the ways Compassion and Choices works to address end-of-life issues at various levels of government, and offers opportunities for involvement. The organization publishes Compassion and Choices Magazine and has compiled a list of recommended publications, including Compassion in Dying: Stories of Dignity and Choice, a book by coCEO and president Barbara Coombs Lee. Death with Dignity National Center (DDNC) 520 SW 6th Avenue, Suite 1030 Portland, Oregon 97204 Phone: (503) 228-4415 Fax: (503) 228-7454 Web site: http://www.deathwithdignity.org A nonprofit organization, the Death with Dignity National Center leads the legal defense of the State of Oregon’s Death with Dignity Law. In addition, DDNC educates the public about the law. The Oregon Death with Dignity Political Action Fund, which is a separate entity, defends the law on the political front and works for the promulgation or defense of similar legislation in other states. The Web site includes extensive background information on Oregon’s Death with Dignity law, including a chronology and other historical information. A section devoted to news allows visitors to the site to search by topic. Another section highlights separate resources for students, physicians, legal professionals, lawmakers, and the general public. DDNC publishes The Dignity Report newsletter.
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Euthanasia Research Guidance Organization (ERGO) 24829 Norris Lane Junction City, Oregon 97448-9559 Phone: (541) 998-1873 Fax: (541) 998-1873 Web site: http://www.finalexit.org/ E-mail:
[email protected] The Euthanasia Research Guidance Organization (ERGO) is a nonprofit educational corporation which was established in 1993 by Derek Humphry, founder of the now-defunct Hemlock Society. In addition to research on end-of-life issues, ERGO offers ethical, psychological, and legal guides for patients and physicians addressing issues and decisions related to the end of life. The ERGO Web site highlights international laws on assisted suicide and includes information about key figures and events in the right-to-die movement. Visitors to the site can subscribe to receive e-mails from the International Right-to-Die News Service. The Web site also has a store that sells relevant books, e-books, videos, and documents. Final Exit Network P.O. Box 965005 Marietta, Georgia 30066 Phone: (800) 524-3948 Web site: http://www.finalexitnetwork.org E-mail:
[email protected] Final Exit Network, a nonprofit organization, is dedicated to helping people address their suffering by providing support, including counseling, and, upon request, information about self-deliverance. In addition, the Final Exit Network encourages people to use advance directives and works to assist those whose advance directives are being ignored. The Web site outlines the organization’s Exit Guide program, which pairs a person facing end-of-life decisions with a guide who presents information about the various care options available, including information about self-deliverance options. In addition, the site includes information about membership, volunteer opportunities, and events. The organization’s online bookstore sells print and nonprint works by Derek Humphry (founder of Euthanasia Research Guidance Organization [ERGO]).
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The Hastings Center 21 Malcolm Gordon Road Garrison, New York 10524-4125 Phone: (845) 424-4040 Fax: (845) 424-4545 Web site: http://www.thehastingscenter.org E-mail:
[email protected] Founded in 1969, the Hastings Center is an independent, nonpartisan, and nonprofit organization. In addition to biotechnological and environmental issues, the center addresses healthcare matters, including end-of-life care. The Web site highlights current research, lists available publications, provides information about the organization’s extensive library, and details the center’s Visiting Scholars Program. The Hastings Center Report is a bimonthly journal that examines ethical issues related to medicine and the environment. Due to the high volume of research conducted at the Hastings Center, the organization publishes numerous books, monographs, special reports, and other documents. Hospice Association of America (HAA) 228 Seventh Street, SE Washington, DC 20003 Phone: (202) 546-4759 Fax: (202) 547-9559 Web site: http://www.nahc.org/haa/ The Hospice Association of America (HAA), a national organization, represents the interests of more than 2,800 hospices, as well as caregivers who provide care to terminally ill patients. HAA’s main goals include heightening public awareness of hospice services, promoting hospice as an integral part of health care, and establishing high standards of patient care within the hospice environment. The Web site provides an overview and updates of legal, regulatory, and legislative issues related to hospice, as well as information regarding meetings at the local and regional levels. The Consumer Information section provides a comprehensive look at questions and issues related to hospice. Key features include a consumer’s guide to hospice, a history of hospice, a fact sheet, statistics, and the Hospice Patient’s Bill of Rights. The Hospice Association of America publications include Caring magazine, several videos, manuals for operating hospice
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programs, and guides for managing issues related to Medicare and Medicaid. Hospice Education Institute 3 Unity Square P.O. Box 98 Machiasport, Maine 04655-0098 Phone: (207) 255-8800 Fax: (207) 255-8008 Web site: http://www.hospiceworld.org E-mail:
[email protected] The Hospice Education Institute is a nonprofit organization dedicated to improving hospice care and making it widely available throughout the United States and the world. The institute works for and with the terminally ill and their caregivers. The Web site offers an overview of the organization and its services, provides historical highlights of the hospice movement, and gives information regarding upcoming seminars on hospicerelated issues. Hospice Education Institute publications include pamphlets on topics related to hospice and The Hospice Education Institute’s Notes on Symptom Control in Hospice and Palliative Care. Human Life International (HLI) 4 Family Life Lane Front Royal, Virginia 22630 Phone: (800) 549-LIFE Fax: (540) 622-6247 Web site: http://www.hli.org E-mail:
[email protected] Founded in 1981, Human Life International has grown to its selfdescribed state as the largest international pro-life, pro-family, pro-woman organization in the world. The organization advocates the sanctity of life from conception until death occurs naturally. The Web site describes Human Life International’s activities throughout the world, provides links to satellite office Web sites, and highlights ways supporters can become advocates. HLI publishes Special Report, a monthly publication, covering international pro-life efforts and news from HLI missionaries; Front Lines, a quarterly publication providing updates on HLI activities and issues; and other advocacy publications.
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International Task Force on Euthanasia and Assisted Suicide P.O. Box 760 Steubenville, Ohio 43952 Phone: (740) 282-3810 Web site: http://www.iaetf.org or www.internationaltaskforce.org The International Task Force on Euthanasia and Assisted Suicide, through networking, research, education, and other activities, addresses issues related to euthanasia, assisted suicide, advance directives, disability rights, pain control, and euthanasia practices. The Web site provides information about the organization, its activities, and current news on topics of interest. The online book store sells publications, documents, videos, and other items. The International Task Force publishes a newsletter, Update. The Kennedy Institute of Ethics at Georgetown University Healy, 4th Floor Georgetown University Washington, DC 20057 Phone: (202) 687-8099 Fax: (202) 687-8089 Web site: http://kennedyinstitute.georgetown.edu/ index.htm E-mail:
[email protected] The Joseph P. and Rose F. Kennedy Institute of Ethics was established in 1971 through a grant from the Joseph P. Kennedy, Jr. Foundation. Described as the oldest and most comprehensive academic bioethics center in the world, the institute offers degree and nondegree programs. The Web site highlights the activities of institute scholars in numerous areas of bioethics including end-of-life issues, health care, intellectual disability, and eugenics. In addition, a link is provided to the institute’s library, which is accessible to the public. This library, which is nonpartisan in nature, affords researchers the opportunity to critically examine various viewpoints relevant to issues of bioethics. Many of the Kennedy Institute’s publications are issue-specific; however, the Kennedy Institute of Ethics Journal provides a scholarly look at various viewpoints on issues in bioethics. Publications in the Scope Note series cover a specific issue and
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include various viewpoints, as well as empirical information and legal precedents. MacLean Center for Clinical Medical Ethics 5841 South Maryland Avenue, MC 6098 Chicago, Illinois 60637 Phone: (773) 702-1453 Fax: (773) 702-0090 Web site: http://medicine.uchicago.edu/centers/ ccme/index.htm E-mail:
[email protected] Founded in 1984 with funding from the family of Dorothy J. MacLean, the MacLean Center for Clinical Medical Ethics was the first program in the nation devoted to clinical medical ethics. The MacLean Center is dedicated to addressing ethics issues from the perspective of various disciplines, including medicine, surgery, and psychiatry, as well as law, business, public policy, social sciences, and the humanities. The Web site highlights clinical medical ethics issues and outlines the organization’s services, including an ethics consultation service for physicians at University of Chicago hospitals and a fellowship program for training in medical ethics. The site’s Faculty section provides curriculum vitae of many faculty members, including their publications. National Center for Death Education (NCDE) at Mount Ida College Mount Ida College 777 Dedham Street Newton, Massachusetts 02459-3323 Phone: (617) 928-4649 Fax: (617) 928-4713 Web site: http://www.mountida.edu/sp.cfm?pageid=307 E-mail:
[email protected] The National Center for Death Education (NCDE) at Mount Ida College promotes knowledge and understanding in the area of thanatology (the study of death and dying). An educational center, NCDE provides professional learning opportunities and resources to assist caregivers and others who support the dying as well those who are grieving. The Web site includes information on thanatology-related courses and programs, as well as a link to NCDE’s library.
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National Citizens’ Coalition for Nursing Home Reform (NCCNHR) 1828 L Street, NW, Suite 801 Washington, DC 20036 Phone: (202) 332-2276 Fax: (202) 332-2949 Web site: http://www.nursinghomeaction.org The National Citizens’ Coalition for Nursing Home Reform (NCCNHR) was founded in 1975 after advocates spoke at a conference in Washington, DC, about the need to dramatically improve nursing home conditions. Today, NCCNHR works at the federal and state levels to address issues related to resident care in nursing homes. Issues include inadequate staffing, poor working conditions, use of restraints, resident rights, and more. The Web site highlights ways for family members to serve as advocates for nursing home residents, provides links to relevant government policies, offers an online library, and includes links to state ombudsmen. NCCNHR’s publications for consumers include annual meeting materials, family involvement information, and guidelines to resident rights. Professional versions of the annual meeting materials and guidelines to resident rights are also available. Other professional publications include sources and references on nursing home reform law, research and reports, and training materials. Miscellaneous publications, including History and Role of the Long-Term Care Ombudsman Program, are also available for sale. A newsletter, Quality Care Advocate, is free to members. National Hospice Foundation (NHF) 1700 Diagonal Road, Suite 625 Alexandria, Virginia 22314 Phone: (703) 516-4928 Fax: (703) 837-1233 Web site: http://www.nationalhospicefoundation.org E-mail:
[email protected] The National Hospice Foundation (NHF) is a nonprofit organization dedicated to increasing awareness about the issue of end-oflife care, including hospice and palliative care options. As the principal fundraising partner of the National Hospice and Palliative Care Organization (NHPCO), NHF works to raise awareness and
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funds to ensure that hospice and palliative care continue to be options for people at the end of their lives. The Web site includes a history of the National Hospice Foundation, information about hospice and palliative care, and a search tool to locate a hospice and/or palliative care organization. National Hospice and Palliative Care Organization (NHPCO) 1700 Diagonal Road, Suite 625 Alexandria, Virginia 22314 Phone: (703) 837-1500 Fax: (703) 837-1233 Web site: http://www.nhpco.org E-mail:
[email protected] The National Hospice and Palliative Care Organization (NHPCO) represents hospice and palliative care organizations, as well as caregivers, from areas throughout the United States. Founded in 1978 as the National Hospice Organization, the group changed its name to the National Hospice and Palliative Care Organization in 2000. In addition to developing programs to increase awareness about hospice and palliative care, NHPCO provides information and educational resources to its members, monitors legislation, and conducts research. The Web site provides general information about hospice and palliative care, as well as links to access advance directives by state. In addition, the site highlights information about conferences and other resources and offers information relevant to hospice and palliative care for people facing end-of-life issues and decisions. NHPCO’s publications are geared toward specific groups within the organization’s membership. NewsBriefs is a weekly memo for organizations that provide hospice and/or palliative care. NewsLine, which is published monthly, is also for these providers, as well as other organizations that belong to NHPCO. Insights is a quarterly magazine for professionals and volunteers who work in a hospice and/or palliative care setting. The Journal of Pain and Symptom Management, a peer-reviewed journal, is published monthly.
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National Right to Life Committee (NRLC) 512 10th Street, NW Washington, DC 20004 Phone: (202) 626-8800 Web site: http://www.nrlc.org/ E-mail:
[email protected] The National Right to Life Committee was founded in 1973 following the U.S. Supreme Court ruling in Roe v. Wade. Although the organization’s main focus is on fighting abortion, its overall concern with issues of medical ethics includes issues related to euthanasia and infanticide. The Web site provides a means for interested parties to learn more about current efforts, legislation, and available resources. The site also provides information regarding its advocacy issues, including statistical information, links to other Web sites, and definitions of key words. The National Right to Life Committee offers various online documents, including e-mail newsletters, downloadable brochures, periodicals, and fact sheets. Not Dead Yet 7521 Madison Street Forest Park, Illinois 60130 Phone: (708) 209-1500 Fax: (708) 209-1735 Web site: http://www.notdeadyet.org E-mail:
[email protected] Not Dead Yet, founded in 1996, opposes legalized assisted suicide. The organization was established following Dr. Jack Kevorkian’s acquittal in the suicides of two women who had disabilities but were not terminally ill. Not Dead Yet works with other national disability rights organizations to spread their message about the dangers legalized assisted suicide would present for people with severe disabilities. The organization’s Web site offers articles, fact sheets, links to other organizations, information about the Not Dead Yet Speakers’ Bureau, a list of partner organizations, and highlights of court cases, including amicus briefs submitted by the organization.
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Park Ridge Center 205 West Touhy Avenue, Suite 203 Park Ridge, Illinois 60068-4202 Phone: (847) 384-3507 Fax: (847) 384-3557 Web site: http://www.parkridgecenter.org/ E-mail:
[email protected] The Park Ridge Center is an independent, nonprofit, and nonsectarian organization. Affiliated with Advocate Health Care, the center engages in research, education, and consultation aimed at delving into the interaction between health, faith, and ethics. The Web site includes a brief message from the organization’s president outlining news and current projects. In addition, the site features links to Park Ridge Center publications, affiliated programs, and consultation services. A peer-reviewed journal, Second Opinion, is published quarterly. The E-Ethics Newsletter is offered on a monthly basis. Past issues of the Bulletin, a publication which focused on a specific topic in each edition, are also available. Supportive Care Coalition: Pursuing Excellence in Palliative Care c/o Providence Health System 4805 NE Glisen 2E07 Portland, Oregon 97213 Phone: (503) 215-7009 Fax: (503) 215-5054 Web site: http://www.SupportiveCareCoalition.org E-mail:
[email protected] Supportive Care Coalition: Pursuing Excellence in Palliative Care is a coalition of Catholic health ministries working to advance excellence in palliative care through knowledge transfer, advocacy, and partnerships. The coalition’s member organizations include some of the nation’s largest Catholic health systems and operate health facilities in 48 states. Informed by its Catholic faith and values, the coalition envisions a society in which all persons living with or affected by a chronic or life-threatening condition receive compassionate, holistic, coordinated care. In addition to an overview of the organization, the Web site provides a plethora of resources related to palliative care, including
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assessment tools, successful practices, and articles and essays. The site also offers a section with resources on ethics issues. The Supportive Care Coalition publishes a quarterly newsletter, Supportive Voice, and a bimonthly E-news listserv and offers reference manuals. Terri Schindler Schiavo Foundation (TSSF) 5562 Central Avenue, Suite 2 St. Petersburg, Florida 33707 Phone: (727) 490-7603 Web site: http://www.terrisfight.org/ E-mail:
[email protected] The Terri Schindler Schiavo Foundation, a nonprofit corporation, was founded in 2001. The organization, which opposes euthanasia and physician-assisted suicide, engages in an educational campaign to build public support for its efforts. The foundation’s longterm goal is to establish a network of Terri Schindler Schiavo Centers to care for brain-injured patients. The Web site provides information on activities and events, features links to other organizations, offers ways to get involved, and highlights the story of Terri Schindler Schiavo, in whose memory the organization is named. United States Conference of Catholic Bishops (USCCB) 3211 4th Street, NE Washington, DC 20017-1194 Phone: (202) 541-3000 Web site: http://www.usccb.org/index.shtml The United States Conference of Catholic Bishops (USCCB) was formed in 2001 when two organizations, the National Conference of Catholic Bishops and the United States Catholic Conference, were combined. Today, the organization addresses numerous issues, including abortion, capital punishment, euthanasia, environment, labor, and poverty. The Web site provides links to USCCB documents and other materials relevant to the organization’s advocacy issues, as well as an online version of the Bible and other documents related to Catholicism. The organization offers videos, DVDs, study guides, books, materials related to the various issues USCCB addresses, as well as numerous church-related documents.
