“Although the status quo will be regarded as a hardship by some terminally ill patients who want the 'option' of physician-assisted suicide to be immediately available,” Hogan said, “the public interest in protecting vulnerable citizens from the irreparable harm of death is greater. Surely the first assisted-suicide law in this country deserves a considered, thoughtful constitutional analysis.”
If the Oregon law ever takes effect, three conditions would have to be met before a terminally ill patient could receive aid-in-dying: (1) two doctors must agree that the patient has six months or less to live; (2) the patient must ask for a doctor's help in committing suicide at least three times, the last time in writing, with the statement signed and dated by the patient in the presence of two witnesses; and (3) the patient's doctor must wait at least 15 days after the first request, and at least two days after the third one, before writing a prescription for lethal drugs.
The Oregon law also requires that the drugs be self-administered, with or without a doctor's presence. “Nothing in this act 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,” it states. In addition, the Death With Dignity Act says that prescribing lethal drugs under the conditions it sets forth “shall not, for any purpose, constitute suicide, assisted suicide, mercy killing or homicide.”
Why did the Oregon initiative succeed at the polls whereas similar measures in Washington and California failed? According to Lee LaTour, national public relations coordinator for the Eugene-based Hemlock Society, “Oregonians were much better informed about the law's provisions, and about the issues surrounding physician aid-in-dying. That's because so much has happened since the California and Washington laws were voted down.” She also feels the Oregon proposal “was very well written, very well thought out. It answered people's questions and addressed issues that needed to be addressed.”
In LaTour's opinion, the key to victory in Oregon was the requirement that the lethal drugs be self-administered. “That kept decisions on taking drugs in the hands of patients rather than the hands of doctors, who were involved only to the extent of prescribing the drugs. Also, there were a lot more safeguards in the Oregon bill than there were in the earlier ones.”
Anti-euthanasia groups offered different post mortems on the Oregon vote. To Grimstad of the Center for the Rights of the Terminally Ill, the outcome reaffirmed the state's reputation as a maverick on political and social issues. Marker, contradicting LaTour's analysis, says “Oregon voters were not really informed as to what the measure was.” Opponents, headed by a group called the Coalition for Compassionate Care, “chose to run a campaign of what could best be described as political pacifism,” Marker says. “While the pro-euthanasia folks were playing hardball, those opposing Measure 16 were playing Wiffle Ball - if they were even in the ballgame at all.”
The International Anti-Euthanasia Task Force's bimonthly newsletter pointed to a number of “problem areas” in the Oregon law. For instance, the measure applies only to eligible residents of Oregon. “However, nowhere does it define residency, nor does it require anyone to determine whether the patient is a resident.” The absence of safeguards in the law for pharmacists filling prescriptions for lethal drugs is another potential source of trouble, the task force said. “In fact, pharmacists fear that insurers may refuse malpractice insurance to any pharmacist dispensing a lethal prescription.”
As Oregonians await further rulings by Judge Hogan, bills based closely on Measure 16 are under consideration in the legislatures of at least eight states - California, Connecticut, Maine, Massachusetts, Michigan, New York, Vermont and Wisconsin. None is expected to win legislative approval. In fact, similar bills have died this year in Colorado, Maryland, New Hampshire, New Mexico and Washington.
Humphry says he's not surprised at the outcome in the states. “I think a lot of legislators are saying . . . why don't we wait to see whether this is constitutional or not before we rush around legislating.”
Dr. Death and the Courts
In a separate opinion, the appeals court reinstated the murder charges originally brought against Kevorkian in 1992 in connection with the Wantz-Miller deaths. It cited a 1920 Michigan court case in which a man who had placed a glass of poison within reach of his ill wife was prosecuted and found guilty of murder.
The May 1994 rulings were appealed to the Michigan Supreme Court, which handed down its decision on Dec. 13. Declaring that the state's ban on assisted suicide was indeed constitutional, the court held that helping a person take his or her life “may be prosecuted as a common law felony” even in the absence of a statute expressly forbidding the practice.
The high court also reversed the lower-court ruling on Kevorkian, stating that assisted suicide may be prosecuted as murder only “where there is probable cause to believe that death was the direct and natural cause of a defendant's act.” Even so, Oakland County Prosecutor Richard Thompson said he still intended to seek a murder conviction in the Wantz-Miller case. “I think it can be shown very clearly” that Kevorkian “met the court's test for murder,” Thompson said.
On the same day the Michigan Supreme Court ruled on Kevorkian's role in the Wantz-Miller case, the state House of Representatives approved a measure to reinstate the assisted-suicide ban that had expired Nov. 25. The state Senate had taken similar action on Dec. 7. Nonetheless, Leelanau County Prosecutor Tom Aylsworth announced in January that Kevorkian would not be charged with helping two elderly people commit suicide in 1993 because investigators had been unable to find enough evidence.
“Attempting to reinterview witnesses nearly two years following the alleged crime has proven to be difficult and futile,” Aylsworth said in a statement released Jan. 13. “Based upon the evidence we have now, there is a reasonable likelihood of acquittal.”
Kevorkian, for his part, announced March 6 that he planned to appeal Michigan's ban on assisted suicide to the U.S. Supreme Court. The American Civil Liberties Union (ACLU), representing two cancer patients, had filed a separate appeal of the ban to the Supreme Court a week earlier. On April 24, the Supreme Court rejected both appeals without comment, clearing the way for Kevorkian to stand trial on murder charges in the Wantz-Miller case.
Kaplan of the group Choice in Dying feels Kevorkian “has done a great service by focusing the media and the public's attention on end- of-life decision-making.” She adds, however, that he also has “scared huge numbers of people, who think his way is the only way available to them. Most people don't really want to commit suicide. Most people are more afraid of pain than they are of dying. They're more afraid of abandonment, of being alone, than they are of dying. When you can reassure them that they don't need to be in pain, that they don't need to be alone, a lot of their fear goes away, and their interest in assisted suicide fades.”
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* The panel had issued a report on April 25, 1994, recommending that the state legalize assisted suicide for terminally ill patients but cautioning that strict guidelines should be adopted to regulate the practice.
Pope John Paul II added his voice to the aid-in-dying debate in a March 30 encyclical letter, “Evangelium Vitae” (Gospel of Life). Assailing what he called a spreading “culture of death,” the pontiff reaffirmed traditional Roman Catholic doctrine on the subject.
