capstone official final paper

!2

Mission Statement …………………………………………………….………………………………………………. 4

Introduction …………………………………………………………………………………………………………… 5

Chapter 1 - The Netherlands and Oregon ………………..………………………………………………………….. 10

1.1 Legalization of Euthanasia in the Netherlands: A Medical Viewpoint……..……………………………

1.2 Categories of Euthanasia ………………..…………………………..…………………………………..

1.3 Legalization of PAS in Massachusetts: A Medical Viewpoint …….……………………………………

1.4 Medications Involved in PAS ……..……………………………………………………………………

1.5 Released Medical Statistics: Death with Dignity in Oregon ……………………………………………

Chapter 2 - Legal Aspects ………………………………………………………….……………………………….. 24

2.1 Background on the Legality of Physician-Assisted Suicide .……………………………………………

2.2 The History of Euthanasia from a Legal Perspective ……………………………………………………

2.3 Religious Opposition to PAS …….………………………………………………………………………

2.4 Euthanasia Legislation in Europe ………………………………………………………………………..

2.5 PAS and the Supreme Court ……..………………………………………………………………………

2.6 Oregon Leads the Way …..………………………………………………………………………………

2.7 Medical Options for Massachusetts …..…………………………………………………………………

2.8 PAS: Unregulated Dangers ………………………………………………………………………………

Table of Contents

choice Amanda Harrington | Anna Dreyer | Candice Shadgoo

Ehis Osifo | Madison Palms | Nona Haller | Robert Baillargeongroup

!3choice

groupAmanda Harrington | Anna Dreyer | Candice Shadgoo


Chapter 3 - Ethical Aspects …………….………………..………………………………………………………….. 38

3.1 Background Information on the Ethics Behind PAS …….……………………………………………….

3.2 Objections to PAS …………….……………………………………..……………………………………

3.3 Support For PAS ………………………………………………………………………………………….

3.4 Dr. Kevorkian: Sinner or Saint? ………………………………………………………………………….

3.5 A Case Study: Brittany Maynard …………………………………………………………………………

3.6 Final Thoughts on Ethical Argument …………………………………………………………………….

Final Policy Recommendations ..….………………………………….……………………………………………… 51

Appendix ….…………………………………………………………………………………………………………. 54

Glossary …………………………………………………..………………………………………………………….. 66

Bibliography ……………………………………………..……………………………………………………………69

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CHOICE, the Coalition for Honor, Opportunity, Independence, and Choice in

Euthanasia, is represented by seven individuals. When the suffering becomes

unbearable, CHOICE believes that patients should have the right to choose whether to

let the disease take its course or to take immediate relief. Our group is a nonprofit

organization, which seeks to provide an option of a death with dignity. At this time, we

are proposing a referendum, which revisits the legalization of physician-assisted

suicide, for the 2018 ballot in the Commonwealth of Massachusetts. In addition to a

proposed re-vote, CHOICE believes that essential changes must be made to the

previous proposal in order to specify requirements for the Death with Dignity Act.

Our Mission

choicegroup



!5

Introduction


Ehis Osifo | Madison Palms | Nona Haller | Robert Baillargeonchoice

group

Abstract

Physician-assisted suicide (PAS) has been a controversial practice in the historical, legal,

ethical, and medical communities. At this time, the option to legalize PAS has been presented to

the voters of Massachusetts twice. However, both times, the referendum failed to gain sufficient

support. In order to persuade Massachusetts voters and the Massachusetts government that

assisted suicide should be an option for consenting adults who are terminally ill and experiencing

unbearable pain, this paper examines the traditional objections and the expected benefits.

Accordingly, this paper will trace the historical routes of euthanasia, and specifically PAS. Our

proposal will review the methods of euthanasia and PAS, as they apply to the Netherlands and

Oregon. Furthermore, by deconstructing the ethical arguments surrounding the PAS controversy,

we intend to illustrate why this specific form of euthanasia is not meant to devalue life or exploit

the rights of the terminally ill. In order to advocate for an ideal model for Massachusetts to

follow, we intend to examine the legal ramifications and medical protocol involved in PAS. The

goal of this paper is to guide public opinion, particularly the legal, medical, and philosophical

communities, that legalizing PAS in Massachusetts merely expands a patient’s rights, and thus

should be ratified without question.

Introduction

PAS has a long and controversial history. In recent years, Massachusetts has rejected two

bills, which would legalize PAS for terminally ill and suffering individuals. CHOICE, the

Coalition for Honor, Opportunity, Independence, and Choice in Euthanasia seeks to create a

referendum that would allow doctors to prescribe lethal drugs to terminally ill patients who

!6

request a peaceful way to end their suffering. In order to explain the importance of this legal

action, our group, CHOICE, plans to address the concerns raised in previous debates on PAS.

Moreover, we seek to explore the medical, legal, and ethical ramifications of adopting this new

legislation and explain why we support an individual’s right to die.

PAS is divided into several categories: active euthanasia, passive PAS, voluntary PAS and

involuntary PAS. Physicians frequently help to guide patients concerning treatment methods.

Often, these choices lead to a patient’s death, either by withdrawing or withholding treatment

that would prolong life for a short period of time. This type of passive PAS is typically less

controversial than prescribing medication to patients for voluntary PAS. At CHOICE, our goal is

to legalize PAS, in order to provide more end of life options and rights for suffering patients.

PAS is very controversial: the medical dilemmas must be understood and addressed in

order for voters to make an informed choice that will create a groundbreaking and purposeful

legislation. CHOICE seeks to provide strict guidelines for the process and protocol of PAS. By

reviewing the medical guidelines in different states and countries, we hope to create a working

framework for the Commonwealth of Massachusetts. It is important to develop a criterion that

patients must meet in order to screen patients and ensure that life is not devalued. By creating a

clear code, we hope to negate the possibility of exploitation and abuse of PAS. Some of the

dilemmas we will explore involve individuals who change their mind after beginning the

screening process or individuals whose illness prevents them from fully ingesting the prescribed

substance. Part of the information we seek to disseminate includes documented opinions from

doctors, nurses, social workers, and patients. As a result, we aim to give a varied and thorough

analysis of the situation through a medical lens.

!7

A look at recent legal cases in the United States will help our organization frame the

referendum that we are proposing, in a way that will clarify the legal issues regarding PAS in

Massachusetts. Two cases in particular, Washington v Glucksberg and Vacco v Quill, demonstrate

the Supreme Court’s opinion that the Fourteenth Amendment does not include the right to die.

Therefore, all laws pertaining to PAS should be decided on a state level. Our organization strives

to make the referendum clearer and palatable for the voters of Massachusetts by proposing a

prototype for PAS. This will be modeled after Oregon’s framework, rather than the broader

defined practices in nations, such as the Netherlands. Once again, CHOICE would like to

emphasize that the proposed referendum would not require a terminally ill patient to make use of

the pill, but rather gives that individual the option of a death with dignity. We would also like to

clarify that, as our proposed legislation would have specific criteria patients would have to meet,

there will be individuals seeking PAS who would not be eligible.

When composing this referendum, our organization explored the ethical aspects of PAS.

Currently, only four U.S. states have legalized PAS, as many voters label assisted death practices

as murder. However, we feel that PAS is a human right, when performed in accordance with the

regulations. If a patient is terminally ill and his or her quality of life is abysmal, that patient

should have the right to end his or her suffering. Looking at cases concerning PAS, we reviewed

German thinkers such as Haeckel, Jost, Binding, and Hoche. CHOICE would like to emphasize

that we do not advocate for forced PAS as a means of selectively shaping society. Our

organization is merely providing feeble patients with another option for dealing with pain.