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Organizations Overseas Association pour le Droit de Mourir dans la Dignite (ADMD) 50 rue de Chabrol 75010 Paris, France When calling from the United States: Phone: +33-1-48-00-04-92 Fax: +33-1-48-00-05-72 Web site: http://www.admd.net/ E-mail:
[email protected] Association pour le Droit de Mourir dans la Dignite (ADMD), or the Association for the Right to Die with Dignity, works to make pain relief accessible, to secure the right for patients to refuse treatment to prolong life, to make the living will a legally recognized document, and to make euthanasia legal. The Web site summarizes the organization’s initiatives, highlights relevant legislation, and includes information about end-oflife policies in France and other countries. In addition, the site features a section about future goals. ADMD’s Bulletin is published four times per year and the Letter is published semiannually. Care NOT Killing Box 56322 London, England SE1 8XW Phone: +020 7633 0770 Fax: +020 7681 1924 Web site: http://www.carenotkilling.org.uk/ E-mail:
[email protected] Care NOT Killing, an alliance of organizations and individuals, promotes palliative care as an end-of-life option and opposes euthanasia and assisted suicide. The organization works to improve available palliative care options and campaigns against legalizing euthanasia and assisted suicide. The Web site offers information on the organization’s efforts, provides information about bills and laws regarding euthanasia and assisted suicide, and features links to anecdotal information, articles, and documents. Care NOT Killing offers an E-newsletter and issue alerts.
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Dignity in Dying 13 Prince of Wales Terrace London, England W8 5PG Phone: +0870 777 7868 Web site: http://www.dignityindying.org.uk/ E-mail:
[email protected] Dignity in Dying was founded in 1935 as the Voluntary Euthanasia Society. Members approved the new name at the organization’s annual meeting in 2005. The organization is dedicated to improving patient choice in end-of-life care. To that end, Dignity in Dying engages in lobbying and defending patients’ legal rights, as well as advocating on behalf of terminally ill patients who feel their wishes are being ignored. The organization also works to educate people, especially in the legal and medical professions, about end-of-life issues. The Web site features stories from and about people who faced, or are facing, end-of-life issues. It also outlines patients’ rights, provides opportunities for involvement, highlights news and events, and offers information about living wills. In addition, the site provides links to legislation, and legal documents. Publications include the Dignity in Dying Report. This publication is geared toward the medical and legal communities, as well as researchers, and it highlights research and other key information in the realm of “assisted dying.” Dying with Dignity 55 Eglinton Avenue East, Suite 802 Toronto, Ontario M4P 1G8 Canada Phone: (416) 486-3998 or (800) 495-6156 Fax: (416) 486-5562 Web site: http://www.dyingwithdignity.ca/ E-mail:
[email protected] Dying with Dignity is a national organization dedicated to enhancing the quality of dying by creating additional end-of-life choices in Canada. This Web site features information about living wills and Dying with Dignity’s counseling program. The site also offers a glossary, a summary of Canadian law on assisted dying, information about laws related to end-of-life issues in other countries, a reading list, and links to other organizations.
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The organization’s Web site includes links to various documents, including reports and speeches, relevant to end-of-life issues. EXIT 17 Hart Street Edinburgh, Scotland EH1 3RN Phone: +44 131-556-4404 Web site: http://www.euthanasia.cc/ E-mail:
[email protected] Previously known as the Scottish Voluntary Euthanasia Society, EXIT is dedicated to promoting personal choice in end-of-life decisions. EXIT also campaigns for improvements in palliative care and other end-of-life options. The organization’s Web site offers extensive information and resources on euthanasia, assisted suicide, and other matters related to the end of life. EXIT offers a “Living Will Info Pack” and several books for sale. In addition, back issues of the EXIT Newsletter are available. EXIT International P.O. Box 37781 Darwin, NT 0821 Australia Phone: +61 500 83 1929 Fax: +61 8 8983 2949 Web site: http://www.exitinternational.net/ E-mail:
[email protected] EXIT International, previously known as the Voluntary Euthanasia Research Foundation, was founded by Dr. Philip Nitschke. The organization was established in response to the repeal of Australia’s Rights of the Terminally Ill Act, considered the first successful example of voluntary euthanasia legislation in the world. In addition to advocating for new laws, EXIT International works to provide people with information regarding end-of-life options. The Web site includes a history of the organization, biographical information about founder and director Dr. Philip Nitschke, background information about Australia’s Rights of the Terminally Ill Act, and anecdotal information about people Dr. Nitschke has assisted in ending their lives. EXIT International publishes a newsletter, Deliverance.
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Friends at the End (FATE) 11 Westbourne Gardens Glasgow, Scotland G12 9XD Phone: +0141 334 3287 Fax: +0141 334 3287 Web site: http://www.friends-at-the-end.org.uk E-mail:
[email protected] Friends at the End (FATE) is committed to increasing awareness about choices available to people at the end of their lives and to providing support to people who face end-of-life decisions. In addition to funding and supporting research into issues related to death, Friends at the End works to enhance education for the medical community about death and terminal illness. The Web site provides access to various resources related to end-of-life issues, including living wills and a welfare attorney. It also highlights meeting reports and provides materials for research, including articles and legislative items. FATE publishes a member newsletter. Ontario Consultants on Religious Tolerance (OCRT) Box 27026 Kingston, Ontario K7M 8W5 Canada Phone: N/A Fax: (613) 547-9015 Web site: http://www.religioustolerance.org Ontario Consultants on Religious Tolerance (OCRT) is a volunteer-based organization dedicated to promoting religious tolerance. The organization, founded in 1995, consists of an Agnostic, an Atheist, a Christian, a Wiccan, and a Zen Buddhist. Together, they address various issues through essays and other writings for public consumption via the Internet. The Web site contains background on the organization, as well as thousands of articles on current events and controversial issues, with a focus on issues that are controversial within the realm of religion. The section devoted to euthanasia features an introduction, information on the religious aspects of the issue, and articles which examine the issue in various contexts.
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Right to Die Society of Canada (RDSC) 145 Macdonell Avenue Toronto, Ontario, M6R 2A4 Canada Phone: (416) 535-0690 Fax: (416) 530-0243 Web site: http://www.righttodie.ca/ E-mail:
[email protected] The Right to Die Society of Canada was founded 1991. It is not a nonprofit organization because its officers did not want the constraints that govern organizations with nonprofit status. The organization, which operates with voluntary officers and advisers, devotes its funds to printing and mailing newsletters, advocacy, and public education activities. In addition to a comprehensive history of the organization, the Web site offers a “Researchers’ Buffet,” which includes viewpoints from both sides of the right-to-die movement, as well as news, legislation, and a glossary. The Right to Die Society of Canada is one of five Canadian organizations that collaborate to publish Free to Go, a quarterly newsletter. SAVES – The Living Will Society P.O. Box 1460 Wandsbeck, KwaZulu-Natal 3631 South Africa Phone: +031 266 8511 Fax: +031 267 2218 Web site: http://www.livingwill.co.za/ E-mail:
[email protected] SAVES – The Living Will Society is a nonprofit organization which promotes the living will as a means to save patients and their loved ones from suffering and pain, anxiety, valueless prolongation of terminal illness, existence without quality of life, and spending life savings unnecessarily. The Web site offers information about preparing a living will, a link to membership, an explanation of informed consent, and guidelines for medical practitioners.
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Directory of Organizations
Voluntary Euthanasia Society of New Zealand P.O. Box 26 095 Epsom, Auckland 1030 New Zealand Phone: +09 630 7035 Web site: http://www.ves.org.nz/contact.htm E-mail:
[email protected] The Voluntary Euthanasia Society of New Zealand is dedicated to making it legal for a person who is terminally ill, or facing an unacceptable quality of life, to decide to end life. This organization was created when the Voluntary Euthanasia Society (Auckland) Inc. and the Wellington Voluntary Euthanasia Society merged. The Web site contains an overview of the concept of voluntary euthanasia, a brief summary of New Zealand’s existing laws related to end-of-life issues, links to international news, and research tools, including polls, articles, and links to other Web sites. World Federation of Right to Die Societies Web site: http://www.worldrtd.net/ The World Federation of Right to Die Societies, established in 1980, counts thirty-eight organizations from twenty-three countries among its members. The federation is committed to securing and protecting an individual’s right to die. The World Federation of Right to Die Societies meets every two years; these international conferences are hosted by one of the member organizations. The Web site offers links to the member organizations, opportunities to get involved, a section with news divided by country, and links to other organizations. A newsletter, the World Federation of Right to Die Societies Newsletter, is published twice a year.
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8 Resources
Resources to Assist in the Study of Euthanasia
T
he books, articles, periodicals, and nonprint resources listed in this section will provide readers with accessible outlets for additional research on euthanasia and end-of-life issues. Given the sheer volume of materials on the subjects, it was necessary to adopt certain criteria to determine what should be included in this list. First and foremost, the list of books includes only those that are in print as of this writing. In addition, materials were included only if there was a focus on euthanasia, assisted suicide, or other end-of-life issues relevant to this publication. Finally, all of the entries were examined for relevance and timeliness. To facilitate use of this resource, the list is divided as follows: • • • • •
Print Resources Periodicals Nonprint resources Databases Internet sites
All of the sources are annotated and listed alphabetically within each category.
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Print Resources Medical-Bioethical Books Foley, Kathleen, and Herbert Hendin, eds. 2002. The Case against Assisted Suicide. Baltimore, MD: Johns Hopkins University Press. 371 pp. ISBN: 0-8018-6792-4. This book offers a collection of essays on the topic of assisted suicide. Beginning with a chapter that addresses autonomy, compassion, and rational suicide, the book, declaring that legalized assisted suicide would pose risks for some populations, includes a chapter highlighting concerns relevant to those constituencies. Finally, in a section titled “A Better Way,” the authors, along with Dame Cicely Saunders who founded the modern hospice movement, explore hospice and palliative care options. Jamison, Stephen. 1997. Assisted Suicide: A Decision-Making Guide for Health Professionals. San Francisco: Jossey-Bass Publishers. 248 pp. ISBN: 0-7879-0873-8. As the title notes, this book is geared toward health care professionals. It provides information on the debate surrounding assisted suicide and offers decision-making tools regarding a patient’s request to die. The book also offers insight into family dynamics and assistance for working through the myriad issues associated with the concept of assisted suicide. Magnusson, Roger S. 2002. Angels of Death: Exploring the Euthanasia Underground. New Haven, CT: Yale University Press. 325 pp. ISBN: 0-300-09439-6. This book focuses on the practices of physician-assisted suicide and euthanasia in the United States and Australia. The author surveyed and interviewed health care professionals in both countries about instances in which euthanasia and physician-assisted suicide occur. Interviews, using pseudonyms for the medical personnel, are included in the book. McKhann, Charles F., 1999. A Time to Die: The Place for Physician Assistance. New Haven, CT: Yale University Press. 268 pp. ISBN: 0300-07631-2.
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A specialist in cancer surgery, Dr. Charles McKhann examines issues associated with dying in the United States, including the needs of the patient, concerns and issues for physicians, legal questions, and arguments against physician-assisted suicide. He also argues on behalf of rational suicide and contrasts similar cases in the United States and the Netherlands.
Articles Campbell, Courtney S., and Jane Hare. 1995. “Conflicts of Conscience: Hospice and Assisted Suicide.” Hastings Center Report 25 (3): 36–43. The article addresses the unique issues that have arisen in Oregon-based hospice agencies as a result of the passage of Measure 16, Oregon’s Death with Dignity Act. In addition to information about hospice in Oregon and a summary of the hospice community’s concerns about the implications of Measure 16, the article notes that the Oregon Hospice Association released a statement expressing opposition to Measure 16. Finally, the article highlights the ways Oregon’s hospice network prepared to cope with Measure 16 following its approval by the state’s voters. Darr, Kurt. 2000. “Physician-Assisted Suicide and Health Services Delivery.” Hospital Topics 78 (2): 28–32. The article begins by comparing euthanasia with physicianassisted suicide and outlining the differences between the two concepts. The article also offers an explanation and information about Oregon’s Death with Dignity Act, highlights the physicianrelated issues that arise in the context of end-of-life matters, and frames the issue of physician-assisted suicide in terms of the delivery of health services and economics. Ersek, Mary. 2005. “Assisted Suicide: Unraveling a Complex Issue.” Nursing 35 (4): 48–52. This article begins by defining the various terms that arise in discussions of end-of-life issues. It also outlines arguments on both sides, highlights existing laws, and provides key information for healthcare professionals who might meet with end-of-life assistance requests from patients. Ferrell, Betty, and Rose Virani. 2000. “End-of-Life Care: Nurses Speak Out.” Nursing 30 (7): 54–57.
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This article begins by asking how well nurses serve terminally ill patients. The answer, according to nurses surveyed by researchers at the California-based City of Hope National Medical Center, is that it could be better. The article outlines the survey responses. Gorman, Daniel. 1999. “Active and Passive Euthanasia: The Cases of Drs. Claudio Alberto de la Rocha and Nancy Morrison.” Canadian Medical Association Journal 160 (6): 857–860. This article begins by differentiating between passive euthanasia and active euthanasia and offers two cases to illustrate the differences and stimulate further examination of the issue of active euthanasia. The author also employs hypothetical cases to facilitate further exploration of the issues. Loconte, Joe. 1998. “Hospice, Not Hemlock.” Policy Review 88: 40–48. This article examines the issue of dying in the United States and provides a wealth of information on the hospice option. In addition to a history of hospice, the article offers specifics about the types of care available. Arguments about the effectiveness of hospice care are also presented. Mogg, Marcelle. 2006. “The Right to Decide.” Australian Nursing Journal 13 (8): 18–21. The article, citing the cases of Terri Schiavo in the United States and Maria Korp in Australia, provides an overview of the Respecting Patient Choices (RPC) program, which originated at the Austin Hospital in Victoria. The program is an advance care planning initiative. Mulligan, Margaret. 1996. “Nurse-Assisted Suicide: Indictment of Physicians’ Care?” Physician’s Management 36 (9): 33. This article reviews a study by David A. Asch, M.D., MBA published in the New England Journal of Medicine. The study examined the issue of nurses performing euthanasia or assisted suicide. This article reports the results and notes the author-acknowledged weaknesses of the study. Petrou, Michael. 2005. “A Time to Die.” Maclean’s 118 (36): 22–25. The article uses anecdotes to compare the options available to a terminally ill person in Canada with the options available to a terminally ill person in Holland.
