Physician Assisted Suicide

What Are the Ethical Issues?

Physician assisted suicide (PAS) is a contentious topic, and an issue about which most people have strong opinions. Aside from the question of whether we have the right to decide when a person dies, many people fear that the legalization of PAS could lead to euthanasia.

There are several ethical issues to be addressed when looking at PAS. First, is it ever ethical for physicians to help terminally ill, chronically ill, or disabled patients end their own lives? Second, if PAS is ethical in some circumstances, what level of assistance can physicians give to their patients? Third, could the legalization of PAS place pressure upon patients to end their lives? Fourth, could the legalization of PAS lead to euthanasia? Finally would the legalization of PAS be detrimental to the doctor-patient relationship?

What are the Facts?

Physician Assisted Suicide

Physician Assisted Suicide (PAS) is defined in several different ways. In medical literature it has been defined as “an act of self-destruction committed by a patient with the assistance of a physician.” 1 In the Pain Relief and Promotion Act of 1999, the Senate defined PAS as “provision of means to another person with the intent of enabling or assisting that person to kill himself or herself (as by ingesting a lethal overdose).” 2 Neither definition states that the patient must be terminally ill.

Euthanasia

Euthanasia has also been defined in several ways; literally it means ‘good death,’ 3 (from Greek, eu + thanatos. 4) It has been defined in medical literature as “an act whereby a physician intentionally causes the death of a terminally ill patient.” 1 In the Pain Relief and Promotion Act of 1999, euthanasia was defined by the Senate as “the use of active means by one person to cause the death of another person (as by lethal injection) because, as a result of illness, injury, or disability, either the person is deemed to be dying or suffering or the person is considered to be a ‘burden’ on family, community or society.” 2

Again, these definitions have different emphases and raise some questions: Does the actor have to be a physician? Does the patient have to be terminally ill or can their suffering be from chronic illness or disability?

There are three types of euthanasia:

Voluntary euthanasia A patient requests that the doctor end his or her life
Nonvoluntary euthanasia A patient lacks the capacity to request that a doctor end their life
Involuntary euthanasia A patient is opposed to having his or her life ended by a doctor 5

Withdrawal of Medical Support and Treatment

In the U.S. there is a legal right to be free from unwanted bodily invasion. This right stems from common law and the Constitution. Common law holds that unwanted medical treatment is a battery, 1 and the Supreme Court has held that the Due Process Clause protects the right of competent persons to refuse medical treatment, hydration, and nutrition. 6

Many states have laws regarding advance directives that precisely define what treatment a patient wants in the event they become incapacitated. The most common of these directives is a Do Not Resuscitate or DNR order. State laws such as the West Virginia Health Care Decisions Act, formalize this process, define the information that must be on the POST (Physician orders for scope of treatment) form, and also define what happens when a patient has not made an advance directive. This Act also defines medical power of attorney and surrogate decision maker—the people who can legally make medical decisions for an incapacitated patient. 7 WV advance directive forms, information in POST forms, and other resources can be found at the website for the WV Center for End-of-Life Care at http://www.hsc.wvu.edu/chel/wvi/. 8

The physical difference between withdrawal of medical treatment and PAS/euthanasia is that when medical treatment is withheld or withdrawn, the patient dies of the underlying disease, whereas with PAS and euthanasia, the patient dies from the toxin given by the physician. 1, 6

Terminal Sedation/The Double Effect

Terminal sedation is a medical term defining a situation where a terminally ill patient in untreatable pain is sedated to unconsciousness for the remainder of their life, to alleviate their suffering. Terminal sedation is often justified by the double effect, a philosophical/theological term where the morality of an action with multiple results is dependant upon the intent of the actor and the desired result. 9 The double effect as applied to end-of-life care states that “it can be morally good to shorten a patient’s life as a foreseen and accepted but unintended side effect of an action taken for a good reason, even if it is agreed that intentionally killing the patient or shortening the patient’s life is wrong.” 9