Although many wish to prolong a life despite the cost, we argue that forcing an individual to

finish out his or her life in pain is unethical.

!8

By addressing the medical, legal, and ethical perspectives of PAS, we hope to educate

the voters prior to the impending referendum. We are confident that this thorough examination

will persuade the citizens of Massachusetts to vote in favor of this referendum. A referendum that

will give terminally ill and suffering patients, who meet all of the criteria, the option to choose a

relatively quick and painless death.

!9

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Chapter 1 The Netherlands & Oregon

groupchoice Amanda Harrington | Anna Dreyer | Candice Shadgoo


As CHOICE develops a new initiative for PAS in Massachusetts, Oregon will serve as the

primary model to demonstrate both the practicality of PAS, as well as illustrate its procedures. In

1977, Oregon, Arkansas, California, Idaho, New Mexico, Nevada, North Carolina, and Texas

ratified the Right to Die Bill; a bill that advocated for the right to refuse treatment in order to

prolong a life. However, the 1977 legislation did not allow doctors, through artificial means, to

assist in ending a life. It was not until November 8, 1994, when Oregon’s Death With Dignity

Act passed, that PAS was first legalized in the United States (ProCon.org 16). Under this

legislation, doctors have the right to prescribe lethal medications to terminally ill patients who

are granted permission for assisted suicide. This act calls for a differentiation between suicide

and PAS, protecting the legal rights of patients who seek a trained physician to allow for a death

with dignity (ProCon.org 16). This need to create a fair legal response to the demand for PAS

directly impacts medical protocol.

In order to be eligible to acquire lethal medications, the Death with Dignity Act has a

strict protocol that each individual must adhere to. If a terminally ill patient voluntarily wishes to

die, he or she must meet the following four qualifications: “[he or she must be] an adult (age 18

or older), [he or she must be] an Oregon resident, [he or she must be] capable (able to make and

communicate health care decisions), and [he or she must be] diagnosed with a terminal illness

(incurable and irreversible) that will lead to death within six months” (Marker 15). In spite of the

change in legislation, the number of patients who have successfully applied for and received the

lethal medications involved in PAS remains relatively low, as the state itself makes the process

long and challenging in order to avoid abuse. Even if patients were to meet all four of the

qualifications, they would still be required to follow elaborate testing to ensure sanity. Within

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two fifteen-day periods, the patient is required to make two oral demands to a licensed Oregon

physician, requesting a prescription for lethal medication. After these requests are noted, the

prescribing physician and a separate, consulting physician must determine and confirm whether

the patient is eligible for assisted suicide. If either the prescribing or the consulting physician

were to believe the patient’s decision is impaired by a psychiatric disorder, they must require the

patient to undergo a psychiatric examination. Once a patient receives clearance for assisted

suicide under the Death with Dignity Act, the prescribing physician must present the patient with

other alternatives to assisted suicide. These alternatives include pain control as well as either

hospice or comfort care. Lastly, once a decision has been reached, the patient must notify his or

her relatives and the prescribing physician must report the prescription to the Oregon Health

Services. In order for a terminally ill patient to receive the needed medications, all of the given

prerequisites must be completed prior to the assisted suicide. By following the Death with

Dignity Act, both the patients and the physicians are protected from criminal prosecution.

1.1 Legalization of Euthanasia in the Netherlands: A Medical Viewpoint

Because there are a variety of assisted deaths, confusion tends to permeate across all

discussions. PAS is when a physician prescribes a patient with a lethal medication to use at his or

her own discretion (The World Federation of Right to Die Societies 1). However, euthanasia is

when a doctor plays a direct part in the patient’s death by injecting them with lethal medications

(The World Federation of Right to Die Societies 1). Additionally, the term “assisted suicide” in

relation to Oregon’s Death with Dignity Act possesses a different definition than other medical

cases concerning euthanasia, such as those seen in the Netherlands. On April 1, 2002, the Dutch

Senate voted 46 to 28 to legalize this process, making the Netherlands the first country to

!12

legalize euthanasia. Looking at the medical aspects of euthanasia in the Netherlands helps

provide our organization, CHOICE, with the building blocks for our proposed referendum.

In the Netherlands, euthanasia is defined as the termination of life by a doctor at the

request of a patient. This does not mean discontinuing treatment when further care is no longer

effective in preserving life. In order to balance the needs of patients and the objective of doctors,

the Dutch government carefully restricted access to and performance of euthanasia.

Consequently, the government included an exemption from criminal liability in the Dutch

Criminal Code. This inclusion gives immunity to the doctors who assist in a patient’s death,

providing that they satisfy the policy of due care and that they notify the regional euthanasia

review committee. In an effort to keep the policy credible, the Netherlands government stated

that they wished to, “bring matters into the open, to apply uniform criteria in assessing every

case in which a doctor terminates life, and to ensure that maximum care is exercised in such

exceptional cases” (Netherlands Ministry of Foreign Affairs 2). Far from devaluing life,

Netherlands’ policy seeks to give the best care to a patient by offering every opportunity to treat

and ease suffering.

Nevertheless, after its legalization, euthanasia is still considered a criminal offense in the

Netherlands. However, the Dutch Criminal Code has been amended to exclude doctors from

responsibility if they disclose of their actions and show that they have followed the criteria

reported in the act. In order to prevent abuse of this procedure, “the actions of doctors in such

cases are assessed by review committees (appointed by the Minister of Justice and the State

Secretary for Health, Welfare and Sport)” (Netherlands Ministry of Foreign Affairs 2). Yet, not

every case of euthanasia will earn a doctor immunity, as the Dutch policy states that the

!13

government intends to scrutinize the execution of this option. Moreover, in those cases, “where a

review committee finds that a doctor has failed to satisfy the statutory due care criteria, the case

will be notified to the Public Prosecution Service and the Healthcare Inspectorate” (Netherlands

Ministry of Foreign Affairs 2). Although the Dutch government’s legislation seeks to maintain

maximum care for all patients, it does not wish to cause discomfort among physicians that wish

to help patients who are eligible for euthanasia. In this way, committees that review cases

involving euthanasia will include doctors as, “research has shown that doctors are more likely to

report cases of euthanasia if their own peers have a hand in the initial review of

them” (Netherlands Ministry of Foreign Affairs 5). The Dutch Euthanasia Act considers the

welfare of patients and their medical advisors. The Act’s practicality provides strict criteria for

euthanasia and reveals a possible model for the Massachusetts government to follow.

Some of the success of the Dutch Euthanasia Act may be seen through the results of

studies, which document the feelings of patients and health care professionals concerning

euthanasia. Since the legalization of euthanasia, the Netherlands University Medical Center

conducted a study to survey health care professionals and the general public concerning their

views on the Dutch Euthanasia Act. Some of the feedback referenced traditional arguments for

the support of euthanasia; such as, relief of unbearable suffering and respect for a patient’s

freedom. Moreover, much of the support came from the legislation’s emphasis of careful and

transparent practice. Of the general public that was surveyed, majority favored the right to

euthanasia. However, most professionals and some members of the general public expressed

hesitancy concerning the boundaries of euthanasia (Kouwenhoven 6).