Forgoing “extraordinary or disproportionate” measures to keep a terminally ill person alive, Pope John Paul declared, is “not the equivalent of suicide or euthanasia.” Rather, it “expresses acceptance of the human condition in the face of death.”
On the other hand, he condemned euthanasia as “a grave violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person.” The pope added: “Even when not motivated by a selfish refusal to be burdened with the life of someone who is suffering, euthanasia must be called a false mercy, and indeed a disturbing 'perversion' of mercy. True 'compassion' leads to sharing another's pain; it does not kill the person whose suffering we cannot bear.”
Looking ahead, few experts are willing to make firm predictions on the legalization of assisted suicide. Hemlock Society spokeswoman LaTour is encouraged that bills based on the Oregon law have been introduced in more than a dozen states this year, although none is likely to be enacted. The very fact that the measures have been debated is a step forward, she feels. “For some states, this is the first time legislation like this has been considered. For others, it's the second time. But most of the bills are brand-new.”
Kaplan of Choice in Dying feels the debate on end-of-life decision-making “is still in its formative stages. As the issues are discussed more, and we focus less on the contraptions that Jack Kevorkian uses to help people kill themselves and more on the question of choice, I think we may see some shifts of opinion.”
At the federal level, the organization is seeking more uniform implementation of the 1990 law that requires hospitals and other health-care facilities that receive Medicare or Medicaid payments to inform patients about their ability to make out living wills or other advance directives.
“Some hospitals have done an absolutely marvelous job,” Kaplan says, while others “have done zip.” A major problem, she feels, is that “the point of admission to a health-care facility is the wrong time and the wrong place to be making end-of-life decisions. The time to do it is when you're well, and can sit down with your loved ones and your physician and think through what it is that you want. At a time of crisis, it's much harder to do that.”
Murray at Case Western Reserve predicts there will be “more grass- roots efforts . . . to pass laws permitting assisted suicide, and perhaps even active euthanasia. Politically, I see an interesting quandary for conservative Republicans. On the one hand, because of their deep roots in the pro-life camp, you would expect them to be profoundly opposed to assisted suicide or active euthanasia. On the other hand, an equally strong part of the conservative agenda is to get the government out of people's lives - to give individuals more control over themselves. That might lead us to expect more support for laws permitting active euthanasia and assisted suicide.”
People who tend to be most enthusiastic about aid-in-dying issues, Murray suspects, are “upper-middle-class, white, reasonably well- educated people who strongly value their own autonomy. They're likely to be small-business persons, management or executive types, and their families. And they tend to be staunchly in the Republican camp, along with many pro-life people.”
“People who find abortion morally reprehensible are also likely to be frightened [by assisted suicide],” Murray says. “They may even be frightened by the withholding-of-life-support issue. Pro-lifers generally believe that human beings have no right to determine when a life is over; they feel that only God can decide that. The principle applies equally, in their opinion, to life before birth and to life shortly before death.”
This being the case, Murray says he “would be rather uneasy” if he was a GOP state legislator, since the issue “is more likely to take shape in the states than at the federal level in the short term.” Pleasing everyone won't be possible, he says, because “Once the issue is joined, you're going to have to choose sides.”
The IAETF's Marker says the nation is “at a point where the aid- in-dying issue can go either way,” though her gut feeling is that “people do not favor this.” If voters gain “greater understanding of what 'death with dignity' and other such terms really mean, we're not going to be looking at a bleak future where euthanasia is the American way of death and people are expected to request their lethal injection at an appropriate time,” she says. “I think people will look back and say, 'Oh my goodness, do you realize what we almost did?' ”
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Should active euthanasia be legalized?
Cheryl K. Smith
Former Staff Attorney, Hemlock Society U.S.A.,. From ABA Journal, April 1993.
Americans have a common-law and constitutional right to refuse unwanted medical treatment. This right extends to the removal of life-sustaining equipment, including the administration of artificial nutrition and hydration. This “right-to-die” should extend to aid-in-dying, or active euthanasia, for the terminally ill, at their request.
Patient autonomy weighs heavily in favor of the legalization of voluntary active euthanasia. Respect for a person's autonomy requires that his or her considered value judgment must be taken seriously, even if that judgment is believed to be mistaken. Of course, the person desiring aid-in-dying must be both competent and fully informed. This implies voluntariness and disclosure of the risks, benefits, reasonable alternatives and probable results.
Relief of suffering, always a major goal of medicine, provides the best rationale for legal aid-in-dying for the terminally ill. Some argue that the Hippocratic Oath flatly prohibits physician participation in voluntary active euthanasia. The oath, however, contains an internal inconsistency that may make it impossible to adhere to in cases of intractable pain. The oath requires physicians to relieve pain, as well as giving no deadly medicine. In such cases, both courses - relieving pain and not giving a deadly drug - may not be possible. . . .
Another reason for legalizing active euthanasia relates to regulation of the practice. It is currently occurring outside the law and without any reporting requirements. Few cases are discovered, fewer are prosecuted, and juries are hesitant to convict in those cases that are brought to trial, causing unnecessary expenditures and wasting judicial resources. Legalization, with medical record documentation and reporting requirements, will enable authorities to regulate the practice and guard against abuses, while punishing the real offenders.
Even with legalization, inadequate pain control and depression must be addressed. Some have argued that the physician-patient relationship is based on trust and that trust would be violated if doctors were allowed to participate in voluntary active euthanasia. In fact, the opposite my be true: Patients who are able to discuss sensitive issues such as this are more likely to trust their physicians.
Such open dialogue will enhance detection of treatable depression. . . . A study of euthanasia in the Netherlands shows that two-thirds of patients who asked their physicians for assurance that they would be assisted in dying when at the end stage of their disease did not need the assistance because other suitable alternatives were given.
Copyright 1993 American Bar Association. Reprinted with permission of the ABA Journal
Professor of Law, University of Michigan,. From ABA Journal, April 1993.
The distinction between letting people die and killing them by lethal injection is now an integral part of the medico-legal landscape. This is the compromise we have arrived at in the struggle to take a humane approach toward seriously ill patients while still preserving as many traditional restraints against killing as we possibly can. This may be neither the logician's or the philosopher's way, but it may nevertheless be a defensible pragmatic way to do so.
As eminent bioethicist Thomas Beauchamp of Georgetown University has written, rules against killing “are not isolated moral principles,” but “pieces of a web of rules” that forms a moral code. “The more threads one removes,” warned Beauchamp, “the weaker the fabric becomes.”