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Spinney, Laura. 2005. “Last Rights.” New Scientist 186 (2496)t: 46–49. This article examines end-of-life issues. There is an anecdotal account of a woman who, suffering from amyotrophic lateral sclerosis (ALS), or Lou Gehrig’s disease, struggles with deciding whether to die by allowing the disease to take its course or hasten her own death. The article also offers comparisons of existing laws on end-of-life issues.
Spiritual-Social-Cultural Books Atwood Gailey, Elizabeth. 2003. Write to Death. Westport, CT: Praeger. 185 pp. ISBN: 0-275-97713-7. This book examines and analyzes the ways in which news coverage of end-of-life issues has influenced public perception and legislation on euthanasia and physician-assisted suicide. It includes analysis of the news coverage surrounding Dr. Jack Kevorkian and Karen Ann Quinlan, as well as an analysis of the positive or negative news coverage in various publications including U.S. News & World Report, the New York Times, and Newsweek. Battin, Margaret Pabst. 2005. Ending Life: Ethics and the Way We Die. New York: Oxford University Press. 344 pp. ISBN: 0-19-514027-3. The book’s first section, “Dilemmas about Dying,” examines various issues, including the concept of euthanasia and whether a physician is ever obligated to assist a patient in dying. The section on historical, religious, and cultural concerns includes an examination of the same-day deaths of Thomas Jefferson and John Adams, as well as the ethical issues attached to the concept of suicide bombing. The final section, which examines death in the future, includes scrutiny of various issues that were not yet concerns for previous generations who wrestled with end-of-life issues, including genetic indicators that provide knowledge of death. Beauchamp, Tom L., ed. 1996. Intending Death: The Ethics of Assisted Suicide and Euthanasia. Upper Saddle River, NJ: Prentice Hall. 234 pp. ISBN: 0-13-199555-3. This book is a collection of essays which examine various ethical issues related to assisted suicide and euthanasia. Through
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these essays, the book addresses philosophical points, clinical issues, and political, legal, and economic concerns. Cauthen, Kenneth. 1999. The Ethics of Assisted Death. Lima, OH: CSS Publishing Company. 101 pp. ISBN: 0-7880-1332-7. This book highlights the arguments for and against physician-assisted death, outlines the personal stories of Karen Ann Quinlan, Austin Bastable, Nancy Cruzan, and several others, and analyzes legal rulings. It also offers the author’s own analysis, with biblical and philosophical references to buttress his reasoning. Cohen-Almagor, Raphael. 2001. The Right to Die with Dignity. New Brunswick, NJ: Rutgers University Press. 304 pp. ISBN: 0-81352986-7. This book examines the medical ethics concerns surrounding right-to-die issues. In addition, it examines the sanctity and quality of life in issues of medical ethics and analyzes the role of the patients’ loved ones in end-of-life decisions. The author provides his own analysis and insight into Oregon’s Death with Dignity Act and euthanasia policies and practices in the Netherlands. Evans, Glen, and Norman L. Farberow. 2003. The Encyclopedia of Suicide. New York: Facts on File. 329 pp. ISBN: 0-8160-4525-9. This book is literally an encyclopedia of suicide. It begins with a history of suicide and includes entries related to suicide from A to Z. Assisted suicide, euthanasia, and several of the organizations listed in Chapter 7 of this volume are among its entries. Firestone, Robert W. 1997. Suicide and the Inner Voice: Risk Assessment, Treatment, and Case Management. Thousand Oaks, CA: Sage Publications. 333 pp. ISBN: 0-7619-0555-3. This book provides an overview of suicide, including suicide among specific age groups, suicide prevention, risk assessments, and treatment strategies. The chapter addressing suicide among older people includes specific treatment notes and addresses the right-to-die controversy. Hamel, Ronald P., and Edwin R. DuBose, eds. 1996. Must We Suffer Our Way to Death? Dallas, TX: Southern Methodist University Press. 355 pp. ISBN: 0-87074-393-7.
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This book is a collection of essays examining the concepts of assisted suicide and euthanasia from various perspectives. The first section addresses these concepts from various academic perspectives, including law, sociology, and medicine. The second section, with essays by theologians, examines issues of assisted death in the context of various religions. Hawkins, Gail N., ed. 2002. Physician-Assisted Suicide. San Diego, CA: Greenhaven Press. 75 pp. ISBN: 0-7377-1056-X. This book is a collection of point-counterpoint essays addressing a variety of topics related to physician-assisted suicide, including ethics, public opinion, and whether citizens have a right to physician-assisted suicide. Humphry, Derek. 2002. Final Exit. New York: Dell Publishing. 220 pp. ISBN: 0-385-33653-5. This book offers practical guidelines for people who are “mortally ill and [desire] a quick end.” In the author’s introduction, he describes his own experience of assisting in the suicide of his wife, Jean, at her request. The book contains chapters on various topics, including seeking a physician to help, ways to die, and choosing the time for death. In addition, practical matters, such as life insurance, a checklist, and letters to write prior to death, are also included. Joiner, Thomas. 2005. Why People Die by Suicide. Cambridge, MA: Harvard University Press. 276 pp. ISBN: 0-674-01901-6. This book is the result of study and personal experience. The book offers a human spin on the statistics, data, and other information surrounding the issue of suicide. The book’s prologue offers insight into the author’s personal experience and how it led him to explore existing theories about suicide and develop his own hypotheses. Kopelman, Loretta M., and Kenneth A. De Ville, eds. 2001. Physician-Assisted Suicide: What Are the Issues? Boston: Kluwer Academic Publishers. 235 pp. ISBN: 0-7923-7142-9. This book is a compilation of papers presented at a conference of the Department of Medical Humanities in the Brody School of Medicine at East Carolina University and elsewhere. The editors begin the book by providing background information on
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physician-assisted suicide, including information about key legal matters, the history of the issue, and opposing viewpoints. The papers are divided into key topic areas, including the permissibility of physician-assisted suicide, challenging physician-assisted suicide, clinical perspectives, and the future of the issue. Larson, Edward J., and Darrel W. Amundsen. 1998. A Different Death. Downers Grove, IL: InterVarsity Press. 288 pp. ISBN: 08308-1518-X. This book examines the concept of euthanasia vis-à-vis Christian teachings. Chapters explore various issues, including the concepts of euthanasia and suicide since early Christianity, legal issues, and the right-to-die movement. Lee, Barbara Coombs. 2003. Compassion in Dying: Stories of Dignity and Choice. Troutdale, OR: NewSage Press. 137 pp. ISBN: 0-93916549-X. This book, by the president of Compassion in Dying, is a series of personal stories about death on one’s own terms. The book includes a foreword by former Oregon governor Barbara Roberts highlighting Oregon’s Death with Dignity Act and how it came to be. Lewis, Milton James. 2007. Medicine and Care of the Dying: A Modern History. Oxford; NY: Oxford University Press. 277 pp. ISBN: 0-1951-7548-4. Medicine and Care of the Dying: A Modern History covers a plethora of issues including the dying person’s search for meaning as well as pain management and other issues related to palliative care. Lewis, Penney. 2007. Assisted Dying and Legal Change. Oxford; NY: Oxford University Press, 217 pp. ISBN: 978-0-19921-287-3. This book focuses on the various legal issues related to assisted dying, including legalization of providing such assistance. Long, Robert Emmet, ed. 1995. Suicide. New York: H.W. Wilson Company. 162 pp. ISBN: 0-8242-0869-2. This book offers a collection of articles from magazines and other periodicals. One group of articles addresses the situation
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surrounding the death of Nancy Cruzan and another focuses on Dr. Jack Kevorkian and the issue of assisted suicide. Lukas, Christopher, and Henry M. Seiden. 1998. Silent Grief: Living in the Wake of Suicide. Northvale, NJ: Jason Aronson. 252 pp. ISBN: 0-7657-0056-5. This book uses personal stories to relate experiences of suicide survivors. It offers survivors information on what they can expect following their attempted suicide and the emotional reactions that can occur. Another section highlights some of the bargaining survivors do to ease the pain and otherwise cope. A final section outlines ways that survivors can help themselves and others. Manning, Michael. 1998. Euthanasia and Physician-Assisted Suicide. New York: Paulist Press. 120 pp. ISBN: 0-8091-3804-2. This book, by a physician and priest, outlines the history of euthanasia, including both secular and religious milestones. It outlines the slippery slope argument, addresses the issues of euthanasia and physician-assisted suicide in the context of medical professionals, and highlights information from the Netherlands. It also emphasizes the importance of differentiating between the concepts of killing someone and allowing them to die in euthanasia arguments, since some view them as two separate issues, while others do not. Marcus, Eric. 1996. Why Suicide? San Francisco: HarperSan Francisco. 240 pp. ISBN: 0-06-251166-1. This book addresses various issues related to suicide, including suicide among teens and youth, suicide among the elderly, and ways to cope with the suicide of a friend or loved one. The book answers numerous questions about suicide, providing everything from statistical information to information about laws related to suicide. In addition, the book provides practical information such as matters related to life insurance when suicide is the cause of death. McIntosh, John L., John F. Santos, Richard W. Hubbard, and James C. Overholser. 1994. Elder Suicide: Research, Theory, and Treatment. Washington, DC: American Psychological Association. 260 pp. ISBN: 1-55798-240-6. This book examines the issue of suicide as it pertains specifically to the elderly. One chapter, on special high-risk factors, notes
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that the elderly are often at greater risk for suicide due to factors including retirement, widowhood, and illness. The authors also examine and analyze theories of suicide, clinical approaches specific to the elderly, and prevention. Mishara, Brian L., ed. 1995. The Impact of Suicide. New York: Springer Publishing. 230 pp. ISBN: 0-8261-8870-2. This book examines the ways suicide impacts family members and friends, helpers, the individual, and society. The book contains useful facts, statistics, and other data, and offers information on issues such as counseling. Scherer, Jennifer M., and Rita J. Simon. 1999. Euthanasia and the Right to Die. Lanham, MD: Rowman & Littlefield. 150 pp. ISBN: 08476-9166-7. This book provides historical information on issues related to death and dying. It includes information from the United States, Canada, the Netherlands, the United Kingdom, Australia, China, Japan, South Africa, and Israel. Smith, Wesley, J. 2003. Forced Exit: The Slippery Slope from Assisted Suicide to Legalized Murder. Dallas, TX: Spence Publishing Company. 364 pp. ISBN: 1-890626-48-1. In his introduction, Wesley J. Smith tells the story of a dear friend who chose to end her life. As he tells it, this experience was pivotal for him: It motivated him to crusade against euthanasia and eventually to write this book. He addresses various issues relevant to euthanasia, including the concepts of “disposable people” and “death fundamentalists,” or people who are obsessed with death. He also examines the issue in the context of the Netherlands and lists some of the most common arguments against his own positions. Szasz, Thomas. 1999. Fatal Freedom: The Ethics and Politics of Suicide. Westport, CT: Praeger. 177 pp. ISBN: 0-275-96646-1. In this book, the author argues that suicide should be a choice for individuals. In support of that argument, the book’s chapters offer a breakdown of the concept of suicide, including the terminology surrounding it and the way it is addressed in our society. One chapter, “Prescribing Suicide: Death as Treatment,” specifically addresses the issues of euthanasia and physician-assisted suicide.
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Weir, Robert F., ed. 1997. Physician-Assisted Suicide. Bloomington, IN: Indiana University Press. 266 pp. ISBN: 0-253-33282-6. This book is a collection of essays which present various viewpoints on the topic of physician-assisted suicide. In the section on historical interpretations, one author examines the significance of accurate or inaccurate history in contemporary legal decisions. In the section on ethical assessments and positions, one author posits that there are cases in which physician-assisted suicide is morally justified. The section on medical practices and perspectives features essays examining the acceptability of physicianassisted suicide as a medical practice. Weisstub, David N., David C. Thomasma, Serge Gauthier, and George F. Tomossy, eds. 2001. Aging: Decisions at the End of Life. Boston: Kluwer Academic Publishers. 261 pp. ISBN: 1-4020-01827. This book is the final volume in the trilogy of the International Library of Ethics, Law, and the New Medicine. The book consists of papers on various topics related to end-of-life issues. The papers are divided into topics, including quality of life, palliative care, assisted death, suicide, and research ethics. Werth, James L., Jr. 1996. Rational Suicide: Implications for Mental Health Professionals. Washington, DC: Taylor & Francis. 152 pp. ISBN: 1-5603-24244. This book begins with an overview of suicide and recent views on the topic of rational suicide. It also offers arguments against rational suicide, criteria for determining rational suicide, and ethical and legal considerations. Whiting, Raymond. 2002. A Natural Right to Die. Westport, CT: Greenwood Press. 222 pp. ISBN: 0-313-31474-8. In this book, the author notes that euthanasia is, de facto, practiced in the United States. He argues that the historical aspects of whether a right to die exists can be a useful tool in making determinations, as a society, about end-of-life issues. In addition to examining the history of the issue, he offers a study of the international aspects and history and development surrounding the right-to-die issue. Yount, Lisa. 2000. Physician-Assisted Suicide and Euthanasia. New York: Facts on File. 282 pp. ISBN: 0-8160-4021-4.
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This book provides a thorough overview of end-of-life issues. An overview, including an introduction to the concept, legal highlights, and a chronology, is followed by information for additional research. Appendices highlight Oregon’s Death with Dignity Act and various key legal rulings. Zucker, Marjorie B., ed. The Right to Die Debate. Westport, CT: Greenwood Press. 303 pp. ISBN: 0-313-30522-6. This book provides a documentary history of the debate surrounding right-to-die issues in the United States. The book begins with excerpts from William Shakespeare and John Donne and moves on to definitions of death, including language from Edgar Allan Poe. The section on death in the nineteenth century includes a letter from Florence Nightingale. The book also includes documents which address living wills, advance directives, patients’ rights, and medical powers of attorney. Legal citations include documents from relevant Supreme Court cases, as well as documents and decisions from some lower courts, including various state supreme courts.
Articles Arnold, Elizabeth Mayfield. 2004. “Factors That Influence Consideration of Hastening Death among People with LifeThreatening Illnesses.” Health & Social Work 29 (1): 17–26. This article notes that little research exists on why certain people explore the option of assisted suicide while others in similar medical situations do not. The article cites various studies and data in examining factors including pain, hope, and social support. In addition, the author conducted a survey of individuals with life-threatening illnesses to gain better insight into the issue. The results are reported in the article. Cahill, Lisa Sowle. 2005. “Catholicism, Death and Modern Medicine.” America 192 (14): 14–17. This article compares the circumstances surrounding the deaths of Pope John Paul II and Terri Schiavo and highlights a speech Pope John Paul II gave on end-of-life issues in March 2004. Critical analysis of the pope’s speech is included, as is discussion of the speech’s relevance to the Schiavo case.