!14

Although concordance is easily reached for patients faced with unbearable physical

suffering, that agreement splinters when discussing “early dementia, depression and being tired

of living” (Kouwenhoven 6). There seems to be a consensus that the quality of life should

depend more upon physical limitations than mental and emotional distress. However, in some

cases, the public and healthcare professionals do feel that euthanasia and PAS might be

appropriate, as seen in patients with advanced dementia, who have previously outlined their

desire for assisted death with such a diagnosis. The desire to end one’s life, if mental faculties

prevent meaningful interaction with the world, gained approval with the public and some health

care workers, but was frowned upon by numerous physicians. Although dementia proves to be a

controversial area, the study concluded that in the Netherlands, the Dutch Euthanasia Act holds

sufficient support from both healthcare professionals and the general public.

Similar Dutch studies confirm the acceptance of euthanasia in the Netherlands. According

to a study conducted by the Netherlands Department of Public Health, after two decades of

research on euthanasia, results have demonstrated that an end-of-life decision is a significant

aspect of end-of-life care: “in approximately 4 out of every 10 patients, death is preceded by a

decision that possibly or certainly hastened their dying process” (Rietjens 20). The results

indicate that high quality end-of-life care should not solely focus on prolonging a patient’s life at

all costs. Rather, high quality care may also be aimed towards improving the quality of life

through the prevention and relief of symptoms. Moreover, the study demonstrates that public

control and accountability of the practice of euthanasia is possible. Statistics reveal that a

growing number of physicians abide by the notification procedure. This developing trust in the

system can be traced, as “in 1990, 18% of the cases of euthanasia were reported, [and] this

!15

percentage has increased up to 80% in 2005” (Rietjens 20). The study underscores the successful

implementation of the Netherlands’ legal requirements, and suggests that the law ensures a stable

and open environment to prevent abuse and to provide patients with the best healthcare possible.

Medical studies in the years since the legalization of the Dutch Euthanasia Act weaken

the central arguments against the legalization of euthanasia. For example, claims that euthanasia

will result in a slippery slope has been proven groundless. Apart from religious or principal-

based arguments, the slippery slope argument serves as the central argument against the

legalization of euthanasia and without it, the focus remains where it should be: on a patient’s

well-being. As demonstrated in a study done by the Netherlands Department of Public Health,

patient request for euthanasia did not increase between 1990 and 2005. In spite of the anxiety

that PAS would be used to exploit vulnerable minorities, “there is no evidence for a higher

frequency of euthanasia among the elderly, people with low educational status, the poor, the

physically disabled, people with psychiatric illnesses, or ethnic minorities” (Rietjens 20). In fact,

the two studies conducted by the Netherlands University Medical Center and by the Netherlands

Department of Public Health reveal that overall, physicians uphold the legal code, which, “has

improved their legal certainty and contributes to the carefulness of life-terminating

acts” (Rietjens 1). In this way, the Euthanasia Act may be considered a thoughtful and successful

way to ensure the rights of both patients and physicians.

In conclusion, the Dutch Euthanasia Act serves as a groundbreaking legal endeavor to

provide physicians with immunity when aiding the suicides of consenting eligible terminally ill

patients. The legislation not only creates stringent criteria for consideration when requesting

PAS, but also creates specific protocol for executing this last resort and fairly reviewing the

!16

cases. As studies reveal the success of the Dutch Euthanasia Act and the overall approval of the

public and medical profession, the Netherlands’ legal decision concerning PAS may be seen as

one possible model for Massachusetts.

1.2 Categories of Euthanasia

Doctor Ezekiel J. Emanuel proposed to break down the medical decisions concerning

euthanasia into six different categories. Based on the patient’s ability to consent, the physician’s

actions and intent, there are different terminologies that can be used to describe the situation:

voluntary/involuntary/non-voluntary active euthanasia, terminating life-sustaining treatments

(also known as passive euthanasia), and PAS (Lunge et al. 3). Although CHOICE intends to only

legalize PAS in Massachusetts, it is important to understand the boundaries concerning assisted

death by learning about the umbrella options for euthanasia. Voluntary active euthanasia occurs

when a patient self-administers medications that cause death; the term also applies when the

patient requests this medication that they will then ingest. On the other hand, involuntary active

euthanasia allows a patient to receive lethal medications although the patient did not explicitly

request for the prescription. Non-voluntary active euthanasia completely separates itself from all

forms of prescribed death because medication can be administered to a patient even if he or she

is mentally incapable of request. An example of this form of euthanasia could concern a

terminally ill patient is in a coma who cannot decide for himself whether or not to request death.

On another note, terminating life-sustaining treatments refers to the act of withdrawing or

withholding medical treatments from a patient, thus leading to the patient’s death. All of the

terms and actions stated above are not legalized under Oregon’s Death With Dignity Act.

However, PAS is the only legal option for Oregon residents. As defined by Emanuel, physician

!17

assisted suicide is “a physician providing medications or other interventions to a patient with

understanding that the patient intends to use them to commit suicide” (Lunge et al. 3). The act

does not “authorize a physician or any other person to end a patient’s life by lethal injection,

mercy killing or active euthanasia” (Lunge et al. 4). The Death With Dignity Act only authorizes

PAS by lethal prescription but rejects all other forms of euthanasia.

1.3 Legalization of PAS in Massachusetts: A Medical Viewpoint

If Massachusetts adopts legislation allowing for PAS, the government should take care to

balance the necessary checks to prevent abuse with excessive bureaucracy that sabotages the

intent of this option. As the process of clearing a patient can take several weeks, statistics report

the low actuality of terminally ill patients actually undergoing assisted suicide. Since health care

systems are under no obligation to partake with the Death with Dignity Act, assisted suicide

cannot affect life insurance policies. Moreover, Oregon Health Services have created a reporting

system that lists every physician who has prescribed any type of lethal medication, as well as the

number of patients who die from assisted suicide (See Figure 1).

Although terminally ill patients may meet all of the four qualifications and be granted the

right to assisted suicide, they might not actually ingest the prescribed pills. During the first three

years after the Death with Dignity Act was legalized, assisted suicide remained a rarity. The

numbers of PAS deaths continued to be quite moderate (See Figure 1). Although from 1998 to

1999 the number of recorded assisted deaths increased by 59%, there was a 0% increase from

1999 to 2000 (Oregon Public Health Division 1). These findings illustrate that any concerns that

patients will abuse the Death with Dignity act are irrelevant. Although, since 1997 to modern

times, the rate of deaths from assisted suicide has increased 443%, the actual number of deaths,

!18

71 people in 2013, is quite modest (Oregon Public Health Division 1). According to Oregon’s

Public Health records, only 112 lethal medication prescriptions were written for a 122 people

during the year 2013, only six people more than the 116 prescription in 2012. The most recent

data released from the Oregon’s Public Health was from January 22, 2014; this released the

statistic that out of every 10,000 deaths due to terminally ill Oregon residents, only 21.9 deaths

correspond with the Death With Dignity Act (Oregon Public Health Division 4). Regardless of

the limited number of individuals actually following the process of PAS from first request to

death, Oregon’s decision remains significant for guaranteeing patient and doctors’ rights. It is

these rights that our organization seeks to uphold with our proposal for Massachusetts.