Terminal sedation is used when the suffering of a terminally ill patient cannot be alleviated in any other way. An example of this is the shortness of breath that occurs in a patient dying of lung cancer. Although drugs may be used to treat the pain associated with the cancer, painkillers cannot treat the fear and suffering associated with the inability to draw a breath. Terminal sedation is also associated with the withdrawal or withholding of medical support. 10

Euthanasia is illegal in all fifty states, 11, 12 while physician assisted suicide is illegal in forty-nine of the fifty states. Only Oregon has legalized PAS, and then only under specific conditions. 11, 13 There are two sources of support for laws regarding PAS: Common law and the Constitution. British and American common law have, for 700 years, banned suicide and assisted suicide. Constitutional support for such laws comes from Supreme Court cases like Blackburn v State (1872), which clearly stated that these prohibitions extend to the terminally ill.

‘the life of those to whom life ha[d] become a burden—of those who [were] hopelessly diseased or fatally wounded—nay, even the lives of criminals condemned to death, [were] under the protection of the law, equally as the lives of those who [were] in the full tide of life’s enjoyment, and anxious to continue life.’ 14

These prohibitions have been reconfirmed across the country with a variety of laws banning assisted suicide. 14

In the United States, suicide was decriminalized starting in the 18th century, 14 and today no states treat suicide as a crime. 15 Despite this decriminalization of suicide, assisted suicide remains illegal in 49 states. Only in Oregon, where the Death with Dignity Act was created by state referendum, is PAS legal.

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. 1, 16

In 1997, the U.S. Supreme Court ruled that laws in New York and Washington prohibiting PAS were not unconstitutional and that claims of such were not supported by either the Equal Protection Clause or the Due Process Clause of the 14th Amendment: 14, 15, 17

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 to any person within its jurisdiction the equal protection of the laws. 18

In the case Washington v. Glucksberg,the Supreme Court found that a Washington law outlawing assisted suicide was not unconstitutional, because the Due Process Clause does not give competent adults the right to commit suicide. Chief Justice Rehnquist stated that although the Due Process Clause “protects the traditional right to refuse unwanted lifesaving treatment…the asserted ‘right’ to assistance in committing suicide is not a fundamental liberty interest protected by the Due Process Clause.” 14 The reasons given were:

“(L)egal physician assisted suicide could make it more difficult for the State to protect depressed or mentally ill persons, or those who are suffering from untreated pain, from suicidal impulses.”
“The State has an interest in protecting the integrity and ethics of the medical profession.”
“(T)he State has an interest in protecting vulnerable groups—including the poor, the elderly, and disabled persons—from abuse, neglect, and mistakes.”
(T)he state may fear that permitting assisted suicide will start it down the path to voluntary and perhaps even involuntary euthanasia.” 14

In the case Vacco v. Quill the Supreme Court rejected the claim that a New York law banning assisted suicide violated the Equal Protection Clause. Chief Justice Rehnquist cited the intent of the doctor in providing painkilling drugs as part of the grounds for distinguishing between assisted suicide and justified treatment. It was the opinion of the Court that “even as the States move to protect and promote patients’ dignity at the end of life, they remain opposed to physician assisted suicide.” 17

Chief Justice Rehnquist also stated that the “right to refuse treatment was grounded not...on the proposition that patients have a general and abstract ‘right to hasten death,’ but on a well established, traditional right to bodily integrity and freedom from unwanted touching.” 17

In her concurring opinion for Washington v. Glucksberg and Vacco v. Quill, Justice O’Connor stated it is important that “a patient who is suffering from a terminal illness and who is experiencing great pain has no legal barriers to obtaining medication, from qualified physicians, to alleviate that suffering, even to the point of causing unconsciousness and hastening death.” 14 This statement should allay the fears of the medical community that doctors who use terminal sedation to alleviate suffering might be prosecuted under state laws banning assisted suicide.