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Dixon, Nicholas. 1998. “On the Difference between PhysicianAssisted Suicide and Active Euthanasia.” Hastings Center Report 28 (5): 25–29. In this article, the author argues that, despite the efforts of some policy experts to establish a clear differentiation between physician-assisted suicide and euthanasia, the same arguments apply to both issues. The article highlights various arguments on the issues and cites the reasons that they apply to both. Driedger, Sharon Doyle with Jennifer Hunter, Nomi Morris, and Mark Nichols. 1998. “Everyone Knows It Happens.” Maclean’s, March 9, 50, 2 pp. This article introduces the reader to several people who are struggling with terminal illnesses and offers perspectives from both sides of the right-to-die debate. The article also offers results from a poll of Canadian physicians regarding euthanasia and provides information on palliative care. Girsh, Faye. 2000. “Death with Dignity: Choices and Challenges.” USA Today Magazine, March, 62–64. The article begins by examining the options available for people facing end-of-life decisions and cites surveys and studies which buttress the idea of change in this area. In addition to anecdotal information about people who have made various choices related to the ends of their lives, the article highlights Oregon’s Death with Dignity Act and urges readers to know their rights in this matter. Gittelman, David K. 1999. “Euthanasia and Physician-Assisted Suicide.” Southern Medical Journal 92 (4): 369–374. This article defines euthanasia and physician-assisted suicide and offers a history of the issues, results from polls on the issues, an international perspective, and information on related psychiatric issues. In addition, it discusses ethical and legal concerns and examines the potential for abuse. Grace, Julie. 1999. “Curtains for Dr. Death.” Time, April 5, 48. This article, reporting that Dr. Jack Kevorkian was found guilty of murder in the death of Thomas Youk, recounts details from the trial. The article also provides highlights of the videotape, aired on 60 Minutes, which resulted in Kevorkian’s trial and con-
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viction. In addition, the article includes reaction from Youk’s widow, Melody, and his brother, Terry. Keizer, Garret. 2005. “Life Everlasting.” Harper’s Magazine, February, 53–61. This article highlights the case of Lloyd Thompson, a Vermont physician who was reprimanded by the state medical board for his role in the death of an 85-year-old patient. It also examines existing euthanasia laws and provides information about some organizations concerned with end-of-life issues. Lauritzen, Paul. 2006. “Caring at the end.” Commonweal 133 (5): 14–16. This article examines the case of Terri Schiavo, and the general topic of withholding nutrition and hydration, vis-à-vis the teachings of the Roman Catholic Church. The article cites statements made by Pope John Paul II and quotations from various people who weighed in on the Schiavo case. Mackelprang, Romel D., and Romel W. Mackelprang. 2005. “Historical and Contemporary Issues in End-of-Life Decisions: Implications for Social Work.” Social Work 50 (4): 315–324. This article examines end-of-life issues and places them in a historical context. It includes a brief discussion of some existing laws and the impact they have had on the issue to date. The article also includes a section on end-of-life issues and decisions, especially as they relate to social work. Martindale, Diane. 2005. “A Culture of Death.” Scientific American, June, 44–46. This article highlights Russel Ogden’s research into the occurrences of laypeople (i.e., people with no medical training) assisting in suicides. The research, which began as Ogden’s graduate project, detailed the experiences of laypeople who had assisted others in committing suicide. Osgood, Nancy J. 1995. “Assisted Suicide and Older People—A Deadly Combination: Ethical Problems in Permitting Assisted Suicide.” Issues in Law and Medicine 10 (4): 415–435. This article begins with a synopsis of the case of Janet Adkins, a 54-year-old woman suffering from Alzheimer’s disease,
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who sought Dr. Jack Kevorkian’s assistance with committing suicide. The author provides statistics about suicide in the elderly and addresses this issue. Parks, Jennifer A. 2000. “Why Gender Matters to the Euthanasia Debate.” Hastings Center Report 30 (1): 30–36. This article asks whether men and women are treated differently when it comes to assistance in dying. The author provides background on the topic and cites data related to Dr. Jack Kevorkian’s patients in the United States and euthanasia in the Netherlands. In addition, the author offers context for the issue by providing arguments about additional areas in which women and men are treated differently. Rayner, Claire. 2000. “You Say Murder, I Say Euthanasia.” New Statesman, June 19, 31. This article describes a forum on euthanasia held at the Science Museum in London, England. The forum marked the arrival of a new exhibit featuring a euthanasia machine developed by Dr. Philip Nitschke and donated to the museum by the Voluntary Euthanasia Research Foundation of Australia. Based on the controversy surrounding the forum and the exhibit, the author proposes that requests for euthanasia be addressed on a case-by-case basis. Rogatz, Peter. 2001. “The Positive Virtues of Physician-Assisted Suicide.” Humanist 61 (6): 31–34. This article explores the concept of physician-assisted suicide, including arguments on both sides of the issue and highlights of relevant studies. Spinney, Laura. 2003. “Playing God?” New Scientist 180 (2415): 48–51. This article features an interview with Dr. Philip Nitschke, a doctor who assisted in several suicides during the brief period when that was legal in Australia’s Northern Territory. Stevens, Jr., Kenneth R. 2006. “Emotional and Psychological Effects of Physician-Assisted Suicide and Euthanasia on Participating Physicians.” Issues in Law and Medicine 21 (3): 187–200. This article reviews and evaluates published information regarding physician-assisted suicide. Sources include publications
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aimed at both the medical community and the public. The focus of the article is determining the emotional and psychological impact on physicians who assist patients in committing suicide. Vatz, Richard E., and Lee S. Weinberg. 1999. “Dr. Kevorkian on the Air: CBS and 60 Minutes Dropped the Ball.” USA Today Magazine, May, 66–68. This article outlines Dr. Jack Kevorkian’s appearance on 60 Minutes on November 22, 1998. During that episode, the program aired a videotape of Dr. Kevorkian administering an injection to Thomas Youk. Youk had Lou Gehrig’s disease (amyotrophic lateral sclerosis [ALS]) and had requested Dr. Kevorkian’s assistance in committing suicide. The authors of this article address the notion of airing this videotape, highlight some of the ensuing reactions, and provide information about Dr. Kevorkian.
Legal-Political Books Battin, Margaret P., Rosamond Rhodes, and Anita Silvers, eds. 1998. Physician-Assisted Suicide: Expanding the Debate. New York: Routledge. 463 pp. ISBN: 0-4159-2002-7. In their introduction, the editors note that the chapters in this book address many of the issues that arose from the Supreme Court’s 1997 decisions in Washington v. Glucksberg and Vacco v. Quill, as well as Oregon’s 1994 vote to uphold Measure 16, the state’s Death with Dignity Act. The book has sections on conceptual issues, considering those at risk, the impact of legalization, and religious perspectives. Colby, William H. 2002. Long Goodbye: The Deaths of Nancy Cruzan. Carlsbad, CA: Hay House. 414 pp. ISBN: 1-4019-0011-9. William H. Colby served as the Cruzan family’s attorney during their legal fight to have Nancy Cruzan’s feeding tube removed. In this book, Colby recounts how Cruzan, age 25, was critically injured in an automobile accident and fell into a coma. The book is Colby’s account of the legal aspects of the case and the way it impacted Cruzan’s family, as well as the nation, in terms of end-of-life issues.
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Dyck, Arthur J. 2001. When Killing Is Wrong: Physician-Assisted Suicide and the Courts. Cleveland, OH: The Pilgrim Press. 127 pp. ISBN: 0-8298-1417-5. The author uses judicial rulings in physician-assisted suicide cases in his examination of the overall issue of physician-assisted suicide. The book discusses some of the most basic legal issues of physician-assisted suicide, including what life-sustaining treatment has meant in a legal context, and cites legal rulings in examining other key aspects of the issue. Hillyard, Daniel, and John Dombrink. 2001. Dying Right. New York: Routledge. 304 pp. ISBN: 0-415-92799-4. This book provides a history of the death-with-dignity movement in the United States. Chapters address specific issues and highlights of the movement, including Oregon’s Death with Dignity Act, legislation in other states, international laws and viewpoints, polling information, and legal rulings. Humphry, Derek. 1993. Lawful Exit. Junction City, OR: The Norris Lane Press. 166 pp. ISBN: 0-9637280-0-8. In this book, the author examines the illegality of assisted suicide in the United States. In addition to recounting highlights of legislative efforts to legalize assisted suicide, Humphry provides analysis of court cases and includes information about the practice of assisted suicide in the Netherlands. Humphry, Derek, and Mary Clement. 1998. Freedom to Die: People, Politics and the Right-to-die Movement. New York: St. Martin’s Press. 388 pp. ISBN: 0-312-19415-3. In this book, the authors argue that the time has come to legalize assisted suicide. The authors chronicle the right-to-die movement, highlight specific cases including Karen Ann Quinlan and those assisted by Dr. Jack Kevorkian, address arguments against assisted suicide, and examine the possible future of the movement. Olick, Robert S. 2001. Taking Advance Directives Seriously: Prospective Autonomy and Decisions near the End of Life. Washington, DC: Georgetown University Press. 228 pp. ISBN: 0-87840-868-1. This book offers a thorough overview of advance directives, including clarification of complex issues. It also suggests changes
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to improve the ways advance directives are used for end-of-life care. The book provides insight into the legal aspects of this issue, with special attention to Karen Ann Quinlan and Nancy Cruzan, as well as legislative highlights. Schneider, Carl E., ed. 2000. Law at the End of Life: The Supreme Court and Assisted Suicide. Ann Arbor: The University of Michigan Press. 369 pp. ISBN: 0-472-11157-4. This book examines the background of the Washington v. Glucksberg case and includes sections on judicial principle, clinical practice, and public policy. Contributors dissect the decision in the case and offer insight in the areas of medicine, ethics, history, and law. Smith, Donald J. 2002. Right-to-Die Policies in the American States: Judicial and Legislative Innovation. New York: LFB Scholarly Publishing. 312 pp. ISBN: 1-931202-40-0. This book addresses what is known as passive euthanasia, or refusing care that would prolong life. It addresses the issue from judicial and legal perspectives, including case studies, an examination of policies, and in-depth looks at legislation, judicial innovation, and places where the two branches meet. Thomasma, David C., Thomasine Kimbrough-Kushner, Gerrit K. Kimsma, and Chris Ciesielski-Carlucci, eds. 1998. Asking to Die: Inside the Dutch Debate about Euthanasia. Boston: Kluwer Academic Publishers. 584 pp. ISBN: 0-7923-5186-X. This book examines euthanasia in the Netherlands, where it is legal. The book focuses on the issue in a variety of ways, including discussions of public policy, personal stories from physicians and families, and the pros and cons associated with the issue. The book contains material relevant to the United States, including a comparison of practices in the Netherlands and the United States.
Articles Bergman, Brian. 1998. “The Final Hours.” Maclean’s, March 19, 46–49. This article recounts the events leading to a judge’s decision against trying Dr. Nancy Morrison, a respirologist in Canada, for murder. The death in question was that of Paul Mills, the patient Dr. Morrison was accused of murdering by lethal injection. Mills,
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65, had cancer and had faced numerous major surgeries; he reportedly told at least one nurse that he wanted to die. Bristo, Marc, and Robert L. Burgdorf, Jr. 1998. “Assisted Suicide: A Disability Perspective.” Issues in Law and Medicine 14 (3): 273–300. This article emphasizes the complexity of the issue of assisted suicide by outlining the endless permutations that make each situation unique and complicated. It highlights the issues involved in the Supreme Court cases at the time of publication. The author includes information from the perspective of persons with disabilities and offers a conclusion and a position statement from the National Council on Disability. Cloud, John, and Abi Daruvalla. 2001. “A License to Kill?” Time Europe, April 23, 60. This article outlines the Dutch legalization of euthanasia, noting that the country is the first to have legalized euthanasia. The article compares the Dutch law with Oregon’s Death with Dignity Act and cites polling information from Europe on the subject of the law. Cohen-Almagor, Raphael. 2003. “Non-Voluntary and Involuntary Euthanasia in the Netherlands: Dutch Perspectives.” Issues in Law & Medicine 18 (3): 239–257. This article begins with an explanation of the medical and legal requirements for euthanasia in the Netherlands. It also includes information from interviews with leading Netherlandsbased experts on euthanasia policy. The interviews focused on cases of nonvoluntary (where consent cannot be given) and involuntary (without consent) euthanasia. Corbett, Bryce, Susan Horsburgh, and Dietlind Lerner. 2003. “Her Son’s Last Wish.” People, October 13, 83–84. This article recounts the case of Vincent Humbert of France. Following a motorcycle accident, Humbert, age 21, could not walk, talk, see, smell, or taste. He wanted to die—and he asked his mother, Marie, to help him. She did, and she was arrested for her actions. Darr, Kurt. 1997. “Physician-Assisted Suicide and the Supreme Court: Implications for Health Services Delivery.” Hospital Topics 75 (3): 4–6.
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This article offers a breakdown of the Supreme Court decisions in Washington v. Glucksberg and Vacco v. Quill, including the rationale for the decisions and background on the issue of euthanasia. Recognizing that these decisions will have implications for hospital administrators and other personnel, the author includes a section on practical ways that hospitals can be prepared to deal with these decisions. Doig, Christopher James, Glenys Godlovitch, and Ian Mitchell. 2005. “Discontinuing Life Support in Comatose Patients: An Example from Canadian Case Law.” Canadian Medical Association Journal 172 (9): 1172–1173. This article presents information about the case of a Canadian man on life support and addresses the legal issues that arose given the lack of an advance directive. The article also includes information about other cases in Canada and mentions the case of Terri Schiavo. Gorsuch, Neil M. 2000. “The Right to Assisted Suicide and Euthanasia.” Harvard Journal of Law & Public Policy 23 (3): 599–710. This article offers an in-depth study of the issue of euthanasia. Topics include the history of the issue, legal milestones, detailed analysis of court decisions, and arguments for and against. In addition to information about Oregon’s implementation of its Death with Dignity Act, the article offers feedback from the Netherlands about that country’s experience with the issue. Guthrie, Patricia. 2006. “Assisted Suicide Debated in the United States.” Canadian Medical Association Journal 174 (6): 755–756. This article contains information about existing assisted-suicide laws in the United States, includes highlights of the Terri Schiavo case and other timely legal matters, and notes that California’s law is under legislative scrutiny at the time of publication. Mariner, Wendy K. 1997. “Physician-Assisted Suicide and the Supreme Court: Putting the Constitutional Claim To Rest.” American Journal of Public Health 87 (12): 2058–2062. This article examines Washington v. Glucksberg and Vacco v. Quill, key Supreme Court cases on the subject of physician-assisted suicide. The focus of the article is the constitutional issues associated with these cases.