1.4 Medications Involved in PAS

It is helpful when creating any proposal concerning PAS to discuss the lethal medications

involved. The two most common medications prescribed for PAS in Oregon are “secobarbital”

and “pentobarbital” (Fass 1). Only 90 grams of a secobarbital capsule and 10 grams of

pentobarbital liquid need to be consumed at one time in order for each patient to die a painless,

non-suffering death. In order for the patient to avoid its bitter taste, both the pentobarbital liquid

and the secobarbital capsule should be mixed with any sweet juice. There are strict rules and

regulations regarding the medication; it must be stored, out of reach from both the patient and

children. This prevents any substance abuse or unintentional overdose. Under the Death With

Dignity Act, the prescribing physician, as well as the pharmacist, must instruct each patient of

the proper steps to consuming the toxic pill. To avoid the probability of vomiting and nausea one

should take each dose on an empty stomach and follow up the medication with an antiemetic.

After ingesting the medication, if a patient decides that he or she no longer wishes to partake in

!19

assisted suicide, he or she can contact emergency medical services to partake in lifesaving

procedures (Fass 1). In this way, Oregon has provided a valuable model on how to prolong life

for a patient who changes his or her mind after requesting and consuming death-inducing

medication.

The disposal of these lethal medications is crucial. Accidental consumption from a third

party, especially children, would be lethal. The Food and Drug Administration of Oregon

mandates every patient taking these medications to be well informed of proper disposal

techniques. Both the pentobarbital and secobarbital drugs cannot be disposed though flushing or

a drain. Rather, the FDA encourages patients to mix the drugs with coffee grounds before

disposing them in the household garbage (Fass 1). Mixing the unused medications with an

unpalatable substance avoids an accidental consumption. Pharmacists are also required to create

a dispensing record every time they need to discard the prescription. Within a ten-day period

since the disposal, pharmacists must report to the Oregon Department of Human Services. This

must include: “the patient's name and date of birth; the prescribing physician's name and phone

number; the pharmacist's name, address, and phone number; the medication and quantity

dispensed; and the dates the prescription was written and dispensed” (Fass 1). By including this

detailed information, there is a lesser chance of accidental consumption and prescription abuse.

Our proposed referendum aims to mimic these security measures to, once again, prevent abuse

and the accidental killing of healthy individuals.

1.5 Released Medical Statistics: Death with Dignity in Oregon

When discussing the medical ramifications of PAS, the most recent information remains

the most vital; therefore, we will be using Oregon’s released statistics from the years 1997 until

!20

2014. In the year 2014, there were 105 deaths that fell under the Death With Dignity act (Oregon

Public Health Division 1). Of those 105 individuals, it has been made apparent that 67.6% were

senior citizens, who aged 65 years or older (Oregon Public Health Division 2). Only one person

between the ages of eighteen to thirty-four requested for lethal prescription in 2014 (Oregon

Public Health Division 4). Throughout the entirety of legalization of assisted suicide, 1998-2014,

only 7 persons from the ages eighteen to thirty-four have actually died from ingesting lethal

doses of medication (Oregon Public Health Division 1). The characteristics of the patients who

died from assisted suicide tend to be quite similar: white (97.1%), married (46.1%), with a

baccalaureate degree or higher (45.9%). 93.0% of those who choose to take the poisonous pill

are enrolled with hospice care (Oregon Public Health Division 2). Those individuals are more

likely to undergo assisted suicide than those who have Medicare, Medicaid, or no insurance

(Oregon Public Health Division 2). Although assisted suicide is an option for those who are

terminally ill, only a very few, specific individuals actually partake in the act.

CHOICE’s Personal Interviews with a Registered Nurse and a Social Worker

As part of gaining a balanced view of PAS, CHOICE interviewed a Social Worker-Case Manager

as well as an acute pediatric registered nurse, who is also a certified public health nurse CNII.

Our group asked both individuals the same questions and received drastically different responses

that illustrated the range of perspectives on PAS.

Sandra Shadgoo, RN BSN PHN CNII, who is certified in California, explained that she

does not agree with PAS or Oregon’s Death with Dignity Act. Part of her objection stems from

religious reasons, and part from an insistence that no diagnosis remains “set in stone” (Shadgoo

1). She considers the oath to preserve life as a tenant that should not be trifled with, and insists

!21

that while she, “believe[s] that a patient should have a death with dignity and without

pain” (Shadgoo 1). However, she does not support PAS because she believes that patients “never

know when something can turn in their favor” (Shadgoo 1).

In contrast, Emily Wallace, a Social Worker-Case Manager who is certified in both New

York and Colorado, considers Oregon’s Death with Dignity Act to be “an amazing option for

individuals who are enduring the tragic effects of debilitating and terminal illnesses. It always

someone control…” (Wallace 1). While Ms. Wallace does not support PAS in all cases, she

believes that “there should be a reasonable amount of suffering and quality of life lost in order

for someone to qualify…” (Wallace 1). In addition to discussing the emotional rollercoaster

experienced by both the terminally ill patient and his or her family, Ms. Wallace mentions the

appropriateness of a protocol to safeguard those individuals who wish for PAS. In fact, Ms.

Wallace overturns some of the stereotypes associated with the psychological and emotional

profiles of individuals desiring PAS, claiming that, “[she] do[es] see a lot of people WITH a

great deal of family support [who] want it all to ‘end’ because they worry about being a burden

to their family…” (Wallace 2).

Both interviews explored the differing interpretations concerning the appropriateness of

PAS. When Massachusetts reviews the information prior to deciding whether or not the

referendum appears on a ballot, the legislature should note that PAS serves as merely one option.

Whereas Sandra Shadgoo, RN BSN PHN CNII, works to strengthen the patient’s mind and offer

care and comfort to both patients and families, Emily Wallace prioritizes a patient’s control. We,

at CHOICE, endorse the positive aspects of a patient directing his or her last days. While we

accept aspects of both mindsets of the two interviewees and understand that by choosing PAS, a

!22

patient may preemptively rule an unexpected positive change to their diagnosis, we feel that for

most patients, having the option of PAS outweighs the minute probability of a medical miracle.

When considering our group’s proposal to allow for consenting adult terminally ill patients to

request PAS, the Commonwealth of Massachusetts does not need to deeply explore other forms

of euthanasia. We specifically seek legalization of only one form of euthanasia, and in fact prefer

that this request be heavily regulated to prevent abuse. However, looking at the Oregon and

Dutch models reveals that any legislation must balance the needs of both patients and doctors. As

it is, very few patients actually choose to die through physician-prescribed lethal medication.

Nevertheless, PAS, which gives death with dignity, should fall under an individual’s right to die.

!23

!24

Chapter 2 Legal Aspects



group

2.1 Background on the Legality of Physician-Assisted Suicide

In order to best express the legal aspects behind PAS, if adopted by the Commonwealth

of Massachusetts, CHOICE feels that it is useful to review the historical and legal situation.

Accordingly, this section will provide an overview of the Fourteenth Amendment’s use in

assisted suicide appeals, and the ensuing decisions of both the federal and state courts. Moreover,

we aim to clarify the legal distinctions between euthanasia and PAS, both for the Netherlands

and for the United States, such as Oregon. Additionally, we seek to review the ramifications of

the Americans with Disabilities Act, the Rehabilitation Act, and the Religious Freedom

Restoration Act, as they apply to patients battling for the right to choose PAS. Also, this chapter

will show the statistics raised in the medical and ethical portions of the research from a legal

perspective, as we look at challenges to requests for PAS. Finally, CHOICE plans to discuss the

opinions of the Massachusetts Medical Society and religious leaders in order to show the current

political climate in Massachusetts concerning PAS.