For that reason, I think that the legalization of active euthanasia will have much greater impact than is generally realized on our society and on the dynamics of the sick room. Criminal penalties create unconscious as well as conscious inhibitions against committing certain acts.
But if active euthanasia were legal, these acts would not only be thinkable, but speakable - an acceptable alternative to treatment that could and would be discussed in polite conversation.
The first person to broach the subject might be the physician or a relative or close friend. Or the gravely ill person might ask advice of those close to her. What should relatives and friends tell her? How would a patient react to the suggestion that she end her life? How many patients would opt for euthanasia because they feel obliged or pressured to do so - to relieve their relatives of financial pressures or emotional strain? And how many severely ill patients will feel that to reject euthanasia, once it is a viable alternative and others are “doing it,” would be selfish or cowardly? . . .
We may be fairly sure of one thing. If we legalize active euthanasia for only the “terminally ill,” it will not remain limited for very long. At first, living-will statutes provided that the directive only became operative when its maker became “terminally ill.” But in response to strong criticism that such a restriction unduly limited the impact of such legislation, a growing number of states have removed the limitation either by statutory amendment or case law.
We may be fairly sure of another thing. If active euthanasia is legalized, it will not be confined to competent patients. As active euthanasia grows in acceptance, there will be a strong impetus to extend the same “benefit” to the incompetent patient who has a life-threatening illness but has never expressed any desire for euthanasia.
Copyright - 1993 American Bar Association. Reprinted with permission of the ABA Journal
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Popular interest in euthanasia, largely dormant since the abuses that occurred in Nazi Germany surfaced after World War II, revives in the United States and Europe.
The Royal Dutch Medical Association says euthanasia should remain a crime but adds that the act may be justified under certain circumstances.
The New Jersey Supreme Court rules that Karen Anne Quinlan, a young hospital patient in a “persistent vegetative state,” has a right through her guardian and family to refuse life-sustaining treatment on the basis of her constitutionally protected right of privacy.
Aid-in-dying begins to emerge as a contentious political issue in the United States.
The Hemlock Society is founded by Derek Humphry and his second wife, Ann Wickett Humphry, to support the option of voluntary euthanasia for the terminally and incurably ill.
Congress authorizes Medicare coverage for hospice care of terminally ill patients.
March 27, 1984
Colorado Gov. Richard D. Lamm is assailed by groups representing the elderly when he tells the Colorado Health Lawyers Association that terminally ill people have a “duty to die and get out of the way.”
Aid-in-dying questions appear on state election ballots as well as state and federal court dockets.
June 4, 1990
Janet Adkins, an Oregon woman in the early stages of Alzheimer's disease, kills herself with the aid of a suicide machine devised by Dr. Jack Kevorkian.
June 25, 1990
Ruling in the case of Cruzan vs. Missouri Department of Health, the U.S. Supreme Court holds that a person whose wishes were clearly known has a constitutional right to refuse life-sustaining medical treatment. But the court also says states may require that comatose patients be kept alive unless there is “clear and convincing evidence” that they would not want to live under such conditions.
Oct. 27, 1990
Congress clears legislation that requires hospitals and other health-care facilities that receive Medicare or Medicaid payments to inform patients about their ability to make out “living wills” or other advance directives about their care should they become unable to communicate.
Aug. 18, 1991
Final Exit, a suicide manual by Derek Humphry, vaults to the No. 1 spot on The New York Times' list of best-selling hardcover “advice” books.
Nov. 5, 1991
Washington voters reject a ballot proposal to permit “physician aid-in-dying.”
Nov. 3, 1992
California voters turn down a proposed death-with-dignity law.
The Dutch Parliament approves legislation that effectively immunizes from prosecution physicians who follow a detailed set of rules for carrying out euthanasia.
Dec. 13, 1993
Wayne County Circuit Court Judge Richard C. Kaufman rules that key sections of Michigan's statute outlawing assisted suicide are unconstitutional.
May 3, 1994
Ruling in the case of Compassion in Dying vs. Washington, Judge Barbara J. Rothstein of U.S. District Court in Seattle holds that a state law banning physician-aided suicide is unconstitutional.
May 10, 1994
The Michigan Court of Appeals strikes down the state's ban on assisted suicide on technical grounds, but declares that there is no right to commit suicide or to have assistance in committing suicide under the 14th Amendment of the U.S. Constitution.
Nov. 8, 1994
Oregon voters narrowly approve an “aid-in-dying” ballot proposal.
March 9, 1995
The 9th U.S. Circuit Court of Appeals upholds Washington's ban on assisted suicide, overturning Judge Rothstein's decision.
March 30, 1995
Pope John Paul II condemns euthanasia as “a false mercy, and indeed a disturbing 'perversion' of mercy.”
April 24, 1994
U.S. Supreme Court refuses to hear appeals brought by Kevorkian and two terminally ill cancer patients challenging Michigan's ban on assisted suicide.
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How the Public Views Assisted Suicide
It has long been recognized that public opinion polls can be tilted by how the questions are framed. A 1993 national survey conducted for Derek Humphry's Euthanasia Research & Guidance Organization found that support for assisted suicide fell when blunt language like “lethal injection” was used, and rose when vaguer terminology like “death with dignity” was substituted.
In face-to-face interviews in August 1993, pollsters asked 1,000 people if they would vote for an assisted suicide law written in frank language, and another 1,000 if they would vote for a law couched in euphemisms. In each case, the softer language won. The responses to the questions are shown below:
Would you vote for or against a law. . .
. . . that allowed a terminally ill person to choose euthanasia rather than prolonging life?
For 55% Against 27% Depends 12% Don't Know 6%
. . . that allowed a terminally ill person to choose to die with dignity rather than prolonging life?
For 65% Against 20% Depends 11% Don't Know 4%
Would you vote for or against a law. . .
. . . that allowed a terminally ill person to choose physician- aided suicide rather than prolonging life?
For 44% Against 36% Depends 12% Don't Know 8%
. . . that allowed a terminally ill person to choose physician's aid-in-dying rather than prolonging life?
For 51% Against 29% Depends 13% Don't Know 6%
Would you vote for or against a law. . .
. . . that allowed a terminally ill person to choose a lethal injection rather than prolonging life?
For 44% Against 36% Depends 12% Don't Know 8%
. . . that allowed a terminally ill person to die by way of a medical procedure rather than prolonging life?