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Quirk, Patrick. 1998. “Euthanasia in the Commonwealth of Australia.” Issues in Law and Medicine 13 (4): 425–446. This article addresses the complex issue of euthanasia in Australia. A chronology of events surrounding the issue is included in the article’s appendix and the article contains a useful description of Australian government to assist the reader in placing the issue in the proper context. Short, Bradford William. 2005. “More History ‘Lite’ in Modern American Bioethics.” Issues in Law and Medicine 21 (1): 3–34. In this article, the author takes issue with the accuracy and interpretation of historical quotations used to buttress support for euthanasia. He asserts that accuracy is crucial because these quotations, and the way they are interpreted, form part of the foundation of contemporary judicial rulings. Stone, Alan A. 1997. “Physician-Assisted Suicide and the Psychiatric Profession.” Harvard Mental Health Letter 13 (7): 4–7. This article uses the circumstances of Sigmund Freud’s death as a springboard to pose contemporary and complex questions about the issue of physicians assisting in the deaths of patients. The article reviews the issues surrounding two cases which, having been heard by the Second and Ninth Circuit Courts of Appeal, respectively, were headed to the United States Supreme Court. In addition, this article raises the question of whether psychiatric disorders provide a justification for physician-assisted suicide.
Works of Fiction Cook, Robin. 1995. Fatal Cure. New York: Berkeley Books. 449 pp. ISBN: 0-425-14563-8. In this book, the author creates a scenario in which managed care plays a sinister role in leading a community down a slippery slope to involuntary euthanasia. Set in a state-of-the-art community hospital in Vermont, the novel tells the story of a husband-andwife medical team and their discovery of a euthanasia program aimed at cutting health care costs. Delblanco, Nicholas. 1995. In the Name of Mercy. New York: Warner Books. 310 pp. ISBN: 0-446-51711-9.
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This novel addresses several issues related to euthanasia. A physician helps his wife, suffering from cancer, to die. Following her death, he complies with requests for assistance with committing suicide from several patients who are facing terminal illnesses. Eventually, he becomes less concerned about people’s wishes and the deaths are no longer limited to those who wish to die. Kellerman, Jonathan. Dr. Death. 2000. New York: Ballantine. 448 pp. ISBN: 0-345-41388-1 In this novel, protagonist Alex Delaware joins his friend, Detective Milo Sturgis, in solving a puzzling mystery. The scenario: Milo has a case in which Dr. Eldon Mate is found dead. The deceased physician, known as Dr. Death for his repeated role in helping people commit suicide, was found hooked up to the machine he created to help people end their lives. Picoult, Jodi. 1996. Mercy. New York: Pocket Books. 416 pp. ISBN: 0-7434-2244-9. This book examines a case of a husband assisting his wife with committing suicide in a small town in Massachusetts. The setting is a rather eccentric community where the residents, who are mostly of Scottish descent, grapple with various issues, including affairs of the heart. Solomon, Andrew. 1994. A Stone Boat. New York: Faber & Faber. 241 pp. ISBN: 0-4522-7498-2. This is the story of a young man who helps his mother commit suicide to end her battle with cancer. Set in the United States and England, the novel also tells the young man’s story about his own doubts regarding his sexual orientation. Tolstoy, Leo. 1981. The Death of Ivan Ilych. New York: Bantam Books. ISBN: 0-4515-2508-6. This is a collection of Tolstoy’s short stories and essays that address issues related to death and dying. All of the works in the book provide a valuable look at the universal issues surrounding death and dying, minus contemporary concerns such as managed care that sometimes cloud the more timeless issues.
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Periodicals Journal: Suicide and Life-Threatening Behavior Newsletters: Surviving Suicide and Newslink American Association of Suicidology (AAS) 5221 Wisconsin Avenue, NW Washington, DC 20015 Web site: http://www.suicidology.org Suicide and Life-Threatening Behavior is a quarterly journal that addresses suicide-related issues from a variety of perspectives, including biology, statistics, psychology, and sociology. Surviving Suicide, which is also published on a quarterly basis, is a newsletter aimed at those who have lost a loved one to suicide. Newslink, the American Association of Suicidology’s official newsletter, is published to keep members up to date on the organization’s activities. Newsletter: Lifesavers American Foundation for Suicide Prevention (AFSP) 120 Wall Street, 22nd Floor New York, New York 10005 Web site: http://www.afsp.org Lifesavers, a quarterly newsletter, communicates important issues and organizational activities. Journals: Journal of Law, Medicine & Ethics and American Journal of Law & Medicine American Society of Law, Medicine & Ethics (ASLME) 765 Commonwealth Avenue, Suite 1634 Boston, Massachusetts 02215 Web site: http://www.aslme.org/ The Journal of Law, Medicine & Ethics, a peer-reviewed journal, is aimed at health care professionals, while the American Journal of Law & Medicine highlights health law and legal and ethical matters related to the practice of medicine. Newsletter: ABCD Exchange Americans for Better Care of the Dying (ABCD) 1700 Diagonal Road, Suite 635 Alexandria, Virginia 22314 Web site: http://www.abcd-caring.org
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ABCD Exchange, published several times per year, covers organizational activities provides information about end-of-life issues. Newsletter: AUL Momentum Americans United for Life (AUL) 310 South Peoria, Suite 300 Chicago, Illinois 60607 Web site: http://www.unitedforlife.org AUL Momentum addresses public policy matters related to the organization’s advocacy issues. Journals: Omega: the Journal of Death and Dying, Death Studies, The Journal of Loss and Trauma, and Mortality Magazine: Living with Loss Newsletter: Forum Association for Death Education and Counseling (ADEC) 60 Revere Drive, Suite 500 Northbrook, Illinois 60062 Web site: http://www.adec.org Omega: the Journal of Death and Dying addresses end-of-life issues, including terminal illness and death and dying. Death Studies, published ten times per year, addresses death-related issues, including bereavement, suicide, and grief therapy. The Journal of Loss and Trauma deals with issues related to personal loss, including death, divorce, illness, and loss of a job. Mortality, published four times per year, addresses issues of death and dying. Formerly known as Bereavement Magazine, the Living with Loss magazine is published four times per year and offers hope and healing. The Forum, a quarterly newsletter, provides professional development and other important information on a variety of topics related to death and dying. Newsletter: Update Center for Christian Bioethics Coleman Pavilion 11121 S. Loma Linda University Loma Linda, California 92350 Web site: http://www.llu.edu/llu/bioethics/ Update, a quarterly newsletter, provides news and opinions on a variety of issues related to projects and issues of the Center for Christian Bioethics. The publication also provides conference updates.
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Magazine: Compassion and Choices Compassion and Choices P.O. Box 101810 Denver, Colorado 80250-1810 Web site: http://www.compassionandchoices.org/ Compassion and Choices magazine is published four times per year. In addition to information on the organization’s activities, the magazine offers a calendar of events, national news, and reader feedback. Newsletter: Death with Dignity Report Death with Dignity National Center (DDNC) 520 SW 6th Avenue, Suite 1030 Portland, Oregon 97204 Web site: http://www.deathwithdignity.org The Death with Dignity Report is a quarterly newsletter covering current news and events about end-of-life issues, including legal developments, legislative updates, organizational activities, and personal stories. Journal: Hastings Center Report The Hastings Center 21 Malcolm Gordon Road Garrison, New York 10524-4125 Web site: http://www.thehastingscenter.org The Hastings Center Report is a bimonthly journal which addresses ethical issues in health, medicine, and the environment. The Report includes both articles and opinion-based pieces. Magazine: Caring Hospice Association of America (HAA) 228 Seventh Street, SE Washington, DC 20003 Web site: http://www.hospice-america.org/ Caring magazine is a monthly publication which addresses various issues related to home care of the dying and hospice, including policy issues, as well as technological and clinical developments. Newsletter: Update International Task Force on Euthanasia and Assisted Suicide P.O. Box 760 Steubenville, Ohio 43952
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Web site: http://www.iaetf.org or http://www.internationaltaskforce.org Update provides current information on euthanasia and assisted suicide in a variety of areas, including legal cases, policy matters, international news, and legislative developments. Journal: Kennedy Institute of Ethics Journal The Kennedy Institute of Ethics at Georgetown University Healy, 4th Floor Georgetown University Washington, DC 20057 Web site: http://kennedyinstitute.georgetown.edu/ index.htm The Kennedy Institute of Ethics Journal offers an academic perspective on various issues in bioethics. Newsletter: Quality Care Advocate National Citizens’ Coalition for Nursing Home Reform (NCCNHR) 1828 L Street, NW, Suite 801 Washington, D.C. 20036 Web site: http://www.nursinghomeaction.org Quality Care Advocate features updates on policy developments, legal news, and legislative updates. Journal: The Journal of Pain and Symptom Management Magazine: Insights Newsletters: NewsBriefs, andNewsLine The National Hospice and Palliative Care Organization (NHPCO) 1700 Diagonal Road, Suite 625 Alexandria, Virginia 22314 Web site:www.nhpco.org The Journal of Pain and Symptom Management is a monthly peerreviewed journal. Insights magazine, published four times per year, provides information and updates for professionals and volunteers who work in a hospice and/or palliative care setting. NewsBriefs is a weekly publication geared toward organizations that provide hospice and/or palliative care. NewsLine, a monthly publication, is also for these providers, as well as other NHPCO member organizations.
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Journal: Second Opinion Newsletter: e-Ethics Newsletter Park Ridge Center 205 West Touhy Avenue, Suite 203 Park Ridge, Illinois 60068-4202 Web site: http://www.parkridgecenter.org/ Second Opinion, published four times per year, examines ethical issues related to health care. The e-Ethics Newsletter is published monthly; it addresses ethical issues in various areas, including health policy and clinical care. Newsletter: Supportive Voice Supportive Care Coalition: Pursuing Excellence in Palliative Care Sr. Karin Dufault, SP c/o Providence Health System 4805 NE Glisen 2E07 Portland, Oregon 97213 Web site: http://www.SupportiveCareCoalition.org Supportive Voice includes best practices in palliative care and offers insights into caring for the dying. Newsletters: Bulletin and The Letter Association pour le Droit de Mourir dans la Dignite (ADMD) 50 rue de Chabrol 75010 Paris, France Web site: http://www.admd.net/ Bulletin, published four times per year, highlights various topics and includes organization news, personal stories, events, and polling information. The Letter, published semiannually, provides a forum for discussion of various matters, including ethical issues related to the end of life. Newsletter: Deliverance EXIT International PO Box 37781 Darwin NT 0821, Australia Web site: http://www.exitinternational.net/ Deliverance, published monthly, includes legal updates, news about the organization, updates about various chapters throughout the world, editorials, and event information.
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Newsletter: FATE Newsletter Friends at the End (FATE) 11 Westbourne Gardens Glasgow, Scotland G12 9XD Web site: http://www.friends-at-the-end.org.uk FATE Newsletter highlights the organization’s activities, news, and events and provides updates on legal developments and other news related to end-of-life issues. Newsletter: Free to Go Right to Die Society of Canada (RDSC) 145 Macdonell Avenue Toronto, Ontario, Canada M6R 2A4 Web site: http://www.righttodie.ca/ Free to Go, published quarterly by the RDSC in collaboration with other Canadian organizations, provides news and updates on developments within the collaborating organizations, legal developments, legislative news, international news and information, anecdotes, and polling information in regard to right-to-die issues.
Nonprint Resources In addition to the books, articles, and other materials mentioned earlier in this chapter, there are numerous nonprint resources that might prove valuable to researchers examining end-of-life issues. This section provides information on videotapes and DVDs (nonfiction and fiction), audio recordings, online databases, and Internet sites.
Nonfiction Videotapes Medical-Bioethical Title: Difficult Decisions: When a Loved One Approaches Death Format: VHS, DVD-R, Digital on Demand Cost: $89.95 ISBN: 0-7365-2295-6 Source: Films Media Group
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(800) 257-5126 http://www.films.com Two families, assisted by a doctor, an ethicist, and others, face difficult decisions on behalf of loved ones nearing death in an intensive care unit. Title: Tired of Living, Feared of Dying Format: VHS Cost: $295 (rental: $75) Source: The Filmmakers Library 124 East 40th Street New York, New York 10016 (212) 808-4980 http://www.filmakers.com Assisted dying is legal in the Netherlands, where this video was made. Seven people share their reasons for seeking assistance with dying; their family members and physicians also express their thoughts and feelings.
Spiritual-Social-Cultural Title: Defining Life: Should One Help a Loved One Die? Format: VHS Cost: $295 (rental: $55) Producer: Beverly Peterson Source: The Filmakers Library 124 East 40th Street New York, New York 10016 (212) 808-4980 http://www.filmakers.com This video provides a glimpse of the struggle family members and friends experience when faced with a loved one’s request for assistance with committing suicide. Title: Doctor Death: Medical Ethics and Doctor-Assisted Suicide Format: VHS, DVD Cost: $89.95 Producer: Universal Television, Inc. ISBN: 1-56950-362-1 Source: Films Media Group (800) 257-5126 http://www.films.com
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This piece highlights Phil Donahue’s interview of Dr. Jack Kevorkian about physician-assisted suicide. Title: Is This Life Worth Living? Format: VHS Cost: $195 (rental: $55) Producer: Slawomir Grunberg Source: The Filmmakers Library 124 East 40th Street New York, New York 10016 (212) 808-4980 http://www.filmakers.com This video allows viewers to enter the lives of three families who are caring for severely brain-damaged or comatose loved ones. Title: Physician-Assisted Suicide: Not Worth Living? Format: VHS Cost: $19.99 Publisher: Focus on the Family Author: John Eldredge Source: Gospel Light (800) 446-7735 http://www.gospellight.com This video addresses euthanasia and physician-assisted suicide from a biblical standpoint. Title: Religion and Euthanasia Format: DVD-R, VHS Cost: $89.95 Source: Films for the Humanities and Sciences (800) 257-5126 http://www.films.com Euthanasia is examined in medical and religious contexts. Highlights include discussion of Dr. Jack Kevorkian’s efforts and legal issues.
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Legal-Political Title: Michigan v. Kevorkian: The Ethics of Assisted Suicide Format: DVD Date: 2002 Cost: $34.95 Publisher: National Film Network LLC ISBN: 0-8026-0091-3 Source: National Film Network (800) 431-4586 http://www.nationalfilmnetwork.com This DVD highlights Dr. Jack Kevorkian’s trial and his efforts to legalize assisted suicide. It includes interviews with family members of people he assisted in committing suicide. Title: In Re Michael Martin: A Battle over Life Support Format: DVD Date: 2002 Cost: $34.95 Publisher: Choices Inc. ISBN: 0-8026-0090-5 Source: National Film Network (800) 431-4586 http://www.nationalfilmnetwork.com Michael Martin was critically injured in a car accident. This video tells the story of his wife’s efforts to remove him from life support. Title: Who Owns My Life? Format: VHS Cost: $350 (rental: $65) Producer: Canadian Broadcasting Corporation Source: The Filmmakers Library 124 East 40th Street New York, New York 10016 (212) 808-4980 http://www.filmakers.com This video tells the story of Sue Rodriguez. Rodriguez suffered from amyotrophic lateral sclerosis (ALS), commonly known as Lou Gehrig’s disease. She took her quest for the right to die to the Supreme Court of Canada.