In general, the Fourteenth Amendment has been used as a rallying point for individuals

seeking to establish rights. However, thus far, the Supreme Court has been reluctant to assert the

correlation between PAS and either the Due Process Clause or the Equal Protection Clause. For

example, in the Washington v Glucksberg case, the Supreme Court left the individual states in

charge of determining the legality of PAS, asserting that the right to assistance in committing

suicide is not a correct interpretation of fundamental liberties protected by the Fourteenth

Amendment (Lunge et al. 8). Similarly, in the Vacco v Quill case, the Supreme Court made it

clear that the New York State government’s prohibition of assisted suicide does not conflict with

the Equal Protection Clause of the Fourteenth Amendment. This court case affirmed the Supreme

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Court’s earlier decision that legislation concerning PAS remains the prerogative of the states

rather than that of the federal government.

With the federal government upholding states’ rights, each state deals with an

examination of the legal, medical, and ethical issues of PAS in its own way. As Oregon debated

ratifying the Death with Dignity Act, controversy grew over the difference between the broad

range of euthanasia categories and the specific form of assisted suicide covered by the act.

Whereas in the Netherlands different groups adopt a variety of terminology to specify various

types of euthanasia, in Oregon, the Death with Dignity Act specifically refers to assisted suicide

by a qualifying consenting adult, who is also an Oregon resident, has decision-making ability,

and suffers from a terminal disease which will directly end his or her life within six months

(Lunge et al. 5).

Even after its adoption, Oregon’s Death with Dignity Act faced challenges. Lee v Oregon

served as an important milestone. In this case, the plaintiff argued that the Death with Dignity

Act violated equal protection and due process rights under the Fourteenth Amendment, as well as

rights under the Americans with Disabilities Act, the Rehabilitation Act, and the Religious

Freedom Restoration Act. The court expressed issues with the act and placed an injunction on a

patient’s right to PAS (Lunge et al. 5). The controversy continued for several years, as the

legality of the act was debated on the state level, and ultimately reached the United States

Supreme Court.

Any successful legislation concerning PAS in Massachusetts must take into account the

current political opinions of influential figures. The Massachusetts Medical Society rejects any

proposed amendments to Massachusetts law because they feel that PAS conflicts with a

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physician’s role to save lives. Other opponents of PAS include Cardinal Sean O’Malley, who

considers PAS a savage means of aiding suicide and murder. While we respect the Cardinal’s

beliefs, CHOICE would ask Cardinal O’Malley and others like him to respect the wishes and

needs of patients who experience first-hand unbearable pain. Their desire for PAS is different

than the motives of a typical suicide. Ultimately, we wish to illustrate, by reviewing the historical

legal issues and the current status of PAS, the feasibility and necessity for adopting a Death with

Dignity Act in Massachusetts.

2.2 The History of Euthanasia from a Legal Perspective

The methods of euthanasia and PAS date back to the empires of ancient Greece and Rome, where

they were widely practiced. Although suicide was considered illegal without proper government

authorization, individuals with severe illnesses could request approval from the Senate to carry

out legal physician-assisted suicides. “Physicians felt obligated to abate the harshness of disease

and ease the patient’s suffering” (HO 318). The approval process, while much simpler than those

written in the laws today, is similar to the Dutch Euthanasia Act and Oregon’s Death with

Dignity Act. The individual would explain to the Senate the reasons that made life intolerable to

him or her, and then the Senate would either grant or deny suicide. If the person decided to take

matters into his or her own hands and commit suicide without approval, there would be severe

consequences, including an unceremonial burial and condemnation of his or her family name.

Beyond the legal aspects of euthanasia and suicide, religion and the Church’s view of suicide

played a major role in England during the early 1800s. Suicide in England during this time was

seen as a direct offense against God and the King. Furthermore, punishment for committing the

act was much more horrific than in ancient Greece or Rome. “English custom mandated

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dragging the ‘suicide’s body, pierced crossways with a stick, through the streets and burying it on

a highway without any ceremony’. Sometimes the heart was removed from the body as a sign of

disrespect” (HO 320). While harsh punishment existed, there were exceptions to the law. The act

of suicide was excused if the person was deemed insane, or if a woman committed the act “in

order to escape a violation of their chastity” (HO 320). Despite exceptions, suicide was strongly

opposed by the Church of England and perceived as a “conscious act of the will against God’s

authority” (HO 320). Since the ancient societies of Greece and Rome, the methods of euthanasia

and PAS have progressed and evolved immensely, becoming a growing topic of debate and

controversy in places across the world.

2.3 Religious Opposition to PAS

Religion, morality, and personal opinion have all played a role in the debate of whether to

legalize PAS for suffering individuals. Supporters have relied heavily on personal stories of

terminally ill people who have experienced unfathomable pain and seek PAS as an option. In

addition, proponents believe that they should have the right to decide whether they want to die.

While supporters fight to merely legalize PAS, the opposing effort has grown even stronger.

Opponents of PAS include numerous groups and organizations such as the Catholic Church and

pro-life groups, not to mention all of the individual opposition. These groups argue that there

should not be a right to die and that legalizing such a medical option would lead to a slippery

slope, in which physicians might persuade ill patients to take the “easy way out,” avoiding all

palliative care.

Additionally, the Catholic Church is adamant that such a practice is a direct offense

against God and should therefore not be legalized. Even others disagree with the guidelines of

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the approval process that one must undergo in order to be granted the opportunity to perform

PAS. Although quite complex, the approval process itself has been a serious hurdle for

proponents of the act. Furthermore, the federal government has left it up to the states to decide

whether or not they wish to legalize PAS. Due to its extreme controversial nature, many lawyers

and politicians have stayed away from the topic at the state level. At the current stage, it seems as

though it will be a matter of time or determination before more states consider the act and put it

on the ballot. Throughout the next few subsections of our paper, we will explore the legality of

PAS in Europe and the United States, and explain why CHOICE believes that PAS should be

voted on once again in the Commonwealth of Massachusetts.

2.4 Euthanasia Legislation in Europe

Although the Dutch Euthanasia Act was passed on April 1, 2002, euthanasia and PAS

were practiced illegally as early as the late 1980s. Unlike in the United States, “normal medical

practice includes ending a patient’s life by treatment of symptoms or ending of

treatment” (LEXNEX). Furthermore, “physicians who end their patients’ lives by treatment of

symptoms or ending of treatment may report their patients’ deaths as natural” (LEXNEX). The

relaxed nature of Dutch law prior to the formal legality of the act in 2002 allowed for patients

and physicians alike to carry out a variety of medical practices without any true consequences. In

order to better understand the method of euthanasia and other end-of-life medical practices, two

studies were completed, one in 1990 and one in 1995. The studies were comprised of doctor

interviews and questionnaires that were conducted in order to provide statistical evidence

regarding the use of end-of-life medical practices. The results of these interviews and surveys

revealed an increase in patient requests for euthanasia and PAS between 1990 and 1995. The

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requests for euthanasia alone rose 37% from 1990 while PAS requests rose 9% (NEJM).

Although the requests for such actions spiked, the death rates from euthanasia and PAS were

only around 2%.