The legality of withdrawal of treatment is upheld by both common law and the Constitution. Common law holds that “the touching of one person by another without consent and without legal justification (is) a battery.” 6 The Due Process Clause gives patients the right to withhold medical treatment: 6 “A patient’s refusal of life sustaining treatment is honored because patients have the right to be free of unwanted bodily invasion.” 5

In 2001, Attorney General John Ashcroft attempted to override the Oregon Death with Dignity Act through his directive that “physician assisted suicide violates the Controlled Substances Act [CSA] of 1970” 19. The Ninth Circuit Court of Appeals however, ruled that this directive was “unlawful and unenforceable.” 20 This case did not rule upon the legality of PAS, only upon whether the Attorney General could use the CSA to punish doctors who prescribed lethal doses of controlled drugs to dying patients. On November 10th of this year, Attorney General Ashcroft appealed this ruling to the Supreme Court. The court will decide next spring whether it will hear the case or let the decision of the lower court stand. 21, 22

In West Virginia, state law clearly condemns assisted suicide and euthanasia, and differentiates PAS from the withholding or withdrawal of life sustaining treatment.

The withholding or withdrawal of life-prolonging intervention from a person in accordance with the decision of a medical power of attorney representative or surrogate decision maker made pursuant to the provisions of this article does not, for any purpose, constitute assisted suicide or murder...Nothing in this article shall be construed to legalize, condone, authorize or approve mercy killing or assisted suicide. 7

PAS and euthanasia received public attention with the trial of Jack Kevorkian for the murder of Thomas Youk. On 26 March 1999, a jury found Kevorkian, who had lost his medical license, guilty of second-murder and the delivery of a controlled substance. 23-25 Although the Kevorkian trial did not argue the merits of PAS and euthanasia, 23, 25 the willingness of the jury to convict Kevorkian of 2nd degree murder may have caused physicians to reconsider their willingness to fulfill PAS and euthanasia requests.

Various studies that have found that relief from pain is at best a secondary factor in desire for euthanasia or PAS. 26 These studies are supported by an analysis of the Oregonians who have taken advantage of their state’s Death with Dignity Act: 85% of patients who requested lethal medication were concerned about loss of autonomy, 77% were concerned about “decreasing ability to participate in activities that make life enjoyable,” while the fourth most common concern was fear of becoming a burden. 13 During the first four years of the act, of the 140 patients who received a prescription, approximately 30% of those who obtained one did not use it, but died instead from their illness. 13 Combined with the fact that loss of autonomy was the greatest concern for a vast majority of patients, it could be concluded that some patients obtained sufficient relief from simply having the ability to end their lives when they chose. 3, 13, 26

That the majority of terminal patients who request PAS are doing so not because of intractable pain worries many that PAS is not necessarily a choice made of free will, and could lead to euthanasia. There is a fear that families, consciously or unconsciously, will persuade or attempt to persuade terminally ill patients to end their lives early. This may sound outrageous, but medical treatment in the U.S. is expensive and growing more so. It is not impossible that families could find end-of-life care a burdensome expense that could be alleviated by PAS.

In addition to financial costs, a tremendous physical and emotional burden is carried by those who care for a terminally or chronically ill family member. The rigors of caring for a dying loved one may be more of a burden than some can bear.

Although euthanasia is illegal and seen by many as morally unacceptable, terminal sedation is a position that has been morally and legally justified as a way to relieve the suffering of patients at the end of their lives. The double effect as applied to end-of-life care was upheld by Justice O’Connor in her concurring opinion in Washington v. Glucksberg and Vacco v. Quill: “A physician may risk hastening the death of a patient in the course of relieving pain if his or her intention is pain relief and not to end the life of the patient.” 27

The basis for the ethics of terminal sedation can be found in Kant’s Duty Ethic, while the double effect goes back to the 13th century writings of Thomas Aquinas. 9 Unlike Utilitarianism, which can be seen to support PAS and euthanasia, Kant’s Duty ethic states that the means are what is important; we cannot justify or condemn actions based solely upon the end result.

When looking at the difference between euthanasia and withdrawal medical treatment, the morality and ethics may be seen by some as perhaps subtle. For those who are wary of subtle ethical differences, the legal difference has been made quite clear: Patients have a legal right to refuse unwanted treatment, but do not have the right to end their own lives.

Who Are The Stakeholders?