For 50% Against 29% Depends 13% Don't Know 7%
A poll conducted for the National Conference of Catholic Bishops in September 1994 supports the finding that the phrasing of questions has an impact on support or opposition to assisted suicide. Five hundred people were asked if they would support a law allowing terminally ill patients to obtain a physician's prescription for lethal drugs to end their lives. Another 500 were asked if they would support a law allowing physician-assisted suicide.
The vaguer terminology drew slightly more support and significantly less opposition. The results are shown below:
Do you favor a law allowing terminally ill adult patients to obtain . . .
A physician's prescription for lethal drugs to end life?
No, against 47% Unsure 10% Yes, favor 43%
No, against 39% Unsure 15% Yes, favor 46%
Sources: Roper Organization poll for the Euthanasia Research & Guidance Organization, “What's in a Word?” undated; The Tarrance Group for the National Conference of Catholic Bishops, “A Survey of Voter Attitudes in the United States,” Sept. 25-28, 1994. The numbers may not add up to 100 percent because of rounding.
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Hospice Care: Comfort and Support for the Terminally Ill
Anyone who has witnessed the trauma of a loved one dying of cancer knows that it is one of life's most horrifying experiences. Cancer deaths can involve months of agonizing pain for the patient and frustration for the patient's family. Adding to the predicament is the fact that most cancer patients die in hospitals - institutions many believe are better equipped to care for the sick than to treat the terminally ill.
For the past 20 years, however, a growing number of cancer victims and their families have found comfort and support in the hospice movement, which is committed to help terminally ill patients and their loved ones confront death with dignity and without pain.
“Hospices provide palliative care, as opposed to curative care,” notes the Washington-based Hospice Association of America (HAA). Moreover, the care “is primarily provided in the patient's home so that peace, comfort and dignity are maintained.”
Peter Bloom, a clinical psychologist who has been affiliated with Hospice of Northern Virginia, explains that “hospice care focuses on four kinds of pain - physical, emotional, social and spiritual. Hospice staffers try to help the terminally ill patient's family and members of the patient's social network address those issues. That's important, because interest in assisted suicide and euthanasia often stems from fear of losing control in one of those areas.”
Besides being expert in pain management, notes Bloom, hospice physicians strive to pass on their expertise to the larger medical community. In the past year, for example, doctors at Hospice of Northern Virginia came in contact with about 500 physicians who had patients receiving hospice care. This gave the hospice physicians a chance to make the other doctors “more competent to deal with pain- control issues,” Bloom says.
Richard M. Doerflinger, associate director of the U.S. Catholic Conference's secretariat for pro-life activities, believes demand for assisted suicide would drop if hospice care became more widely available in this country. “A lot of effort is being made to improve that care and to respond to some of the concerns about dying in pain that feed into the euthanasia movement,” he says. He also feels “the converse is true, that if euthanasia becomes widely acceptable, you can probably forget about improving hospice [care].”
In the Netherlands, where euthanasia is illegal but widely tolerated in practice, “there's almost no hospice development,” Doerflinger notes. “Some observers have pointed to that and said, well, once you start allowing euthanasia, you dry up the motivation to improve real care of the dying. That's because doctors have this easy way - a quick and easy way - to deal with the pain of terminal illness.”
Though the hospice concept dates from ancient times, it did not take root in the United States until March 1974. That was when the nation's first hospice, the Connecticut Hospice Inc., of Branford, began operating. The National Cancer Institute provided funding for its first three years.
From that modest beginning, the U.S. hospice movement has shown explosive growth. HAA estimates there are now 2,000 organizations providing hospice services in the United States.
The movement received a major boost in 1982, when Congress authorized Medicare coverage for hospice care of terminally ill patients. States began offering hospice care as an optional service under Medicaid shortly afterward. A 1989 federal law raising Medicare reimbursement rates for hospice services by 20 percent sparked a further surge of interest in this approach to caring for the terminally ill.
By 1994, HAA reports, 1,602 hospices had Medicare certification. HAA predicts that “the need for Medicare-certified hospices will continue to grow due to the growing aging population, the increase of persons with AIDS and the rise of health-care costs. More importantly, medical professionals, as well as the general public, are choosing hospice [care] over other forms of health-care delivery because of its holistic, patient-family, in-home centered philosophy.”
Eventually, though, the hospice movement may be forced to confront the assisted-suicide issue. “Hospices must address the tension that exists from being advocates for patient choice on all issues but this one,” two hospice officials wrote in 1993. “It would be wise for hospices to develop a response that acknowledges the tension and addresses both the patient's right to choose and the agency's right to adhere to a philosophy of not hastening death.”
 Hospice Association of America, “Hospice Facts and Statistics,” January 1995, p. 1.
 For background, see “The Hospice Movement,” Editorial Research Reports, Nov. 14, 1980, pp. 821-840.
 Future rate increases were tied to annual increases in the price of a market basket of hospital services.
 Hospice Association of America, op. cit., p. 3.
 Kate Colburn and Dee Hively, “The Hospice Phenomenon in Its Second Decade Under Medicare,” Caring (monthly journal of the National Association for Home Care), Vol. XII, No. 11, 1993. Colburn is the executive director and Hively the assistant director of Hospice of Central Iowa in Des Moines.
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Euthanasia Provokes Controversy . . .
Oregon is currently the only jurisdiction in the world where assisted suicide is legal - and even there, doctors may not prescribe lethal drugs for their terminally ill patients pending resolution of challenges to the law in federal court.
The situation in the Netherlands is almost the reverse. Euthanasia remains a criminal offense in that country, punishable by up to 12 years in prison. At the same time, though, Dutch physicians who put hopelessly ill patients to death after being asked to do so are not prosecuted if they follow guidelines formulated by the courts.
Active voluntary euthanasia has been openly practiced in Holland since 1973, when, for the first time, a Dutch physician was charged with participating in a mercy killing. The doctor had acceded to repeated requests for death by her 78-year-old mother, who was partially deaf, incontinent and wheelchair-bound. A court in Leeuwarden found the defendant guilty, but gave her only a suspended sentence.
In that case and other Dutch court cases decided between 1973 and 1984, two conditions were deemed essential for not prosecuting euthanasia. First, the patient had to initiate the request to die, asking repeatedly and explicitly for death. Second, the patient had to be suffering from severe physical or mental pain, with no prospect of recovery.