From the physician’s perspective, however, the numbers were much more inflated, with

88% of doctors having received at least one request for euthanasia or PAS. Of the physicians

interviewed, 23% admitted to ending a patient’s life without his or her explicit request. That

statistic alone is a major reason why the fear of a slippery slope exists for those who oppose the

life ending medical practices. Even though 23% of unrequested deaths were likely the result of a

family member’s decision, the lack of formal Dutch law in regards to these practices was a

mounting issue. A greater overall problem with euthanasia and PAS deaths in the Netherlands lay

in the reporting process: “in the Netherlands, physicians are nineteen times more likely to end

dying patients’ lives using procedures for which reporting is not required” (NEJM.1056). Thus,

with all of the illegal practices and problems surrounding the death reporting process, the

original reporting procedure from 1993 was updated in 1998 to include an initial review of

deaths by a multidisciplinary committee, followed by an informed decision from the prosecutor

to determine whether or not particular requirements for careful practice had been met. Although

the reporting procedure arguably should have been updated sooner, it nevertheless resulted in

fewer violations committed by physicians. From its establishment, reporting percentages by

physicians have increased and the system is now regulated more efficiently. While it is quite

different than the current legislation in Oregon and other states in the United States, the

Netherlands has served as a precedent for end-of-life medical practices.

2.5 PAS and the Supreme Court

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The United States federal justice system has been struggling to legalize euthanasia and

PAS for quite some time now. The first major legal debate in the United States regarding PAS

began with the Supreme Court case of Washington v Glucksberg in 1997. The case, based on the

Due Process Clause of the Fourteenth Amendment, sought to determine whether there was a

constitutional right that allowed for assisted suicide. Dr. Harold Glucksberg, a practicing

physician in the State of Washington, three terminally ill patients, and a nonprofit organization,

known as Compassion in Dying, challenged the state’s ban on assisted suicide, which had been

implemented in the Natural Death Act of 1979. Their argument was centered around the idea that

assisted suicide was a liberty interest protected through the Due Process Clause, a clause

embodied in the Fourteenth Amendment that acts as a safeguard from denial of life, liberty, or

property (WikiDPC). Following the District Court’s ruling in favor of Glucksberg and company,

the case moved to the United States Court of Appeals for the Ninth Circuit. After initially being

reversed, the court reheard the case, upon which it decided to reverse the decision made by the

earlier panel and affirm the District Court’s ruling. From this stage, the case was elevated to the

Supreme Court where the question “presented was whether the protection of the Due Process

Clause included a right to commit suicide, and therefore commit suicide with another’s

assistance” (WikiWVG). Through the court’s deliberation, Chief Justice Rehnquist came to the

conclusion that the Due Process Clause of the Fourteenth Amendment did not in fact protect a

right to commit suicide or to assist in the suicide of another individual. This case was

groundbreaking in terms of the constitutional legality of PAS in America. In its decision, the

Court expressed that “perhaps the individual states were more suited to resolving or at least

addressing the myriad of concerns raised by both proponents and opponents of

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Candice Shadgoo

Candice Shadgoo

PAS” (Leg.St.Vt.). Leaving this decision up to the individual states opened the door for PAS

legislation in places such as Oregon and Washington.

A second, equally important case that focused on a right to assisted suicide and fell at the

exact same time as Washington v Glucksberg, was the court case known as Vacco v Quill. The

case, presented in New York State by numerous physicians who opposed the state’s prohibition

of PAS, argued that the statute violated the Equal Protection Clause of the Fourteenth

Amendment (WikiVvQ). This clause stated that while a patient has the right to refuse treatment

when terminally ill, they do not have an equal right to authorize a doctor to end their life. For this

reason, proponents were in disagreement as they considered refusing treatment and requesting

assistance in death to be the same thing.

However, the District Court’s perspective was not aligned in the same way, and they were

concerned with the legitimate state interest of preserving life and protecting vulnerable persons

(WikiVvQ). The Court of Appeals then reversed the District Court’s decision, reasoning that the

removal of life-support devices was identical to requesting PAS (WikiVvQ). From there, the

Supreme Court issued a 9-0 unanimous decision on the basis that New York’s ban on assisted

suicide did not violate the Equal Protection Clause of the U.S. Constitution. Rather, it determined

that “the distinction between letting a patient die and making the patient die is important, logical,

rational, and well established…[and] comports with fundamental legal principles of

causation” (Leg.St.Vt.). In response to the ruling, Circuit Judge Calabresi offered a concurrence

in which he addressed his “unwillingness to reach the ultimate Due Process and Equal Protection

questions” (HO 523). After looking at both the tradition of assisted suicide and the history of

anti-suicide statutes, he portrayed his opinion. Judge Calabresi asserted that throughout history

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Candice Shadgoo

there has often been an unspoken understanding between a patient and a physician that when the

pain and torment of dying become unbearable, the physician would prescribe medication to ease

the pain, even if that meant hastening the death of a patient (HO 523). Regardless of this

understanding, there have always been statutes prohibiting suicide and assisted suicide. With that

in mind, proponents of end-of-life medical practices are initiating the fight to secure the option to

request PAS in states across the country.

2.6 Oregon Leads the Way

Through the approval of a ballot initiative in November of 1994, Oregon became the first

state to legalize PAS. The Oregon Death with Dignity Act provides an end of life medical option

for those experiencing intolerable pain from terminal illnesses. Although strict guidelines and

regulations have been put in place to ensure safety and honesty, opponents of the act still believe

there is room for abuse. In order to even begin the approval process for PAS, an individual must

be over the age of 18 and a resident of Oregon. Additionally, the patient must be suffering from a

terminal disease that will lead to death within six months. Following these qualifications, the

patient must make one written and two oral requests for medication to end their life with the

written request having been signed, dated, and witnessed by two people in the presence of the

patient (LungRoyaleSlater). The physicians must confirm the patient’s diagnosis as well as

determine whether the patient is coherent enough able to make an informed decision.

At any time in the process, the patient has the right to rescind the request for life-ending

medication. Though it may seem that the process is secure and efficient, there are in fact

opportunities for misuse. From the perspective of opponents, such mishaps may lie in the

physician’s calculation of the patient’s prognosis. While it is not likely that a physician would

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abuse the system intentionally, there are mistakes made when it comes down to estimating the

course of an individual’s ailment. Furthermore, it is possible for a patient with a mental disorder,

such as depression, to bypass certain requirements, possibly with the help of a physician in order

to receive approval for PAS. These two arguments, among others, are what proponents in other

states seeking PAS legalization are facing.

Similar to the analysis and understanding of both physician and patient perspectives on

PAS in the Netherlands, Oregon has performed extensive research and gathered valuable

statistical evidence of its findings. The study, which was completed in 1995 shortly after the

approved Oregon legislation, surveyed 2,761 physicians with regards to their beliefs and

application of the Oregon Death with Dignity Act. The data that was compiled from the survey

reflected different personal attitudes, religious beliefs, and issues of physician concern. From a

legal standpoint, 73% of the physicians surveyed endorsed the right for terminally ill patients to

receive assisted suicide. Of the original group, 46% responded that they may be willing to

prescribe a lethal dose of medication for a terminally ill patient if it were legal, while 52%

indicated they would not be willing to do so (NEJM.1056). From that majority group, more than

half were unwilling to prescribe a lethal dose because of moral objections. Even initially,

personal attitudes and moral values played a large role in physician opinion on the matter.