Everyone is a stakeholder in this issue. All of us are going to die at some point, and even if we ourselves do not need end-of-life care, it is highly likely that a loved one or friend will. Specific stakeholders are: physicians, medical personnel, the terminally ill, the chronically ill, families of the terminally and chronically ill, disabled persons, and society.

What Are The Values?

Because physician assisted suicide deals with the issues of life and death, there are many values involved. Some of the most important values are: autonomy, beneficence, non-maleficence, sanctity of life, justice, altruism, integrity, control, dignity, pain relief, prolongation of life, quality of care, and respectfulness.

What Are The Options?

There are three primary options regarding physician assisted suicide in the U.S. We can legalize PAS on a national level, we can outlaw PAS nationally, or we can allow the states to decide whether to legalize or outlaw PAS. Regardless of what happens, we must make sure that all terminally-ill patients have a legal right to aggressive palliative care, including terminal sedation, and we need to facilitate communication between these patients and their families.

It is my conclusion that physician assisted suicide is not ethically justified, however, I feel that the best legal solution is to allow the decision to be made by the States.

Justify The Chosen Option

The justification for opposing physician assisted suicide comes from both legal and ethical sources. Looking first at the legal sources, common law has held that assisted suicide is illegal; 49 out of the 50 states, including West Virginia, have made euthanasia and PAS illegal; and the Supreme Court has found that there is not a constitutional right to assisted suicide.

There is also the question of whether there can even be a true right to PAS. An article by M.T. Harvey suggests that although a right to PAS such as exists in Oregon may give a patient an external right to PAS, an internal right to PAS cannot exist. What is meant by this is that although a patient in Oregon has the legal right to request PAS, a doctor cannot be made to fulfill a request to which they are ethically opposed. 28 In light of this, it is hard to say that a patient has a true right to end their life, when such a right is dependent upon finding a willing physician.

Kevorkian’s conviction of 2nd degree murder in the death of Thomas Youk raises other issues. Kevorkian said that Youk, who had amyotrophic lateral sclerosis (ALS), was suffering terribly from his disease, and that death was the only solution to his suffering. However, Kevorkian knew Thomas Youk for less than 48 hours before euthanizing him, did not check to see if Youk was suffering from depression or was being properly treated for his disease, and did not check to see if Youk was being coerced by his family members. 25 We should also remember that Stephen Hawking, who is wheelchair bound and has lost the ability to speak, was diagnosed with ALS at the age of 21, yet since his diagnosis has written books, published papers, and continued to contribute to the field of cosmology, 29 including his ground-breaking presentation on black holes at a conference this year. 30

It is thus unreasonable to say that Youk’s only option was death, for that says he had nothing to contribute to society—that his life was valueless. It is likely that such a devaluation of life would occur if PAS becomes legal in the U.S. The terminally ill, the chronically ill, and the disabled could be seen as drains upon society with little to contribute, and could even come to see their own lives as worthless, despite the fact that they may still have much to contribute.

Looking at PAS and euthanasia in the Netherlands where both are legally sanctioned, there are several concerns. In the Netherlands, half of the physicians queried considered it appropriate to suggest euthanasia to their patients. Almost 60% of euthanasia cases were not reported to the authorities. In 1995, 0.7% of all deaths were due to nonvoluntary or involuntary euthanasia, while an earlier study in 1990 found that 0.8% of all deaths—more than 1000—were due to nonvoluntary or involuntary euthanasia. 5, 31-34 It was also found that in some cases patients were coerced by doctors or family members, were not screened or treated for depression, or were not given adequate pain treatment. 5, 35 An article by Hendlin et al mentions some disturbing cases: A wife gave her husband the choice of euthanasia or placement in a nursing home, because she didn’t want to care for him anymore. A woman with breast cancer who was opposed to euthanasia had her life ended by the physician because he “needed (the) bed.” 35 It is obvious that in the Netherlands some doctors are not looking out for the best interests of their patients.