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Audiocassettes Title: Final Exit Author: Derek Humphry Publisher: Dove Entertainment, Inc. Date: October 1991 ISBN: 1-5580-0480-7 Cost: $24.95 Source: http://www.amazon.com This is an audiocassette of Derek Humphry’s book Final Exit. Title: Misguided Mercy: Euthanasia and PhysicianAssisted Suicide Author: Catholic Ministry of Health Care Professionals Publisher: Alba House Source: Alba House (800) 533-2522 http://www.albahouse.org
Databases AgeLine Maintained by AARP (formerly the American Association of Retired Persons), this database contains abstracts of materials related to aging. It is accessible at http://www.aarp.org/ research/ageline. ERIC Sponsored by the Institute of Education Sciences (IES), a division of the U.S. Department of Education, this database allows researchers to search nearly 1.2 million citations related to education. ERIC (Education Resources Information Center) is accessible online at http://www.eric.ed.gov. PubMed Maintained by the U.S. National Library of Medicine, this database provides access to more than 16 million records for biomedical research, including articles dating back to the 1950s. MEDLINE, BIOETHICSLINE, and other medical resources are included in PubMed. It is accessible online at http://www.ncbi.nlm.nih. gov/entrez/query.fcgi?DB=pubmed.
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WESTLAW This database provides a means to conduct research on legal issues. Occasional users of the subscription service can charge their research sessions to a credit card. The service is accessible online at http://www.westlaw.com.
Internet Sites Americans for Better Care of the Dying (ABCD) Web site: http://www.abcd-caring.org The organization’s Web site includes links to news and events and information on existing laws and legislative activity, as well as online publications and references. Association for Death Education and Counseling (ADEC) Web site: http://www.adec.org In addition to a general overview of the organization, the Web site offers professional resources, information about events, resources for people who are coping with loss, and information about certifications in Thanatology (the study of death and dying). Children’s Hospice International (CHI) Web site: http://www.chionline.org/ The Web site offers information about the Children’s Hospice International Program for All-Inclusive Care for Children and their Families (CHI PACC) and access to resources and news updates. Citizens United Resisting Euthanasia (CURE) Web site: http://mysite.verizon.net/cureltd/index.html The Web site outlines this organization’s mission and goals and offers news, educational resources, and links. Compassion and Choices Web site: http://www.compassionandchoices.org/ The Web site explains the services provided by Compassion and Choices, outlines the ways in which the organization works to address end-of-life issues, and offers opportunities for involvement.
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Death with Dignity National Center (DDNC) Web site: http://www.deathwithdignity.org The Web site includes extensive background information on Oregon’s Death with Dignity law, including chronological and historical information. The site also offers a news search tool and features resources geared toward students, physicians, legal professionals, lawmakers, and the general public. Euthanasia Research Guidance Organization (ERGO) Web site: http://www.finalexit.org/ The Web site provides an overview of right-to-die issues, including international laws on assisted suicide, key figures, and chronological information. There is a free listserv and a store that features books, e-books, videos, and documents. Final Exit Network Web site: http://www.finalexitnetwork.org The Web site outlines the Final Exit Network’s Exit Guide program, which offers a person facing the end of life the opportunity to work with a guide who explains options, including self-deliverance. The site also includes information about membership, volunteer opportunities, and events. Hospice Association of America (HAA) Web site: http://www.nahc.org/haa/ The Web site features information about legal, regulatory, and legislative issues as they relate to hospice. Other highlights include a consumer’s guide to hospice, a history of hospice, a fact sheet, statistics, and the Hospice Patient’s Bill of Rights. Hospice Education Institute Web site: http://www.hospiceworld.org The Hospice Education Institute’s Web site provides an overview of the organization, including information about its services. The site also features information about the hospice movement and hospice-related seminars. International Task Force on Euthanasia and Assisted Suicide Web site: http://www.iaetf.org The Web site features an overview of the organization, including news and activities. An online book store includes publications, documents, videos, and other items for sale.
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National Center for Death Education (NCDE) at Mount Ida College Web site: http://www.mountida.edu/sp.cfm?pageid=307 The NCDE Web site provides information on courses and programs relevant to the area of Thanatology. The site also features a link to NCDE’s library. National Hospice Foundation (NHF) Web site: http://www.nationalhospicefoundation.org NHF’s Web site includes a history of the organization and information about hospice and palliative care. The National Hospice and Palliative Care Organization (NHPCO) Web site: http://www.nhpco.org The Web site offers an overview about hospice and palliative care and highlights information about conferences. The site also highlights resources and information geared to people facing end-oflife issues and decisions. Not Dead Yet Web site: http://www.notdeadyet.org Not Dead Yet’s Web site provides an overview of the organization as well as articles, fact sheets, links to other organizations, a list of partner organizations, and highlights of court cases. Supportive Care Coalition: Pursuing Excellence in Palliative Care Web site: http://www.SupportiveCareCoalition.org The Web site offers a variety of resources related to palliative care and features a section with resources on ethics issues. Terri Schindler Schiavo Foundation (TSSF) Web site: http://www.terrisfight.org/ The Web site of the Terri Schindler Schiavo Foundation includes an overview, including information about Terri Schiavo, for whom the organization is named, and includes information about activities and events, links to other organizations, and opportunities for advocacy.
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Association pour le Droit de Mourir dans la Dignite (ADMD) Web site: http://www.admd.net/ ADMD’s Web site includes an overview of the organization and its activities and initiatives, highlights relevant legislation, and features information about end-of-life policies in France and other countries. Care NOT Killing Web site: http://www.carenotkilling.org.uk/ Care NOT Killing’s Web site provides an overview of the organization, highlights bills and laws regarding euthanasia and assisted suicide, and includes links to other resources. Dignity in Dying Web site: http://www.dignityindying.org.uk/ The Web site highlights real-life accounts from and about people who faced, or are facing, end-of-life issues. It includes sections on patients’ rights, opportunities for involvement, news and events, and living wills and offers links to legislation and legal documents. Dying with Dignity Web site: http://www.dyingwithdignity.ca/ This Web site highlights the organization’s counseling program and offers information about living wills. There is also a glossary, information about Canadian and international laws on the subject of assisted dying, and additional resources such as a reading list and links to other organizations. EXIT Web site: http://www.euthanasia.cc/ EXIT’s Web site features a plethora of resources on euthanasia, assisted suicide, and other matters related to the end of life. EXIT International Web site: http://www.exitinternational.net/ The Web site provides an overview of EXIT International, including a biography of founder and director Dr. Philip Nitschke, and information about people who have requested his assistance in ending their lives. The site also offers information about Australia’s Rights of the Terminally Ill Act.
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Friends at the End (FATE) Web site: http://www.friends-at-the-end.org.uk The Web site offers information related to end-of-life issues, including living wills and materials for research, including articles and legislative items. Right to Die Society of Canada (RDSC) Web site: http://www.righttodie.ca/ The Web site includes a history of the organization and extensive resources, including information from both sides of the right-todie movement. SAVES – The Living Will Society Web site: http://www.livingwill.co.za/ The Web site includes information about preparing a living will, an explanation of the concept of informed consent, and guidelines for medical practitioners. Voluntary Euthanasia Society of New Zealand Web site: http://www.ves.org.nz/contact.htm The Web site explains what voluntary euthanasia means and features information about New Zealand’s laws related to end-of-life issues. The site also offers links to international news and other resources. The World Federation of Right to Die Societies Web site: http://www.worldrtd.net/ The Web site includes an overview of the organization and features links to member organizations, international news about end-of-life issues, and links to other organizations.
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Glossary
active euthanasia euthanasia performed on an individual without the individual’s participation. advance directive a legal document that provides a person with a way to make end-of-life wishes known, e.g., whether the person wants certain types of medical treatment to be performed at the end of life. appeal to request that a higher court review the decision in a legal case. assisted suicide taking one’s own life purposely with the assistance of another person. attending physician a doctor who has primary responsibility for a particular patient’s condition. autopsy examination by a pathologist of a deceased person to determine cause of death. bioethics in medical contexts, this area of study generally examines issues of ethics in the context of various disciplines including medicine, sociology, psychology, philosophy, and law. brain death lack of brain function when stimulated. This diagnosis is subject to confirmation by an electroencephalogram. cardiopulmonary resuscitation (CPR) a procedure to restart a heart after it has stopped beating and the patient has stopped breathing. CPR can involve manual pressure to the chest and air applied by mouth to the patient’s mouth, electric shocks to the chest, or intravenous drugs. case law a law that has its foundation in a legal ruling rather than from legislation. coma an unconscious state. Although patients cannot be roused from this state, they can emerge from it. comfort care see palliative care. conflict of interest when an individual’s personal or business interests clash with his or her objectivity in a situation involving an entrusted duty. consent voluntary permission given by a person who is competent to make decisions.
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conservator a person, assigned by a court of law, responsible for making decisions on behalf of another who is not competent to do so. constitutional right a privilege guaranteed to citizens by the Constitution of the United States. coroner the person legally responsible for investigating the cause of death in a situation in which suspicious circumstances require an investigation. death certificate a legal document that, at a minimum, includes the time and cause of death. The death certificate is completed by the patient’s attending physician. depressive suicide suicide that occurs as a result of a patient’s depressed state (sometimes contrasted with rational suicide). do not resuscitate (DNR) a document prepared by a patient indicating the patient’s wishes to forego extraordinary measures, such as CPR. double effect the prescribing of a particular drug or drugs to relieve pain or otherwise ease a patient’s suffering which may cause death as a collateral result. durable power of attorney a legal document in which an individual can designate another person to act as an advocate and make legally binding decisions if the individual becomes too ill, or becomes incompetent, to make decisions. ethics principles that guide the actions of an individual or group. eugenics a selection process that involves eliminating people with certain undesired characteristics and promotes reproduction by people with certain desired characteristics. euthanasia derived from the Greek eu and thanatos, meaning “good death.” health care proxy a legal document in which an individual names a person who will make health care decisions if the individual is unable to do so. home care medical care administered in the patient’s home. hospice a facility or service which provides palliative care (or comfort care) to terminally ill patients. Hospice care also includes counseling and support for the patient’s family members. informed consent a legal right of patients to receive all information relevant to medical procedures and medications prescribed for them. Under informed consent, patients also have the right to refuse care. inpatient a patient admitted for an overnight stay or longer to a medical facility for treatment. inquest a legal proceeding conducted in the event of a suspicious death. intensive care unit (ICU) a hospital unit devoted to providing constant and extensive monitoring, as well as specialized care for critically ill patients.
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involuntary euthanasia euthanasia performed on an individual who has not requested it. life support medical interventions which sustain life when the body is no longer capable of doing so. medico-legal relevant to both medical and legal matters. mercy killing when an individual ends another person’s life as a means of ending that person’s suffering. (This is a separate concept from voluntary euthanasia, which is predicated on the person’s stated wish to die.) natural death death that does not involve heroic measures or any attempt to sustain life. next of kin the person who is the patient’s closest living relative. nonvoluntary euthanasia euthanasia performed on a person who is unable to consent due to incompetence. outpatient an individual who is treated in a medical facility for a period of less than one day. palliative care care that includes pain relief and making the patient as comfortable as possible but does not include any attempt to extend life. This type of care is common among hospice programs. passive euthanasia death that results from the decision to forego actions that could save an individual’s life. pathologist a physician who researches the cause of illness and disease. persistent vegetative state (PVS) a condition characterized by the lack of mental functioning. Some definitions include a specific time period as operative to determining if a persistent vegetative state exists. physician-assisted suicide taking one’s own life purposely with the assistance of a physician. primary care physician the physician who provides general medical care to a patient. prognosis the anticipated result of a patient’s disease or illness. proxy an individual authorized to act on behalf of another person. pseudo dementia symptoms triggered by depression which mimic dementia. Such symptoms may include memory problems, confusion, apathy, and the loss of ability to care for oneself. rational suicide suicide borne of a deliberate and rational decision to take one’s own life. (This term is sometimes contrasted with depressive suicide.) restraining order a court order that forbids an individual from taking a particular action. self-deliverance a term sometimes favored over suicide to indicate that the decision to die was borne of a rational choice.
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slippery slope the notion that if something that is perceived as negative is allowed to happen, similar negative actions of greater harm will follow. The slippery slope argument is sometimes applied to euthanasia in the context that if one type of euthanasia becomes acceptable, all types of euthanasia will eventually become acceptable. suicide intentionally taking one’s own life. suicide clause a provision found in some life insurance policies that states that benefits will not be paid if the death was the result of suicide. terminal illness disease or condition that will result in death. thanatology the study of death. ventilator a machine that provides lung function to a person who is unable to breathe. voluntary euthanasia euthanasia that occurs as a result of a request by the patient. ward of the court an individual whose well-being is under the jurisdiction of a court of law.