In addition to choices formed by attitude or morality, religious affiliation had a factor on

physician opinion. Specifically, more than a majority of physicians who associated as Protestant

or Catholic were unwilling to participate in legalized PAS due to religious beliefs. Despite

personal attitudes, moral obligations, and religious beliefs, an overwhelming majority of

physicians seem to be concerned about malpractice (Pfeiffer). For many, they are simply

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unwilling to perform a procedure such as PAS with all of the uncertainty regarding lethal

prescriptions. While progress continues to be made on the subject, it is essential to provide

physicians with reliable prescription information so that in the future they are able to make

confident decisions within the realm of the law.

2.7 Medical Options for Massachusetts

Since its inception in 1994, Oregon’s Death with Dignity Act has served a valuable

purpose not only in its home state but also nationally as a model for proponents who attempt to

garner support and promote legalization. As representatives of CHOICE, we are fighting to put

PAS back on the ballot in the Commonwealth of Massachusetts in order to provide terminally ill

patients the option to escape the painful confines of their final life stage. Despite the initiative’s

previous failure in 2012, we strongly believe that PAS should be an option for terminally ill

patients. Therefore, along with proposed changes to the 2012 initiative, we are pushing to have

the amended initiative on the ballot in 2018.

Much of the backlash in 2012 was directly related to the phrasing and requirements that

the Question 2 initiative proposed in the PAS approval process. Words such as “recommend”

instead of “require”, and the failure of the legislation to require the presence of a psychiatrist

during the patient’s diagnosis, are criticisms that have been highly emphasized by opponents in

the debate over legalization of PAS in Massachusetts (Roberts). The Massachusetts Medical

Society and prominent Catholic community have also both proved to be another tough obstacle

for advocates of the act. The Massachusetts Medical Society officially opposes the Act because it

is “inconsistent with the physician's role as healer” (SPQ9676). The Catholic Church, on the

other hand, disagrees with the law on the basis that it is not only an act against God, but that it is

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also a potential recipe for abuse, with suicide essentially being made legal. Others in opposition

see the need for improved palliative care, which they believe would allow patients to live longer

and with less pain in hopes of avoiding any potential pressure surrounding the decision to

proceed with assisted suicide. The request for improved palliative care is another responsibility

being placed on doctors as their roles continue to change. In response to the position of the

Massachusetts Medical Society, doctors such as Dr. Marcia Angell argue on behalf of the

patients, not the doctors. She asserts that doctors’ roles as healers must change subtlety in order

to provide assistance to individuals seeking to end their lives. Regardless of all the opposition,

there are benefits for legalizing PAS, and through strict guidelines and regulations, legislation

such as that in Oregon can be implemented and improved in Massachusetts.

2.8 PAS: Unregulated Dangers

Acting in many of the same ways as the Netherlands’ physicians before the formalized

Euthanasia Act, doctors in Massachusetts have been performing the same under the table

operations for desperate patients. In particular, a doctor by the name of Ben Aident has

performed more than two-dozen assisted suicides over the past 20 years. An array of

Massachusetts physicians, like Dr. Aident, are working beyond the eye of the law to help

terminally ill patients receive assisted suicide either by prescribing fatal doses of medication or

by euthanizing patients- directly administering drugs to cause a patient’s death. With terminally

ill patients demanding relief from pain and no legal right to commit suicide in Massachusetts,

this seems to be the only option, as sinister as it may be. Performing these kinds of medical

procedures is both extremely risky and highly illegal. However, what other options does a

terminally ill patient have when the pain becomes unbearable? Patients essentially have two

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options: they can receive comfort care, “the accepted practice of aggressively treating the pain of

incurably ill patients even if, as a side effect, such treatment may hasten death” (SPQ9676), or

they can seek medication for assisted suicide. Both practices are dangerous and currently

unregulated by Massachusetts’s legislature. The argument over PAS shifts even further away

from the legality of the matter. Would the citizens of Massachusetts support the regulation of end

of life medical practices, or are they content knowing that terminally ill patients are struggling to

the point that they are forced to overdose on medication in order to die? While the argument is

not that simple, we, as members of CHOICE, are arguing that the option be made available for

those faced with tremendous pain in their final stages of lives. The passing of such an initiative

in Massachusetts does not guarantee that a patient be given the right to suicide, but merely offers

a terminally ill patient who meets the guidelines a chance to go through the approval process. In

avoiding the slippery slope and adhering to strict legislative requirements, CHOICE wants the

support of Massachusetts citizens in getting PAS back on the ballot to offer terminally ill patients

the right to die in 2018.

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Chapter 3 Ethical Aspects

groupAmanda Harrington | Anna Dreyer | Candice Shadgoo


3.1 Background Information on the Ethics Behind PAS

The controversial issues of euthanasia and PAS have prompted ethical and moral

discussions about an individual’s right to die. A main argument against the legalization of PAS is

the “slippery slope” argument, which features a few major points, including that patients might

feel pressured due to fear of overburdening their families, that the poor and uninsured might

choose it due to aid-in dying care being cheaper than end of life care, and that medication might

be prescribed to those either depressed or mentally ill.

Various scholars have looked to influential philosophers in order to gain insight for what

should be considered a human right and what impact euthanasia may have on society as a whole.

Yvonne Denier, author of Justice, Luck & Responsibility in Health Care: Philosophical

Background and Ethical Implications for End-of-life Care, studied John Rawls’ Theory of Justice

as a starting point for formulating the ethics surrounding justice and responsibility in the

healthcare system. Rawls’s theory states that a just society guarantees equal rights and liberties to

all. Additionally, Denier considers Amartya Sen and Martha Nussbaum, who take Rawls’ theory

a step further by defining an ethical justice system as one in which citizens are not only provided

these freedoms, but also are given the opportunity to actually make what they want out of their

lives. Our democratic society strives to follow these ethical theories of justice, which is why

healthcare is held up to the ethical standard of providing its patients with a variety of medical

resources that provide a plethora of comfortable options for end of life care. Thus, CHOICE

believes that denying the option of PAS to patients goes against the basic ethics of the American

health care system. PAS is an essential end-of-life option that provides equality and comfort to

all patients that allows them to act on their own desires.

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James Rachels, an American philosopher who specialized in ethics, made a compelling

argument for active euthanasia in 1975. Today, his argument is known as one of the most

important claims in Western philosophy. Rachels argues that society’s acceptance of passive

euthanasia over active euthanasia is not rooted in any logical ethical standards. Rather, it is

rooted in how our culture perceives all killing as the moral equivalent to the violence that we are

constantly exposed to in the media. Rachels questions whether there is actually any difference

between letting someone die and killing someone, which is the essential difference between the

two practices. Consequently, Rachels argues that the moral thing to do is to let someone die

painlessly by his or her own will instead of forcing him or her to have a longer and painful death.

3.2 Objections to PAS

There is a plethora of objections to PAS. People believe that this procedure is “murder”

and since murder is wrong, PAS must be inherently wrong. However, CHOICE feels that PAS is

not categorically immoral; rather, we believe that individuals do not understand the background

of PAS. In his article “A Case Against Dutch Euthanasia”, Richard Fenigsen claims that:

An important current of Dutch medical, legal and theological thought was influenced by such

German thinkers as Hackel, Jost, Binding, and Hoche, who introduced the concept of lives

unworthy of being lived, and advocated the extermination of useless individuals to relieve

society of that burden (Fenigsen, 24).