In 1984, Dutch courts added a third condition - that a physician intending to perform euthanasia must first consult a colleague to confirm the accuracy of the diagnosis, verify the planned means of bringing about death and ascertain that all legal requirements are being met. Since then, some courts have also cited as requirements the presence of an incurable disease or a demand that death by euthanasia not inflict unnecessary suffering on others.
A 1991 report commissioned by the Dutch government contained ammunition for both supporters and opponents of euthanasia. The study found that 2,300 deaths, or 1.8 percent of all deaths in the Netherlands in 1990, were deliberately caused by doctors acting on their patients' orders. The relatively small number of such deaths, pro-euthanasia groups said, showed that the Dutch policy was sound.
However, the report also stated that 1,040 additional people were put to death by their doctors in 1990 without their consent, despite the courts' insistence that euthanasia be voluntary. This finding, said anti-euthanasia groups, showed that fears of sliding down an ethical “slippery slope” were justified. In all the deaths cited in the study, doctors had killed patients by lethal injection or by giving them a lethal drug “cocktail” to drink.
In February 1993, the Dutch Parliament approved legislation codifying and clarifying the judicial guidelines governing euthanasia. The law stopped short of legalizing the practice, which remains punishable by up to 12 years in prison, but it effectively immunized from prosecution any doctor who put a patient to death in accordance with four “carefulness requirements.”
These stipulated that (1) a request for death must be made “entirely of the patient's free will” and could not be made by family or friends; (2) the request must be expressed repeatedly and show “lasting longing for death”; (3) the patient must be informed of alternatives; and (4) both patient and doctor must regard the patient's suffering as “perpetual, unbearable and hopeless.”
The 1993 law failed to still criticism of the Dutch euthanasia policy, however. Opponents returned to the attack after the Dutch Justice Ministry announced late last December that two doctors who had killed gravely ill newborn babies would face criminal charges.
One of the doctors, gynecologist Henk Prins, had administered a muscle-paralyzing drug to an infant girl with malformed limbs, spina bifida, partial paralysis and an underdeveloped brain. Prins said he acted with the parents' consent and only after consulting five other physicians, all of whom agreed that the girl had only weeks to live and that her condition could not be improved by operating on her.
On April 26, a Dutch district court ruled that Prins' actions were justifiable. The Alkmaar District Court convicted Prins of murder but decided not to punish him for the offense, Reuters news service reported. Explaining the verdict, Judge Ben Posch said Prins had faced a difficult choice between two irreconcilable duties - preserving the child's life or ending her suffering. “The court concludes . . . that the defendant made a choice which - given the special circumstances of the case - can reasonably be considered as justifiable,” he said.
Euthanasia also is a touchy issue in Canada, where two recent “mercy killing” trials captured nationwide attention. The defendant in the first case was Robert Latimer, 41, a farmer in Wilkie, Saskatchewan. Last November a jury found Latimer guilty of second- degree murder in the death of his 12-year-old daughter, Tracy, who had suffered severe mental and physical retardation from cerebral palsy. After initially denying involvement, Latimer told police he had asphyxiated Tracy with carbon monoxide fumes from the engine of his pickup truck. He received a life sentence, with no possibility of parole for 10 years.
The defendant in the more recent euthanasia trial, which ended in early March, was Jean Brush of Stoney Creek, Ontario, charged with first-degree murder for stabbing her 81-year-old husband to death last summer. Cecil Brush was suffering from Alzheimer's disease and had asked her to help him “go to sleep and not wake up.” The trial judge gave Mrs. Brand a suspended sentence with 18 months' probation, which meant she would spend no time behind bars. “She has already suffered a harsher sentence than could ever be imposed on her life, the loss of her loving husband,” Judge Bernd Zabel said.
Meanwhile, lawmakers in Australia's Northern Territory are considering legislation permitting terminally ill patients to take their lives by lethal injection or swallowing a fatal dose of drugs. The bill would not bar residents of other Australian states from going to the Northern Territories for euthanasia purposes. The International Anti-Euthanasia Task Force quoted an Australian newspaper as saying that the measure was “certain to be opposed by many in Parliament.”
 Quoted by Reuters news service, April 26, 1995.
 Quoted by Scott Steele, “Mercy Killing,” MacLean's, March 13, 1995, p. 32.
Supporters and opponents of assisted suicide agree on at least one thing: The fear of dying in excruciating pain underlies the growing interest in assisted suicide.
Ironically, the fear often is groundless. Pain-management experts say numerous medications are available to dull severe pain without causing the patient to drift off into a stupor and spend his or her remaining days in a vegetative state. The difficulty is that powerful pain killers often are not prescribed or are given in doses that are too small.
Pain-control researchers cite several reasons for this, including (1) inadequate teaching of pain-management techniques in U.S. medical and nursing schools; (2) health professionals' concern about running afoul of laws regulating controlled substances; and (3) physicians' desire to prevent patients in severe pain from becoming addicted to opium-based drugs.
David E. Joranson, associate director for policy studies for the University of Wisconsin Medical School's Pain Research Group, perceives some progress in recent years. Reluctance to prescribe controlled substances for pain relief is “a slowly vanishing concern because of the high priority that pain management is taking in health care in general today,” he says. But many problems remain, he adds, notably state laws limiting the amount of analgesic opioids - opium derivatives - that a physician can prescribe at one time.
American attitudes toward pain management took shape many decades ago. In a paper submitted to the 7th World Congress on Pain, Margaret A. Somerville of Montreal's McGill University's Center for Medicine, Ethics and Law provided a brief overview. “Historically, prior to anesthetics, physicians needed to be able to inflict pain to have any chance of curing or helping patients and, in many instances, of saving lives,” she wrote. “In American medicine prior to 1850, there was a tradition that relief of suffering was at most a secondary concern in comparison to saving life, and only acceptable when it imposed no danger to life. Such historical antecedents may still have some strong subliminal effects.”
In 1992, the U.S. Agency for Health Care Policy and Research (AHCPR), a division of the Public Health Service, issued new treatment guidelines that urged doctors, hospitals and other health-care providers to treat pain more aggressively after surgery.
“In developing the pain rules,” one analysis noted, “the panel reviewed studies documenting the fact that half of surgical patients who are treated with 'as needed' injections of painkillers such as morphine and codeine experience moderate to severe levels of pain. Patients experience pain partly because doctors and patients tend to believe certain myths, including one that patients should be stoic about pain. While a total absence of pain is usually not realistic or even desirable, most discomfort can be treated, and good pain management speeds recovery.”