There are other historical precedents to consider as well. Much of the fear that PAS will turn into euthanasia stems from WWII and the Nazis. In Germany, physicians were integral in the development regulations and plans for euthanasia. 33 Doctors were to “(assess) the competency and quality of life of mentally impaired persons thought to be candidates for lethal injection.” In the 1920s, Karl Binding and Alfred Hocke wrote The Permission to Destroy Life Unworthy of Life, in which “a carefully controlled process was advocated, with applications for killing evaluated by a three-person panel (a general physician, a psychiatrist, and a lawyer). A consenting patient would have the right to withdrawal that consent at any time, and there was also an emphasis on the legal protections of physicians involved in the killing process.” 31 The experience in Germany shows that when when euthanasia is legalized, society finds more groups “eligible” for euthanasia. “Once German society became accustomed to the state putting disabled people to death, there was less shock and protest over the deaths of other undesirables.” 33

Another issue is that a right to PAS must legally lead to a right to voluntary euthanasia. To do otherwise would be a violation of the Equal Protection Clause of the 14th Amendment. The same would also hold true for allowing the chronically ill and disabled, not just the terminally ill, to end their lives. 32

PAS also seems to go against portions of the Public Health Code of Ethics and the Universal Declaration of Human Rights.

The Public Health Code of Ethics states that:

Public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all. 36

Dying is one process that we will all experience. It is imperative that everyone be given an opportunity to have a good death, without having to resort to ending their lives early, under pressure from family members or their doctor.

Although individuals may feel that they should have a right to end their own life as they see fit, public health emphasizes the good of the community, and history and current experience in the Netherlands show that legalization of PAS and voluntary euthanasia lead to involuntary and nonvoluntary euthanasia, without concern for what is best for the patient. In light of this it is against the best interests of the public to legalize PAS.

The Universal Declaration of Human Rights states that:

Article 3
Everyone has the right to life, liberty and security of person
Article 29
1. Everyone has duties to the community in which alone the free and full development of his personality is possible. 37

PAS violates this because it leads to euthanasia, and because many believe that learning continues until death. “Throughout the whole of life one must continue to learn how to live and, what will amaze you even more, dear friends, throughout life one must continue to learn how to die,” Seneca (4BC – 65AD). 3 PAS removes the chance to learn these last life lessons.

Because PAS and voluntary euthanasia have historically been shown to lead to involuntary and nonvoluntary euthanasia, it is imperative that we safeguard the right of the terminally ill, the chronically ill, and the disabled, to keep such abuses from occurring again. The way to achieve this is by not allowing PAS and voluntary euthanasia to become widely legalized and commonplace.

Another problem is that PAS could fundamentally change the nature of the doctor-patient relationship. 31 The primary concern of a physician is to preserve life, however this is changed when doctors take the lives of their patients. A study of oncology patients found that 19% would change physicians if they knew their doctor had participated in PAS or euthanasia. 5 Patients who are depressed are more likely to trust a physician who discusses euthanasia with them, than patients who are not depressed. 26 Terminally ill patients may take their doctor’s mention of PAS not as one option, but as a suggestion of best choice. 31 All of these things are of concern, because as is seen in the Netherlands, doctors have shown themselves willing to commit euthanasia, even if it is against the will of the patient.

Lavery et al state that “(r)equests for euthanasia and assisted suicide do not arise exclusively out of a desire to avoid pain and suffering. Clinical depression, a desire to maintain personal control, fear of being dependent on others and concern about being a burden to loved ones have all been reported as reasons underlying requests.” 38 It is important to consider that patients who request PAS or euthanasia are more likely to be depressed; 26 treatment for depression and pain typically leads patients to withdrawal their requests for PAS and euthanasia; 5, 33 and 30% of those who receive a lethal prescription never use it. 39 Yet in the Netherlands, there is no longer an emphasis or interest on palliative care—the focus is instead upon PAS and euthanasia. 32

Many claim that PAS should exist to end the suffering of terminally ill patients, however the analysis of those who used the Oregon Death with Dignity Act in its first four years found that none of the top reasons for request were intractable pain. All were control issues, and the fourth most important concern was “becoming a burden.” 13 This seems to indicate that patients could be highly influenced by their family members or their doctors to end their lives early.