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Index
AAS. See American Association of Suicidology ABCD. See Americans for Better Care of the Dying Abortion, 2 Abuse, 49–51 Accountability, 192 ACPA. See American Chronic Pain Association Active euthanasia definition of, 1–2, 32 types of, 2, 32 See also Euthanasia ADEC. See Association for Death Education and Counseling Adkins, Janet biographical information on, 127–128 ADMD. See Association pour le Droit de Mourir dans la Dignite Admiraal, Pieter biographical information on, 128 Adria, Ruth, 83 Advance directive, 8, 10, 11, 40, 64–65 Adventists, 153 Africa, 78–81 AFSP. See American Foundation for Suicide Prevention Age of Reason, 5
Aging with Dignity, 199 Ahronheim, Judith, 185 Aid in Dying Communication Project, 200 AIDS, 148 Algeria, 79 ALL. See American Life League All Headline News, 71 Alpers, Ann, 191 ALS. See Amyotrophic lateral sclerosis (ALS) Alzheimer’s Association, 148 Alzheimer’s disease, 39–40, 148 AMA. See American Medical Association America magazine, 20, 22 American Association of Retired Persons (AARP) statement on physician-assisted suicide, 175 American Association of Suicidology (AAS), 148–149, 200–202 American Cancer Society, 148 American Chronic Pain Association (ACPA), 201 American Counseling Association, 201–203 American Foundation for Suicide Prevention (AFSP), 149, 202 American Journal of Public Health, 73
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American Life League (ALL), 203 American Medical Association (AMA), 203 Council on Ethical and Judicial Affairs, 183 American Medical Association Complete Medical Encyclopedia, 13 American Psychological Association (APA), 204 American Society of Law, Medicine and Ethics (ASLME), 204 American Unitarian Association, 24 Americans for Better Care of the Dying (ABCD), 205 Americans United for Life (AUL), 205 Amyotrophic lateral sclerosis (ALS; Lou Gehrig’s disease), 34, 148 Andrews, Kevin, 77–78, 139 biographical information on, 129 Angels of Death: Exploring the Euthanasia Underground (Magnusson), 148 “Anna, Ambiguity, and the Promise: A Lutheran Theologian Reflects on Assisted Death” (Childs), 53–54 APA. See American Psychological Association Arinze, Cardinal Francis, 80, 81 Arthur Koestler: The Story of a Friendship (Mikes), 175 Artificial heart program, 183–184 Asai, Atsushi, 89 Asch, David A., 184 ASLME. See American Society of Law, Medicine and Ethics Assisted suicide, 3 definition of, 1, 32–33
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motivation for, 148 See also Euthanasia; Physicianassisted suicide; Self-deliverance; Suicide Assisted Suicide Funding Restriction Act, 158 Association for Death Education and Counseling (ADEC), 206 Association pour le Droit de Mourir dans la Dignite (ADMD), 219 AUL. See Americans United for Life Australia, 76–78, 159, 188–189 Australian Medical Association, 77 Autonomy, 34, 49–50 Baby boomer generation, 56 Back, Anthony L., 46–47, 48 Baptist Church, 153 Barefoot doctors, 91 Barmakian, Joseph, 65 Battin, Margaret Pabst, 48–49, 141 biographical information on, 129 Belgium, 92–93 Benedict XVI (Joseph Ratzinger) biographical information on, 129–130 Beresford, Larry, 194 Berry, Jason, 45 Bioethical issues. See Medicalbioethical issues Bioethics SWAT team, 89–90 Blogs, 155 Brain death, 13 Brennan, William, 190 British National Health Service, 73 British Voluntary Euthanasia Society, 71 Brunel University, 72 Buddhism, 23–24 Budo, Lori L., 44–45
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Buffalo News, 19 Bulletin of the World Health Organization, 69 Burke, Lillian, 186 Cahill, Lisa Sowle, 22 Callahan, Daniel biographical information on, 130–131 Campbell, Courtney, 23–24, 51, 53 Canada, 81–83 health care in, 156 Cancer, 34, 148 Capital punishment, 2 Care NOT Killing, 219 The Case against Assisted Suicide: For the Right to End-of-Life Care (ed. Foley and Hendin), 14–15, 33, 35, 48, 50, 63–64, 75, 150 Catholic Church, 21–23, 52–53 in Africa, 80 Declaration on Euthanasia, 21–22, 152, 165–172 and euthanasia, 4, 152 and suffering, 52, 53 and suicide, 151–152 Catholic Health Association, 52 Catholicism, 21–23 “Catholicism, Death and Modern Medicine” (Cahill), 22 CBS, 43, 154 CDC. See Centers for Disease Control and Prevention Center for Christian Bioethics, 206–207 Centers for Disease Control and Prevention (CDC), 148 CHI. See Children’s Hospice International Child abuse, 195 Children’s Action, 87 Children’s Defense Fund, 20 Children’s Hospice International (CHI), 207
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Childs, James M., Jr., 53–54 China, 91–92 Chochiniv, Harvey M., 33 Christakis, Nicholas A., 153 Christian Reformed Church of North America, 153 Christian Science, 153 Christian Science Monitor, 84 Christianity and euthanasia, 3–4 and suicide, 51 See also Catholic Church; Religion Church of Christ, 153 Church of the Nazarene, 153 Citizens United Resisting Euthanasia (CURE), 207 Clark, Barney, 183 Clinton, Bill, 158 Cohen, Felicia, 50 Cohen, Herbert, 184–185 Coleman, Diane biographical information on, 131 Colombia, 93–95 Colonial America, 5 Colorado Collective for Medical Decisions, 36–37 Colorado Trust, 36–37 Comfort care, 15, 92. See also Hospice care; Palliative care Communication, 186–187 doctor-patient, 17, 47 Compassion and Choices, 208 Compassion in Dying, 59 Compassion in Dying: Stories of Dignity and Choice (Lee), 196 Compassion in Dying et al. v. State of Washington, 59, 188 Contemplating Suicide (Fairbairn), 187 Continuity of care, 16, 41 Cooper, Jessica, 43, 154
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Corporations, 16 Council on Ethical and Judicial Affairs, 183 Cox, Donald, 183, 192 Cruzan, Nancy, 6, 8–10, 11, 185, 189–190 biographical information on, 131–132 effects of case of, 10 Cruzan v. Director, Missouri Department of Health, 9–10 excerpts from, 189–190, 194 Cultural issues, 55–58. See also Spiritual-social-cultural issues Culture of poverty, 56–58 Culture of youth, 56 CURE. See Citizens United Resisting Euthanasia Curlin, Farr A., 18 Danforth, John, 10 DDNC. See Death with Dignity National Center De Facto euthanasia, 57–58 “Deadly Days in Darwin” (Kissane), 35 Death difficult, 187 discussions of, effects of, 31 fear of, 56 global data on, 69–70 by neglect, 155 Death and Dignity: Making Choices and Taking Charge (Quill), 183, 187 Death registration system, 69–70 Death with Dignity Act. See Oregon Death with Dignity Act Death with Dignity National Center (DDNC), 208 Deciding to Forego Life-Sustaining Treatment: A Report on the Ethical, Medical and Legal
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Issues in Treatment Decisions, 191 Decisions, medical. See Medical decisions Declaration of Geneva, 163–164 Declaration on Euthanasia (Catholic Church), 21–22, 150, 165–172 Deliverance machine, 77 Depression, 33, 149 and the elderly, 193 in United Kingdom, 71 “Depression and the Will to Live in Terminally Ill Patients” (Chochiniv and Schwartz), 33 Deutsch Welle, 87, 88 Dickey, Nancy, 183 Dignitas, 71–72 Dignity in Dying, 220 Disabled people. See People with disabilities Dispatch, 79 DNR. Se Do not resuscitate Do not resuscitate (DNR), 40 “Doctor-Patient Communication about Physician-Assisted Suicide” (Back), 47 Doctor-patient relationship, 16–19, 186, 192 in China, 92 and communication, 17, 47 and managed care, 40–41 in the Netherlands, 75 and religion, 18–19 See also Physicians “Doctors Must Not Kill” (Gaylin, Kass, Pellegrino, and Siegler), 191 Dorff, Elliot N., 21 Double effect, 25–26, 47–49 Dresser, Rebecca, 26 Due Process Clause, 59 Durable power of Attorney, 24–25 Durable power of attorney, 8
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“Dutch Move to Enact Law Making Euthanasia Easier” (Simons), 185 Dutch Voluntary Euthanasia Society, 75 “The Duty of Using Artificial Means of Preserving Life” (Kelly), 193 DVDs, 154 Dying with Dignity, 220–221 The Economist, 93 Egypt, 79 Elderly people, 50 and depression, 193 and suicide, 148–149 Emergency medical services (EMS), 38 Employers, and health insurance, 57 EMS. See Emergency medical services The End of Life: Euthanasia and Morality (Rachels), 184, 193 England, 70 Episcopal Church, 153 Equal Protection Clause, 59 ERGO. See Euthanasia Research Guidance Organization Ethics boards, 90 Ethiopia, 79 Ethnic Variations in Dying, Death and Grief (ed. Irish, et al.), 186 Eugenics, in Nazi Germany, 86 Euthanasia in Africa, 79–81 arguments in favor of, 182–190 arguments opposed to, 190–195 attitudes toward, 2–6 in Australia, 76–78 in Belgium, 92–93 in Canada, 82–83
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in China, 91–92 in Colombia, 94–95 definition of, 1, 32, 148 discussions of, effects of, 31 in France, 84–85 in Germany, 86–88 as global issue, 69–70. See also individual countries history of, 1–12 and individuals and organizations, documents related to, 174–175 instances of, 41–43 in Japan, 89–90 and legal-political issues, 25–27, 58–65, 157–160, 187–190, 194–195 and legal-political issues, documents related to, 175–181 and medical-bioethical issues, 12–20, 34–51, 182–185, 190–193 and medical-bioethical issues, documents related to, 160–164 in the Netherlands, 74–76 origin of term, 2–3 and religion, documents related to, 164–174 and spiritual-social-cultural issues, 21–25, 51–58, 150–155, 185–187, 193–194 and spiritual-social-cultural issues, documents related to, 163–175 and suicide, difference between, 187 types of, 32 in United Kingdom, 71–73 in United States, 72–73, 75–76, 78, 79–81, 83, 85, 88, 90, 92, 93, 94–95 See also Active euthanasia;
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Euthanasia, continued Assisted suicide; Passive euthanasia; Physicianassisted suicide; Selfdeliverance; Suicide “Euthanasia and Religion” (Campbell), 51, 53 Euthanasia and the Right to Die (Scherer and Simon), 56–57, 74–75, 76–77, 151 Euthanasia Laws Bill of 1996, 77–78 Euthanasia program, in Nazi Germany, 5–6, 86–87 Euthanasia Research Guidance Organization (ERGO), 209 EXIT, 221 EXIT International, 221 Fairbairn, Gavin, 187 Family issues, 34–35, 184, 190–191 FATE. See Friends at the End Final Exit Network, 209 Final Passages: Positive Choices for the Dying and Their Loved Ones (Ahronheim and Weber), 185 First Reading Speech (Perron), 189 Foley, Kathleen, 63–64, 150 biographical information on, 132–133 Foti, Charles C., 44–45 Fourteenth Amendment, 59 France, 83–85, 86 Friends at the End (FATE), 222 Frings, Cardinal Joseph, 130 Funding, of health care, 73 Futurist, 23 Garwood, David, 72 Gaviria, Carlos, 94 Gaylin, Willard, 191 Germany, 86–88. See also Nazi Germany
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Girsh, Faye biographical information on, 133 Glucksberg, Harold, 59 Good death, 2–3 Good Housekeeping, 17 Great Britain, 70, 159 Greater Baton Rouge Business Report, 45 Greece, 33 Greeks, 3 Griesa, Thomas, 60 Guardian, 72 A Guide to Self-Deliverance, 71 HAA. See Hospice Association of America Hall, Eleanor, 89 Harris, Harold, 175 The Hastings Center, 210 Health care, 15–20, 73 in Africa, 79 in Australia, 76 in Belgium, 92 in Canada, 81–82, 156 in China, 91 in Colombia, 93–94 and economic factors, 155–156 in France, 84 funding of, 73 in Germany, 86 in Japan, 88–89 in the Netherlands, 74 and poverty, 50, 56–58 in United Kingdom, 71, 72 in United States, 73 Health care proxy, 8, 34 Health insurance, 19–20 among demographic groups, 20 and poverty, 57–58 Health insurance industry, 155–156 Health maintenance organizations (HMOs), 15 and doctor-patient relationship, 40–41
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Hemlock’s Cup (Cox), 183, 192 Hendin, Herbert, 63–64, 75, 150 biographical information on, 133–134 Hinduism, 23–24 Hippocratic Oath, 160–161 Hitler, Adolf, 5–6, 86, 87 HIV/AIDS, 148 HLI. See Human Life International HMOs. See Health maintenance organizations Holland. See Netherlands Hospice Association of America (HAA), 210–211 Hospice care, 14–15, 148, 193 in France, 84 at home, 150 in hospice facility, 150 See also Comfort care; Palliative care Hospice Education Institute, 211 The Hospice Handbook (Beresford), 194 Hospice movement, 150 Hospital ethics boards, 90 How We Die: Reflections on Life’s Final Chapter (Nuland), 193 Human Life International (HLI), 211 Humane death, 5 Humbert, Marie, 84, 85, 134 Humbert, Vincent, 84, 85 biographical information on, 134 Humphry, Ann, 139 Humphry, Derek, 190 biographical information on, 134–135 Hurricane Katrina, 43–45 I Ask the Right to Die (Je Vous Demande le Droit de Mourir), 84
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“‘I Will Give No Deadly Drug’: Why Doctors Must Not Kill” (Kass), 48 Illinois, 195 Improving life, and technological innovation, 38 Income, and health care, 56–57 Incompetent people, and abuse, 50 Infants, handicapped, 195 Informed consent, 187–188 Intensive care unit, 186 International codes, of medical ethics, 161–164 International Herald Tribune, 86 International Task Force on Euthanasia and Assisted Suicide, 212 Internet, 154, 155 Involuntary euthanasia, 155 definition of, 2, 32 See also Active euthanasia “Involuntary Euthanasia of Defective Newborns: A Legal Analysis” (Robertson), 195 Irish, Donald, 186 Islam, 23 and suicide, 51, 153 Japan, 88–90 Jehovah’s Witnesses, 153 Jenner, Harald, 87 John Paul II (Karol Wojtyla), 22–23, 52, 53, 80, 152 biographical information on, 135–136 Jordan, Eddie, 45 Journal of Family Practice, 18 Judaism, 21 and euthanasia, 4 and passive euthanasia, 152–153 and suicide, 51
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Kamisar, Yale biographical information on, 136 Karnofsky, David, 190 Kass, Leon, 48, 191 Kelly, Gerald, 193 The Kennedy Institute of Ethics at Georgetown University, 212–213 Kevorkian, Jack, 42–43, 127–128, 144-145, 154, 158 biographical information on, 136–137 Kissane, David W., 35 Koestler, Arthur “Suicide Note,” excerpts from, 174–175 Koestler, Cynthia, 174, 175 Kolff, Willem, 183–184 Koop, C. Everett, 192 Koppell, Oliver, 59–60 Kübler Ross, Elisabeth biographical information on, 137 Kutner, Luis biographical information on, 137–138 Landman, Willem, 80 Landry, Cheryl A., 44–45 Larue, Gerald, 135 Laryngoscope, 5 Law at the End of Life: The Supreme Court and Assisted Suicide (ed. Schneider), 25, 26 Le Fanu, James, 72 Lee, Barbara Coombs biographical information on, 138 Legal cases. See individual cases Legal issues, 158 Legal-political issues, 25–27, 58–65, 157–160 documents related to, 175–181
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and euthanasia, arguments in favor of, 187–190 and euthanasia, arguments opposed to, 194–195 Legalization, 49, 61 Legislation, 7. See also individual acts Libya, 79 Life-sustaining treatment, 9, 11–12, 22, 87–88. See also Medical treatment Light, Donald, 73 Litigation, 40 Living will, 7–8, 24–25, 64–65 in Germany, 87–88 Lo, Bernard, 191 Lou Gehrig’s disease. See Amyotrophic lateral sclerosis Lutheran Church, 53–54, 153 and Missouri Synod of the Lutheran Church, 164–165 Lynn, Joanne, 50 MacLean Center for Clinical Medical Ethics, 213 Magnusson, Roger S., 148 Mali, 79 Managed care, 15–16 and doctor-patient relationship, 40–41 “Managing Death: The Growing Acceptance of Euthanasia in Contemporary American Society” (Christakis), 153 Marcus, Eric, 149 Marker, Rita biographical information on, 138–139 Martyrdom, 4 Mauritius, 79 McKhann, Charles F., 15, 33–34, 42, 46, 49, 50–51, 56, 87, 152