In March 1994, the AHCPR issued new guidelines for pain relief during cancer treatment. “The cost of cancer pain in suffering, disability and quality of life is high,” the panel said. “[We] recommend that cancer pain be treated aggressively by pharmacologic and non-pharmacologic approaches. In most instances, pain can be treated effectively with relatively low-cost, non-invasive therapies. Given this evidence, health system barriers that interfere with effective pain management - such as restrictive legislation regarding the uses of opioid analgesics and third-party payer practices that do not reimburse for less invasive interventions - should be changed.”
State and federal policies on pain medication may change with the realization that opioids rarely lead to addiction when used for pain- killing. Many pain researchers have concluded that these powerful narcotics are not inherently addictive. Studies and clinical observation show, Fortune magazine reported, that “addiction as a result of prolonged use of opioids as painkillers happens to fewer than one in a thousand patients.”
 Margaret A. Somerville, “Death of Pain: Pain, Suffering and Ethics,” Proceedings of the 7th World Congress on Pain (1994), p. 44.
 “New Guidelines Prescribe Relief From Pain,” Medicine & Health Perspectives, March 16, 1992.
 Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, Management of Cancer Pain, Clinical Practice Guideline No. 9, March 1994. p. v.
 Gene Bylinsky, “New Gains in the Fight Against Pain,” Fortune, March 22, 1993, p. 116.
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Assisted Suicide Laws in the United States
More than 30 states have statutes that make assisted suicide a crime. In some of those states, assisted suicide is considered a form of manslaughter, but in others it is a separately defined crime.
States with statutes that explicitly criminalize assisted suicide:
Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Kansas, Kentucky, Maine, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Oklahoma, Pennsylvania, South Dakota, Tennessee, Texas, Washington and Wisconsin
* States that criminalize assisted suicide through common law:
District of Columbia, Alabama, Idaho, Maryland, Massachusetts, Michigan, Nevada, Rhode Island, South Carolina, Vermont and West Virginia
* States in which the law concerning the legality of assisted suicide is unclear:
Iowa, Louisiana, North Carolina, Ohio, Utah, Virginia, Wyoming
* Has law permitting physician-assisted suicide in limited circumstances:
1.The Oregon law permitting doctors to prescribe lethal medications for terminally ill patients is being challenged in federal court and is not currently in effect.
2. Case law in these states may be applicable to assisted suicide.
3. The Louisiana constitution stipulates that “no law shall subject any person to euthanasia.”
4. These states do not recognize common-law crimes and therefore do not explicitly prohibit assisted suicide.
5.The Ohio Supreme Court ruled that assisted suicide is not a crime.
Source: Choice in Dying Inc.
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Kevorkian, Jack , Prescription: Medicide - The Goodness of Planned Death, Prometheus Books, 1991. Kevorkian, sometimes referred to in the news media as “Dr. Death,” is a retired Michigan pathologist who gained notoriety over the past five years for helping 21 persons to end their lives. In this book, he defends his approach to assisted suicide and argues that it could form the basis of a new medical specialty.
Leenaars, Antoon A. , Suicide and the Older Adult, The Guilford Press, 1992. Leenaars and the other contributors to this collection of articles on suicide and the elderly examine such matters as suicide notes, social support of surviving spouses and gender and suicide in the elderly.
Marker, Rita L. , Deadly Compassion: The Death of Ann Humphry and the Truth About Euthanasia, William Morrow and Co., 1993. Marker, one of country's most outspoken opponents of euthanasia, reviews key developments and issues and provides a moving account of the death by suicide of Ann Wickett Humphry, the second wife of Hemlock Society co-founder Derek Humphry.
Retterstol, Nils , Suicide: A European Perspective, Cambridge University Press, 1993. Originally published in Norwegian, this wide-ranging study pays particular attention to suicide in the Nordic countries. It also covers suicide in art, popular misconceptions about the practice and treatment of those who attempt to take their lives.
Shavelson, Lonny , A Chosen Death: The Dying Confront Assisted Suicide, Simon & Schuster, to be published, June 21, 1995. Shavelson, a photojournalist and emergency-room physician, focuses on five terminally persons who considered asking for help in ending their lives.
Fein, Bruce , “Law and the Morality of Assisted Suicide,” Legal Times, May 16, 1994. Fein, a Washington attorney who held posts in the Reagan administration, argues that it is “perverse to stigmatize through law or otherwise those like [Jack] Kevorkian who merely facilitate the commission” of suicide.
Gifford, Eugenie Anne , “Artes Moriendi: Active Euthanasia and the Art of Dying,” UCLA Law Review, August 1993. Gifford provides an excellent historical overview of how attitudes toward helping people end their lives have evolved over recorded history. She concludes that “none of the philosophical or practical objections to active euthanasia . . . are sufficient to justify a ban on the practice.”
Joranson, David E. , “Are Health-Care Reimbursement Policies a Barrier to Acute and Cancer Pain Management?”, Journal of Pain and Symptom Management, May 1994. Joranson, associate director for policy studies at the University of Wisconsin Medical School's Pain Research Group, notes that “The failure to relieve pain in one-half or more of postoperative and cancer patients is gaining recognition as a national health problem with serious personal, social and economic consequences.”
Marzuk, Peter M. , “Increase in Suicide by Asphyxiation in New York City After the Publication of Final Exit,” The New England Journal of Medicine, Nov. 11, 1993. The authors report “a substantial increase in the number of asphyxiations by plastic bags” in New York City in the year after Derek's Humphry's suicide manual, Final Exit, was published. On the other hand, the researchers found “insignificant changes in the number of suicides by other methods and in the overall suicide rate.”
Schanker, David R. , “Of Suicide Machines, Euthanasia Legislation and the Health Care Crisis,” Indiana Law Journal, summer 1993.
“If reforms are not undertaken to ensure access to adequate health care for all Americans and to provide for more compassionate policies and strategies in the care of the dying,” Shanker writes, “voluntary euthanasia may one day be seen, for the terminally ill and their families, as presumptively correct - the only way out of a hellish situation.”, .
Steele, Scott , “Mercy Killing,” MacLean's, March 13, 1995. Steele reviews the circumstances of a case in which an elderly Canadian woman helped her mentally and physically deteriorating husband to carry out his wish to be put to death.
Teno, Joan M. , “Prognosis-Based Futility Guidelines: Does Anyone Win?” Journal of the American Geriatrics Society, Vol. 42, 1994, pp. 1202-1207. Teno and her co-authors present the findings of a study which concluded that withholding medical treatment from terminally ill patients saves much less money than is commonly supposed.