If PAS is legalized, will the lives of the dying, ill, and disabled be seen as valueless? Members of our society who are older, disabled, or infirm still have much to contribute, but the legalization of PAS would deny this—especially in light of the fact that the fourth most common reason those who chose PAS in Oregon was fear of becoming a burden. This is why hospice is so important—to allow the ill to continue to contribute to society, and to facilitate conversation between dying patients and their families, to clarify the wishes and needs of both.

How Could This Issue Have Been Prevented?

There is no single solution to this problem. As long as people desire control over the end of their lives, there will be requests for PAS and euthanasia. There are, however, some steps that can be taken to improve end-of-life care, which may help reduce the number of patients making these requests.

It is important to note that hospice, which emphasizes palliative care, is becoming more common, and is being covered by more health insurance companies. The Medicare hospice benefit has evolved and improved since it was initially enacted in 1982, and was improved again in 1997, to improve access and reduce restrictions to access. 40 As most patients who request PAS or euthanasia change their minds after receiving treatment for pain and/or depression, the importance of aggressive palliative care cannot be over-emphasized.

Although access to palliative care is important, intractable pain does not seem to be the biggest factor in desire for PAS and euthanasia. Control and fear of becoming a burden are the biggest issues, and it is uncertain whether these issues can be addressed simply with palliative care. Because of this, better and affordable medical treatment are a necessity for ethical end-of-life care. If patients know that their families will not be left with huge medical bills, and if hospice care—including respite care—is more widely used, this should reduce the stress on both the patient and the family. And communication between patients and their families is important, to clarify how the ill and their care takers are dealing with the illness.

It is also important to realize that a legal right to PAS would lead to a legal right to voluntary euthanasia, and history shows that allowing voluntary euthanasia leads to involuntary and nonvoluntary euthanasia. If we are to show respect for life, then we cannot take the first step down what has shown itself to be a slippery slope. But the essential thing is to make sure that all patients in need have access to palliative care and treatment for depression at the end of life, because although there will always be requests for PAS, such treatment should significantly reduce the number of requests and go a long way towards solving the problem.