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on physician-assisted dying, 182–183 McNeilly, Irene, 82–83 McNeilly, Keith, 82 Measure 16, 27, 60–61, 175. See also Death with Dignity Act Measure 51, 158. See also Death with Dignity Act Media, 153–154 Medicaid, 156 Medical-bioethical issues, 12–20, 34–51 documents related to, 160–164 and euthanasia, arguments in favor of, 182–185 and euthanasia, arguments opposed to, 190–193 Medical decisions, 36–37 and abuse, 49–51 Medical ethics, international codes of, 161–164 Medical technology, 6, 190. See also Technological innovation; Technology Medical treatment and medical decisions, 36–37 suspension of, 87–88 See also Life-sustaining treatment Medications, 6 Memorial Medical Center, 44–45 Menden, Germany, 86–87 Mental illness and suicide, 149 See also Depression Mercy killing, 2, 32, 148. See also Involuntary euthanasia Michigan, 157, 158 Middle Ages, 4 Mikes, George, 175 Millard, Killick, 71 Minelli, Ludwig, 71–72 Minyard, Frank, 45 Missouri, 9–10
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Missouri Synod of the Lutheran Church euthanasia document of, 164–165 Mormon Church, 153 Moschovis, Peter P., 18 Moynihan, Lord, 71 Mueller, Pamela, 195 Mueller, Robert, 195 Murphy, Donald J., 36–37 Muscular Dystrophy Associations, 148 Must We Suffer Our Way to Death? (ed. Hamel and DuBose), 21, 53, 153 Natanson v. Kline, 188 National Center for Death Education (NCDE), 213 National Citizens’ Coalition for Nursing Home Reform (NCCNHR), 214 National Hospice and Palliative Care Organization (NHPCO), 215 National Hospice Foundation (NHF), 214–215 National Right to Life Committee (NRLC), 216 Nazi Germany euthanasia program in, 5–6, 86–87 See also Germany Nazi Party, 86, 87 NCCNHR. See National Citizens’ Coalition for Nursing Home Reform NCDE. See National Center for Death Education Neglect, death by, 155 Netherlands, 74–76, 159, 184–185 New England Journal of Medicine, 41 New Orleans Times Picayune, 44 New Scientist, 39
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New York State, 59–60 health insurance in, 19 Newsweek, 20, 22–23 NHF. See National Hospice Foundation NHPCO. See National Hospice and Palliative Care Organization Nitschke, Philip, 77 biographical information on, 139 Nonvoluntary euthanasia definition of, 2, 32 See also Active euthanasia Northern Australia Legislative Assembly, 188–189 Northern Ireland, 70 Not Dead Yet, 216 NRLC. See National Right to Life Committee Nuland, Sherwin, 193 Nurses and accountability, 192 on physician-assisted suicide, 184 “Nurses Speak Out: Does a Terminal Patient Have the Right to Die?”, 193 Nutrition and hydration, 9, 11–12. See also Life-sustaining treatment O’Connor, Sandra Day, 189 OCRT. See Ontario Consultants on Religious Tolerance OHD. See Oregon Health Division Olick, Robert S., 8, 40, 64 Ontario Consultants on Religious Tolerance (OCRT), 222 Ophthalmoscope, 5 Oregon Death with Dignity Act, 27, 36, 41, 60–64, 75, 93, 94, 95, 156–157, 158, 159–160
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excerpts from, 177–181 “The Oregon Experiment” (Foley and Hendin), 63–64 Oregon Health Division (OHD), 63 Oregon Health Services Commission, 158 Pacemakers, 6 Pain, 13–14 Pain medication, 26 Pain Relief Promotion Act, 158–159 Palliative care, 15, 26, 49. See also Comfort care; Hospice care Park Ridge Center, 217 Passion, 191–192 Passive euthanasia definition of, 1–2, 32 and Judaism, 152–153 See also Euthanasia Patient abuse, 50 anxiety, 17 disabled, 38–39, 50. See also People with disabilities elderly, 50. See also Elderly people embarrassment, 17 harm to, 183 incompetent, 39–40, 50 poor, 50. See also Poverty See also Doctor-patient relationship Patient Self Determination Act (PSDA), 10 Pellegrino, Edmund, 191 biographical information on, 139–140 Pentecostal Church of God, 153 People with disabilities, 38–39, 50 and euthanasia program in Germany, 86–87 People’s Daily, 91, 92
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Perron, Marshall, 77, 78, 129, 188–189 Persistent vegetative state (PVS), 14 Personality, 190–191 Philanthropy Magazine, 36 Physical suffering, 34, 36 and pain medication, 26 and spiritual issues, 4, 52, 53 Physician-Assisted Death (ed. Humber, Almeder, and Kasting), 156 Physician-Assisted Dying: The Case for Palliative Care and Patient Choice (ed. Quill and Battin), 47 Physician-assisted suicide, 2 arguments in favor of, 182–190 arguments opposed to, 190–195 definition of, 1, 32 discussions of, effects of, 31 and individuals and organizations, documents related to, 174–175 instances of, 41–43 and legal-political issues, 25–27, 58–65, 157–160, 187–190, 194–195 and legal-political issues, documents related to, 175–181 and medical-bioethical issues, 12–20, 34–51, 182–185, 190–193 and medical-bioethical issues, documents related to, 160–164 and religion, documents related to, 164–174 spiritual-social-cultural issues, 150–155 and spiritual-social-cultural issues, 21–25, 51–58, 185–187, 193–194
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and spiritual-social-cultural issues, documents related to, 164–175 See also Assisted suicide; Euthanasia; Self-deliverance; Suicide Physicians, 5 and accountability, 192 and pain, 14 and passion, 191–192 on physician-assisted suicide, 156–157, 185 prosecution of, 24, 54–55, 153 role of, 46–51 See also Doctor-patient relationship Pius XII, 152 Political issues, 158–160. See also Legal-political issues Polling methodology, 81, 156–157 Postma, Gertruida biographical information on, 140 Pou, Anna, 44–45 Poverty and health care, 50, 56–58 and health insurance, 57–58 PPOs. See Preferred Provider Organizations Preferred provider organizations (PPOs), 15 and doctor-patient relationship, 40–41 Presbyterian Church, 153 Preservation of life, 52 President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, 191 Prevention of Hereditarily Ill Offspring, 87 Preventive care, 57 Profits, 16 Promoting a Suicide Attempt, 188
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Prosecution, of physicians, 24, 54–55, 153 Protestant churches and euthanasia, 4 and suicide, 51 PSDA. See Patient Self Determination Act PVS. See Persistent vegetative state Pythagoreans, 3 Quality of life, 13, 35–36, 46 and people with disabilities, 39 and technological innovation, 38 Quill, Timothy, 48–49, 59–60, 187 biographical information on, 140 on patient harm, 183 Quill v. N.Y. Attorney General, 59 Quill v. Vacco, 156, 181 Quinlan, Karen Ann, 6–7, 8–9, 10, 11 biographical information on, 141–142 effects of case of, 7–8 Rachels, James, 184, 193 biographical information on, 142 Rational suicide, 151 definition of, 33–34 Ratzinger, Joseph. See Benedict XVI Rayner, Claire, 39 RDSC. See Right to Die Society of Canada Reformed Judaism and suicide, 51 See also Judaism Rehnquist, William, 60, 181, 189 Religion, 21–25, 151–153 and doctor-patient relationship, 18–19 and euthanasia, documents related to, 164–174
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and suicide, 51, 151–152 See also individual churches and religions; Spiritual issues Renaissance, 4–5 Report/Newsmagazine, 82 Respirator, removal of, 7. See also Life–sustaining treatment Réunion, 79 The Right to Die Debate (Zucker), 175, 181 The Right to Die (Humphry and Wickett), 190 Right-to-die movement, 159 Right to Die Society of Canada (RDSC), 223 The Right to Die with Dignity, 24–25, 54–55, 172–174 Rights of the Terminally Ill (ROTI) Act, 76–78, 157, 188–189 Rinpoche, Sogyal, 186 Roberts, Barbara, 159–160 Roberts, Frank, 159–160 Robertson, John A., 195 Rodriguez, Sue, 82 “The Role of Critical Care Nurses in Euthanasia and Assisted Suicide” (Asch), 184 Roman Empire, 3–4 Rosochacki, Zandy, 80 Rothman, David, 182, 192 Rothstein, Barbara, 59, 188 ROTI Act. See Rights of the Terminally Ill Act Sacred Congregation for the Doctrine of the Faith, 21, 165 San Diego Union Tribune, 94 Saunders, Dame Cicely, 14–15, 150, 193 biographical information on, 142–143 SAVES–The Living Will Society, 223
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Saving life, and technological innovation, 37–38 Scalia, Antonin, 189 Scherer, Jennifer M., 56–57, 74–75, 76–77, 151, 156 Schiavo, Michael, 11, 85, 143, 154, 155, 158 Schiavo, Terri Schindler, 6, 10–11, 64, 65, 84, 85, 154, 155, 158 biographical information on, 143 effects of case of, 11–12 Schindler, Mary, 11, 143, 154, 155, 158 Schindler, Robert, 11, 143, 154, 155, 158 Schneider, Carle E., 25, 26 Schroeder, Alfred, 187–188 Schwartz, Leonard, 33 Scientific discovery, 4–5 Scotland, 70 Scott, Richard, 135 Seale, Clive, 72 Secularization, 153 Self-deliverance, 2 definition of, 33 See also Assisted suicide; Euthanasia; Physicianassisted suicide; Suicide Self-determination, 24–25, 34, 54–55, 153 Semantics, 191 Siddartha Gautama, 23 Siegler, Mark, 191 Simmons, Rick, 44 Simon, Rita J., 56–57, 74–75, 76–77, 151, 156 Simons, Marlise, 185 Sinclair, Allan, 82–83 60 Minutes (TV news program), 43, 154 Slippery slope, 75, 76 in Nazi Germany, 87 Smith, Wesley J., 36
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biographical information on, 143–144 Snyderman, Nancy, 17–18 Social issues. See Spiritual-socialcultural issues South Africa, 79–80 South African Law Commission, 80 Southern Baptist Church, 153 Spiritual advisors, 53–54 Spiritual issues, 51–55 and physical suffering, 4 See also Religion; Spiritualsocial-cultural issues Spiritual-social-cultural issues, 21–25, 51–58, 150–155 documents related to, 164–175 and euthanasia, arguments in favor of, 185–187 and euthanasia, arguments opposed to, 193–194 See also Cultural issues; Spiritual issues St. Petersburg Times, 11, 64, 65 Sterilization, compulsory, 87 Stethoscope, 5 Stevens, John Paul, 194 Stranger on the Square, by Arthur and Cynthia Koestler (Harris, Harold), 175 Strangers at the Bedside (Rothman), 182, 192 Suffering. See Physical suffering Suicide, 2, 3–4 in Colonial America, 5 definition of, 1, 32–33 and the elderly, 148–149 and euthanasia, difference between, 187 guidelines, disseminating information about, 71 and mental illness, 149 motivation for, 149 and religion, 51, 151–152 in United Kingdom, 71
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See also Assisted suicide; Euthanasia; Physicianassisted suicide; Selfdeliverance Suicide Act of 1961, 71 “Suicide Note,” excerpts from, 174–175 Supportive Care Coalition: Pursuing Excellence in Palliative Care, 217–218 “The Supreme Court and End-ofLife Care: Principled Distinctions or Slippery Slope?” (Dresser), 26 Surgical techniques, 6 Surveys, 156–157 Switzerland, 71–72 Sybrandy, Jaap, 139 Sybrandy, Klazien, 139 T4, 87 Taber’s Cyclopedic Medical Dictionary, 14 Tada, Joni Eareckson biographical information on, 144 Taking Advance Directives Seriously (Olick), 8, 40, 64 “Taking the ‘Right to Die’ Issue to the Supreme Court” (White), 185, 187 Talmud, 152–153. See also Judaism Technological innovation and improving life, 38 and quality of life, 38 and saving life, 37–38 See also Medical technology; Technology Technology, 21–22, 155 and Catholic Church, 52–53 See also Medical technology; Technological innovation Telegraph, 72 Tenet Healthcare, 44–45 Terminology, 32, 34–35
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Terri Schindler Schiavo Foundation (TSSF), 218 The Tibetan Book of Living and Dying (Rinpoche), 186 A Time to Die: The Place for Physician Assistance (McKhann), 15, 33–34, 50–51, 151–152, 183 Timothy E. Quill v. G. Oliver Koppell, 59 Tradition, 55–58 Treatment. See Life-sustaining treatment; Medical treatment TSSF. See Terri Schindler Schiavo Foundation Tunisia, 79 UNESCO Courier, 51 Unitarian Universalist Association (UUA), 24–25, 153 Unitarian Universalist Church, 54–55 Unitarian Universalist General Assembly, 54 Unitarian Universalists, 24–25 and Right to Die with Dignity, 24–25, 54–55, 172–174 United Church of Christ, 153 United Kingdom, 70–73, 86 United Pentecostal Church, 153 United States euthanasia in, compared with Africa, 79–81 euthanasia in, compared with Australia, 78 euthanasia in, compared with Belgium, 93 euthanasia in, compared with Canada, 83 euthanasia in, compared with China, 92 euthanasia in, compared with Colombia, 94–95
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euthanasia in, compared with France, 85 euthanasia in, compared with Germany, 88 euthanasia in, compared with Japan, 90 euthanasia in, compared with the Netherlands, 75–76 Euthanasia in, compared with United Kingdom, 72–73 health care in, 73 United States Conference of Catholic Bishops (USCCB), 218 Universal health care in Canada, 83 See also Health care Universalist Church of America, 24 Update, 72 U.S. Constitution, 9, 58–60, 158, 175–176 excerpts from, 176–177 U.S. Holocaust Museum, 87 U.S. Living Will Registry, 65 U.S. Supreme Court, 25–26 opinions on euthanasia, 181 See also individual cases USCCB. See United States Conference of Catholic Bishops “Useless” people, 86–87 UUA. See Unitarian Universalist Association Vaccines, 6 Vacco, Dennis, 60 Vacco v. Quill, 25–26, 59–60 Villot, Cardinal Jean, 152 Vitalism, 53
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Voluntary euthanasia definition of, 2, 32 See also Active euthanasia Voluntary Euthanasia Laws Bill, 159 Voluntary Euthanasia Society of New Zealand, 224 Voluntary Euthanasia Society of Scotland, 71 “Vulnerable People: Practical Rejoinders to Claims in Favor of Assisted Suicide” (Cohn and Lynn), 50 Wales, 70 Washington Post, 43, 44, 80 Washington State, 59, 60 Washington v. Glucksberg, 25–26, 59, 60, 158, 181 Weber, Doron, 185 Weblogs, 155 “When Is CPR Futile?” (Alpers and Lo), 191 White, Christy Cruzan, 185, 187 Why Suicide? (Marcus), 149 Wickett, Ann, 134, 190 Wojtyla, Karol. See John Paul II World Congress of Family Doctors, 80 World Federation of Right to Die Societies, 224 World Medical Association international code of, 161–163 Youk, Thomas, 42–43, 136, 154, 158 biographical information on, 144–145 Youth, culture of, 56 Zucker, Marjorie B., 175, 181
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About the Authors
Jennifer Fecio McDougall is a freelance writer and editor with extensive experience in local government and nonprofit organizations. She earned a Master of Public Administration (MPA) degree at Canisius College in Buffalo, New York. She lives in Buffalo with her husband, Alex, and their daughter, Maeve. Martha Gorman has written numerous books and articles, among them the first edition of Euthanasia: A Reference Handbook. She is a writer, publisher, and activist living in Buffalo, New York.
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