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The Next Step
Periodical Abstracts database
“AIDS Caregivers Struggling With Assisted Suicide,” AIDS Alert, January 1995, pp. 12-14. Compassion in Dying provides support and advice to dying patients who want to hasten their deaths. About half of the calls to the organization are from people with AIDS.
“Ban on Assisted Suicide Upheld,” The New York Times, March 10, 1995, p. A19. By a 2-to-1 vote, the U.S. Court of Appeals for the Ninth Circuit upheld a Washington state law barring doctors from helping terminally ill patients die, saying it protects the poor and handicapped and keeps doctors from becoming “killers of their patients.”
Brienza, Julie , “Assisted-Suicide Cases to Get Spotlight in Court,” Trial, March 1995, pp. 100-101. People on both sides of the physician-assisted suicide issue are looking to the courts this year for clarity in the controversy over whether terminally ill patients have a legal right to seek aid in hastening their deaths.
Cotton, Paul , “Medicine's Position Is Both Pivotal and Precarious in Assisted-Suicide Debate,” JAMA: The Journal of the American Medical Association, Feb. 1, 1995, pp. 363-364. The ongoing medical ethics debate concerning physician-assisted suicide is examined. Various arguments have clouded the issue, but it appears that very few patients will exercise this option if it is declared legal.
Farrell, Dave , “Assisted Suicide a Troubling, Divisive Issue for State Doctors,” Detroit News & Free Press, Nov. 20, 1994, p. C4. Michigan doctors are deeply divided over physician-assisted suicide, and many are troubled that society expects them to take the lead in dealing with it, according to the chairman of the Michigan State Medical Society.
Gianelli, Diane M. , “Assisted-Suicide Measure Fails in New Mexico; AMA Opposed It,” American Medical News, March 20, 1995, p. 3. An assisted-suicide bill in the New Mexico legislature died in a state Senate committee late last month. The bill was considered the most likely to pass of the dozen or so such measures pending in state legislatures across the U.S.
Gianelli, Diane M. , “Doctors Get No Clear Legal Message in Suicide Ruling,” American Medical News, May 23, 1994, p. 1. The debate over assisted suicide in both Washington state and Michigan is detailed. Washington's ban on assisted suicide has been ruled unconstitutional by a federal court, leaving doctors in “legal limbo.”
Kamisar, Yale , “Assisted Suicide and Euthanasia: The Cases Are in the Pipeline,” Trial, December 1994, pp. 30-35. A challenge of laws barring assisted suicide may reach the Supreme Court by the year 2000. Kamisar discusses the legal issues surrounding these laws and challenges to them.
Momeyer, Richard , “Does Physician Assisted Suicide Violate the Integrity of Medicine?”, Journal of Medicine & Philosophy, February 1995, pp. 13-24. The arguments against physician-assisted suicide are evaluated. Opponents say it violates the integrity of medicine and the physician-patient relation.
Tobin, James , “Poll Shows Support for Assisted Suicide,” Detroit News & Free Press, Dec. 4, 1994, p. A2. Public opinion researchers at the University of Michigan found that most residents of Michigan support doctor-assisted suicide and oppose the state legislature's attempt to ban it. The results of the survey are graphically depicted and examined.
Ballot Measures in Washington and Calif.
“Aid-in-Dying Group Appeals in Assisted-Suicide Ruling,” American Medical News, April 10, 1995, p. 11. Lawyers for Compassion in Dying, a group that helps the terminally ill commit suicide, claims a federal judge's position on abortion influenced his opinion in a ruling that threw out Washington's assisted-suicide law. The group has filed an appeal to the 9th U.S. Circuit Court of Appeals in San Francisco.
Annas, George J. , “Death by Prescription,” New England Journal of Medicine, Nov. 3, 1994, p. 8. Physician-assisted suicide has been the subject of reports by commissions in New York and Michigan, and court decisions on the constitutionality of laws against assisted suicide are on appeal in Washington and Michigan. Initiatives on the ballot in Washington, California and Oregon are highlighted.
Robert W. Wood; , “Attitudes Toward Assisted Suicide and Euthanasia Among Physicians in Washington State,” New England Journal of Medicine, July 14, 1994, pp. 89-94. A survey of physicians in the state of Washington indicates that attitudes toward physician-assisted suicide and euthanasia are polarized. A slight majority favors legalizing physician-assisted suicide and euthanasia in at least some situations, but most would be unwilling to participate in these practices themselves.
“Federal Court Upholds Ban on Assisted Suicide,” The Washington Post, March 10, 1995, p. A17. A Washington state law that bars doctors from helping terminally ill patients die protects the poor and the disabled and keeps doctors from becoming “killers of their patients,” the 9th U.S. Circuit Court of Appeals said in upholding the ban.
Hudson, Terese , “Court Strikes Down Assisted Suicide Ban in Washington State,” Hospitals & Health Networks, Aug. 5, 1994, p. 180. A federal district court judge in Washington has struck down that state's assisted suicide ban, saying it violates the 14th Amendment. It was argued that the law discriminates against those seeking assisted suicide because they cannot hasten death in this manner.
Euthanasia and The Netherlands
“Dutch Bring a Test Case in Euthanasia,” The New York Times, Dec. 23, 1994, p. A3. Two Dutch doctors who killed gravely ill newborn babies face criminal trial in the Netherlands in a case that will test a Dutch law on euthanasia to determine what it prescribes for cases when a doctor ends the life of a patient who is unable to ask for death.
Fumento, Michael , “Euthanasia in Netherlands Is Cautionary Tale for U.S.,” Insight on the News, April 17, 1995, pp. 34-35. A comprehensive examination of the Netherlands' euthanasia laws is presented, and the ramifications for legalized euthanasia in the U.S. are considered. The euthanasia laws in the Netherlands are being abused because they can be interpreted so liberally.
Hendin, Herbert , “Seduced by Death: Doctors, Patients, and the Dutch Cure,” Issues in Law & Medicine, fall 1994, pp. 123-168. A number of Dutch court decisions regarding euthanasia and physician-assisted suicide have received international attention. The rationales for physician-assisted suicide and euthanasia are discussed.
Jochemsen, H. , “Euthanasia in Holland: An Ethical Critique of the New Law,” Journal of Medical Ethics, December 1994, pp. 212-217. A proposal for the legal regulation of euthanasia, assisted suicide and the termination of a patient's life without request has been approved by the Netherlands Parliament. This law and the data it is based on are discussed.