    References

  1. Walker RM. Physician-assisted suicide: the legal slippery slope. Cancer Control. Jan-Feb 2001;8(1):25-31.
  2. The Pain Relief Promotion Act, Senate(2000).
  3. Peck MS. Denial of the Soul. New Tork: Harmony Books; 1997.
  4. Merriam-Webster's Collegiate Dictionary. 11th ed. Springfield; 2003.
  5. Lo B. Resolving Ethical Dilemmas: A Guide for Clinicians. 2nd ed. Philadelphia: Lippincott Willians & Wilkins; 2000.
  6. Cruzan v. Director, MDH, 88-1503 (USSC 1990).
  7. West Virginia Health Care Decisions Act, §16-30-1 to §16-30C-16.
  8. West Virginia Center for End-of-Life Care. West Virginia Center for End-of-Life Care. Available at: http://www.hsc.wvu.edu/chel/wvi/. Accessed Nov 30, 2004.
  9. Boyle J. Medical ethics and double effect: the case of terminal sedation. Theor Med Bioeth. 2004;25(1):51-60.
  10. McStay R. Terminal sedation: palliative care for intractable pain, post Glucksberg and Quill. Am J Law Med. 2003;29(1):45-76.
  11. Cantor NL. Twenty-five years after Quinlan: a review of the jurisprudence of death and dying. J Law Med Ethics. Summer 2001;29(2):182-196.
  12. Meisel A, Snyder L, Quill T. Seven legal barriers to end-of-life care: myths, realities, and grains of truth. Jama. Nov 15 2000;284(19):2495-2501.
  13. Wineberg H, Werth JL, Jr. Physician-assisted suicide in Oregon: what are the key factors? Death Stud. Jul 2003;27(6):501-518.
  14. Washington v. Glucksberg, 96-110 (USSC 1997).
  15. Mariner WK. Physician assisted suicide and the Supreme Court: putting the constitutional claim to rest. Am J Public Health. Dec 1997;87(12):2058-2062.
  16. Oregon Death with Dignity Act, 127.800 §1.01 to 127.897 §6.01 (2003).
  17. Vacco v. Quill, 95-1858 (USSC 1997).
  18. Constitution of the United States.
  19. Ashcroft v. State of Oregon 2004).
  20. State of Oregon v. John Ashcroft, 02-35587 6601 (Court of Appeals for the Ninth Circuit 2004).
  21. AP. Ashcroft asks Supreme Court to block assisted suicide law. Nov 11, 2004. Available at: http://www.cnn.com/2004/LAW/11/10/scotus.assisted.suicide.ap/index.html. Accessed Nov 11, 2004.
  22. AP. White House Wants Suicide Law Blocked. Nov 10, 2004. Available at: http://www.nytimes.com/aponline/national/AP-Scotus-Assisted-Suicide.html?oref=login. Accessed Nov 10, 2004.
  23. Johnson D. Kevorkian Sentenced to 10 to 25 Years in Prison. New York Times. April 14, 1999;A: 1.
  24. Grace J. Curtains for Dr. Death: after assisting 130 suicides since 1990, Jack Kevorkian is found guilty of a murder in Michigan. Time. Apr 5 1999;153(13):48.
  25. Marker R, Hamlon K. Prisoner number 284797. Hum Life Rev. Summer 1999;25(3):65-76.
  26. Emanuel EJ, Fairclough DL, Daniels ER, Clarridge BR. Euthanasia and physician-assisted suicide: attitudes and experiences of oncology patients, oncologists, and the public. Lancet. Jun 29 1996;347(9018):1805-1810.
  27. McIntyre A. The double life of double effect. Theor Med Bioeth. 2004;25(1):61-74.
  28. Harvey MT. What does a 'right' to physician-assisted suicide (PAS) legally entail? Theor Med Bioeth. 2002;23(4-5):271-286.
  29. Hawking S. Professor Stephen Hawking's website. Available at: http://www.hawking.org.uk/home/hindex.html. Accessed Nov 1, 2004.
  30. Whitehouse D. Black holes turned 'inside out'. BBC News Online. 22 July 2004. Available at: http://news.bbc.co.uk/1/hi/sci/tech/3913145.stm. Accessed Dec 1, 2004.
  31. Boehnlein JK. The case against physician assisted suicide. Community Ment Health J. Feb 1999;35(1):5-14.
  32. Hendin H. Summary for Congressional Subcommittee on the Constitution Suicide, Assisted Suicide and Euthanasia: Lessons From the Dutch Experience. House Judiciary Committee. April 29. Available at: http://www.house.gov/judiciary/2169.htm. Accessed November 22, 2004.
  33. Gittelman DK. Euthanasia and physician-assisted suicide. South Med J. Apr 1999;92(4):369-374.
  34. van der Maas PJ, van der Wal G, Haverkate I, et al. Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. N Engl J Med. Nov 28 1996;335(22):1699-1705.
  35. Hendin H, Rutenfrans C, Zylicz Z. Physician-Assisted Suicide and Euthanasia in the Netherlands. JAMA. June 4 1997;277(21):1720-1722.
  36. APHA. Public Health Code of Ethics. APHA. Available at: http://apha.org/codeofethics/ethics.htm. Accessed Nov 26, 2004.
  37. U.N. Universal Declaration of Human Rights. U.N. Available at: http://www.un.org/Overview/rights.html. Accessed Nov 26, 2004.
  38. Lavery JV, Dickens BM, Boyle JM, Singer PA. Bioethics for clinicians: 11. Euthanasia and assisted suicide. Cmaj. May 15 1997;156(10):1405-1408.
  39. Werth JL. Using the Youk-Kevorkian case to teach about euthanasia and other end-of-life issues. Death Stud. Mar 2001;25(2):151-177.
  40. NHPCO. The Development of Hospice. National Hospice and Palliative Care Organization (NHPCO). 2002. Available at: http://www.nhpco.org/i4a/pages/index.cfm?pageid=3253&openpage=3253. Accessed 24 February, 2004.