Salome, Louis J. , “Euthanasia Accepted in Holland,” Atlanta Constitution, April 22, 1994, p. A13. Euthanasia, while technically illegal, is accepted in Holland. Dutch supporters of mercy killing say the absence of legal sanction adds some dignity to the procedure and avoids the long-running spectacle in the U.S. surrounding Jack Kevorkian. Kevorkian is being tried in the assisted suicide of a man in the summer of1993.
S.A. Duursma; , “Euthanasia: The Dutch Experience,” Age & Aging, January 1994, pp. 3-8. Although rules about euthanasia have been developed in the Netherlands, the practice has not been legalized. The history of and guidelines for euthanasia in the Netherlands, which support both patient and physician in the request for euthanasia, are discussed.
Spanjer, Marjanke , “Assisted Suicide for Mental Distress,” Lancet, Jan. 28, 1995, pp. 246-247. Issues that have emerged in the debate over whether physician- assisted suicide of mentally distressed persons in the Netherlands should be allowed are discussed. There is doubt as to whether assisted suicide is the right way to relieve severe mental suffering.
Waxman, Sharon , “The Dutch Way of Death: Euthanasia Is Accepted. But It's Not Easy,” The Washington Post, Jan. 31, 1995, p. B1. Euthanasia and assisted suicide have been legal in effect since January 1994 in the Netherlands. The opinions regarding such practices voiced by physician Gerrit Kimsma are examined.
Dr. Jack Kevorkian
“Suicide Decision May Spell Trouble for Kevorkian,” Detroit News, Dec. 14, 1994, p. B7. Jack Kevorkian and advocates of assisted suicide suffered a big setback when the Michigan Supreme Court ruled that it is constitutional to make assisted suicide a crime.
“Kevorkian Vows to Keep Fighting Laws Barring Assisted Suicide,” The New York Times, Dec. 18, 1994, p. 43. Jack Kevorkian has lashed out at the Michigan Supreme Court for ruling that assisted suicide is a crime and has indicated he will continue to crusade for what he says is a right protected by the U.S. Constitution. The court also overturned a ruling by the Michigan Court of Appeals on May 10, 1994, which had found a state law banning assisted suicide unconstitutional.
Martindale, Mike , “Kevorkian Vows to Keep Assisting Suicides, Urges Doctors to Set Guidelines,” Detroit News, Nov. 30, 1994, p. B3. Jack Kevorkian said that nothing short of “being burned at the stake” would stop him from helping other patients die. Kevorkian's vow came at a press conference as he urged Michigan's doctors to quickly draw up guidelines for physician assisted suicide.
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Choice in Dying - The National Council for the Right to Die
200 Varick St., New York, N.Y. 10014,
Choice in Dying educates the public on the legal and psychological implications of terminal-care decision-making.
P.O. Box 11830, Eugene, Ore. 97440-4030,
The society strives to foster a climate of public opinion tolerant of people's right to terminate their lives at a time and in a manner of their own choosing.
Hospice Association of America
519 C St. N.E., Washington, D.C. 20002,
HAA promotes the concept of hospice, which offers home-based care for the terminally ill and their family members.
International Anti-Euthanasia Task Force
P.O. Box 760, Steubenville, Oh. 43952,
IAETF opposes so-called death-with-dignity laws. It publishes a bi-monthly newsletter.
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Bruce Fein, “Law and the Morality of Assisted Suicide,” Legal Times, May 16, 1994, p. 23.
 Ibid., p. 28.
 Eugenie Anne Gifford, “Artes Moriendi: Active Euthanasia and the Art of Dying,” UCLA Law Review, August 1993, p. 1585.
 Franklin G. Miller, et al., “Regulating Physician-Assisted Death,” The New England Journal of Medicine, July 14, 1994, p. 120.
 U.S. District Court for the Western District of Washington, Seattle Division, Compassion in Dying v. Washington, May 3, 1994.
 9th U.S. Circuit Court of Appeals, Compassion in Dying v. Washington, March 9, 1995.
 Miller, et al., op. cit., p. 119.
 Yale Kamisar, “Euthanasia Legislation: Some Non-Religious Objections,” in Euthanasia and the Right to Death, A.B. Downing, ed. (1969), pp. 95-96.
 New York State Task Force on Life and the Law, When Death Is Sought: Assisted Suicide and Euthanasia in the Medical Context, May 1994.
 Lonny Shavelson, A Chosen Death: The Dying Confront Assisted Suicide (scheduled for publication by Simon & Schuster on June 21, 1995), p. 106.
 Miller, et al., op. cit., p. 120.
 David R. Schanker, “Of Suicide Machines, Euthanasia Legislation and the Health Care Crisis,” Indiana Law Journal, summer 1993, p. 1006.
 Joan M. Teno, et al., “Prognosis-Based Futility Guidelines: Does Anyone Win?” Journal of the American Geriatrics Society, Vol. 42, November 1994, p. 1206.
 Schanker, op. cit., p. 998.
 For background on euthanasia practices in Nazi Germany, see “Assisted Suicide,” The CQ Researcher, Feb. 21, 1992, p. 152.
 See 1990 CQ Almanac, pp. 566-567.
 Quoted by Stephanie B. Goldberg, “Assisted Suicide Resolution Defeated,” ABA Journal, April 1992, p. 107.
 Ann Wickett Humphry, 49, who had been diagnosed with breast cancer, committed suicide in August 1991. She and Derek had been divorced in 1990. Rita Marker provides extensive background on Ann's death in her 1993 book, Deadly Compassion.
 Derek Humphry, Final Exit (1991), p. 139.
 Gifford, op. cit., p. 1547.
 U.S. District Court for the Southern District of New York, Quill v. Koppell, Dec. 15, 1994.
 Lee v. Oregon, Preliminary Injunction Opinion, p. 27. Cited in IAETF Update, January-February 1995, p. 2.
 “Oregon's Shame,” IAETF Update, November-December 1994, p. 3.
 IAETF Update, March-April 1995.
 Quoted in The New York Times, Dec. 18, 1994, p A43.
 Excerpts from the English-language version of “Evangelium Vitae” released by the Vatican. These and other excerpts were published by The New York Times, March 31, 1995, p. A12.
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Right to Die
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Right to Die
Sep. 05, 1997
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May 05, 1995
Assisted Suicide Controversy
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Medical Profession and Personnel
Right to Die
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