The event that Fenigsen mentions in his article concerned people who were “euthanized”

against their will. The key point of euthanasia and PAS is the fact that it is the voluntary and

conscious decision of the patient to die. What Fenigsen is discussing is murder, while the PAS

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that CHOICE proposes to be put back on the Massachusetts ballot is part of a patient’s right to

die.

By bringing up the Holocaust in his article and referring to the way in which Nazi

officers euthanized those who were not able (the old, the crippled, the mentally disabled),

Fenigsen associates euthanasia with one of the most horrific atrocities in the modern world.

However, Fenigsen’s argument misses the point. We do not deny that the Holocaust provided

examples of murder. However, CHOICE views PAS solely as a patient’s attempt to seek an

alternative and relatively painless dignified death. It is because of the popular conjunction of

euthanasia with the Holocaust that PAS is received so poorly. CHOICE believes that if people

knew exactly what PAS entails, then they would be open to learning more about it and could

even allow for assisted death to become a legal option instead of an illegal stigma.

A similar misconception surrounding PAS stems from the idea that PAS rejects

individuals and devalues human life. In his article, Fenigsen suggests that euthanasia creates a

divide between the majority and those individuals who might seek euthanasia and PAS, claiming

that:

Instead of the message of humane society sends to its member—‘Everyone has the right to be

around, we want to keep you with us, everyone of you’—the society that embraces euthanasia,

even the ‘mildest’ and most ‘voluntary’ forms of it tells people: ‘we wouldn’t mind getting rid of

you (Fenigsen 26).

This statement also lacks voracity, in part because it shows a failure to understand the

definition of euthanasia and to take in account its many categories. We are not telling people that

they cannot be around; we are not taking people’s right to live away from them, but rather, we

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are offering very sick people who are in very serious pain, and who meet the very rigorous

requirements, an option. They do not have to take this option, as no one is forcing them to

choose PAS. We are merely proposing that those who find their suffering unbearable, and who

meet the requirements, be able to die with dignity. Ultimately, CHOICE seeks to put life and

death where it belongs: in the patient’s hands.

For many, PAS conflicts with the more accepted social mandate to extend life whenever

possible. In a chapter of their book, “Chapter XXI: The Philosophy of Euthanasia”, Richard and

Rysard Fenigsen discuss that “hopelessly ill people” do not have to die because there are

measures that can be taken to prolong their lives. The problem with this idea is that being

“hopelessly ill” and being able to live for a long time are not mutually exclusive. Some of the

individuals who choose PAS do have the option to prolong their lives for a time, but find that

their continued existence would be too painful for themselves and for their loved ones. Those

who object PAS argue that the option demonstrates that it is cruel of society to “let someone die,”

when there is a chance for at least temporary survival. But, one may also debate that the ultimate

cruelty comes from forcing someone to prolong his or her life when that existence will be filled

with unbearable agony.

3.3 Support For PAS

There is a variety of other reasons why people take a stand against euthanasia, from

religious doctrine, to personal beliefs, to historical anecdotes. However, it is important to

consider the fact that those reasons should not exist at the state level. In fact, any patient who

finds that religious reasons, personal beliefs, or historical background prevent him from

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endorsing PAS will simply not choose that option. Ultimately, these reasons are not the primary

issues we are combating in our effort to make PAS legal.

PAS should be legalized because individuals deserve the entirety of their options when

staring death in the face. We are proposing that this bill be put back on the Massachusetts ballot

because we believe that people who are enduring such physically painful and tiring conditions,

as well as meeting all the necessary criteria, should have the right to die. One of the criteria,

which differentiates forms of PAS from murder, revolves around consent. Although E. Garrad

and S. Wilkinson’s article “Passive Euthanasia” refers to PAS as “murder,” that is not the correct

connotation. Murder means “wrongful death,” but, so long as the person who elects to begin the

process of PAS remains fully aware of what he or she is doing and meets all the necessary

criteria, assisted suicide can be an ethical and positive decision.

Although our proposal for PAS in Massachusetts only asks for it being made available to

terminally ill consenting adults, the referendum would still fall under these notions of basic

human rights. Indeed, Denier, Gastmans, and Vandevelde also mention Robert Nozick’s notion

that, “individuals have a property right in their own person (their body, talents and

skills)” (Denier 3). Whereas murder wrongfully deprives the victim of his or her right to life,

PAS restores the patient’s right to his or her own choices regarding his or her own life. Nozick’s

idea puts emphasis on the fact that individuals own their bodies, and they should be able to do—

within reason and while still obeying the law—whatever they want with their bodies and no one

should be able to tell another what they are and are not allowed to do with it.

Adding PAS does not diminish the value of other current medical care. In their article,

Denier, Gastmans and Vandevelde state that:

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It is important that democratic equality provides reason to supply those who are approaching the

end of life with sufficient medical resources and that they are not driven into refusing available

life-extending treatment or, if legal, PAS to avoid treatable pain and suffering or becoming a

burden. This includes providing access to a range of comfort care including effective analgesics

and mental health therapy (Denier et al. 140).

Their comment summarizes our proposed bill aptly. The point that Denier, Gastmans and

Vandevelde assert here is that PAS will not be available to all, and that it is not a light issue. To

undergo the process of PAS, the patient will have to pass rigorous tests and meet many strict

requirements. If someone were in tolerable pain, or only wants to undergo assisted suicide so that

he or she would no longer be a burden to others, then the safety nets and hurdles would prevent

him or her from being able to undergo PAS. A patient would have to be in an intolerable amount

of pain and to have a severely lowered quality of life for him or her to be a candidate. Possibility

doesn’t always mean guarantee.

Although objectors cite morality as a primary obstacle to legalizing PAS, the situation

does not seem designed for moral absolutes; rather, intent must be considered. In James Rachels’

article “Active and Passive Euthanasia”, he outlines the reasons why people have flawed

understanding euthanasia, suggesting that: “one reason why so many people think that there is an

important moral difference between active and passive euthanasia is that they think killing

someone is morally worse than letting someone die. But is it? Is killing, in itself, worse than

letting die?” (Rachels 2). Rachels later goes on to discuss two fictional scenarios in which one

man named Smith kills his brother to get his inheritance money, while another man named Jones

lets his brother drown in order to get his inheritance money. Is Jones more morally correct than

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Smith? Rachels thinks both Smith and Jones’ actions reveal an inherent moral corruptness

because their intent remains selfish. In contrast, euthanasia, Rachels argues, is morally just

because the intent of the action is to end suffering rather than to gain a reward.

Intent also remains significant when discussing quality of life and PAS as an alternative

to unbearable pain. Rachels comments on the morality of euthanasia again, noting that, “the

process of being ‘allowed to die’ can be relatively slow and painful, whereas being given a lethal

injection is relatively quick and painless” (Rachels 1). He argues that it is more moral to allow

someone to die in peace of his or her own volition than to let that person live in pain against his

or her will. This choice becomes especially important if the patient’s pain is drawn out because

physicians use drastic measures to keep him or her alive. Rachels proceeds to assert that: “the

bare difference between killing and letting someone die does not, in itself, make an morel

difference. If a doctor lets a patient die, for humane reasons, he is in the same moral position as

If he had given the patient a lethal injection for human reasons” (Rachels 2). Once again, Rachels

brings up intent. The intent for the doctor is the same as if he or she were actively involved the

patient’s death, as both passive and active forms of PAS end similarly. Why not end the suffering

sooner, if the patients asks for PAS and qualifies for that option? In this way, morality will be

satisfied.

Rachels also considers the consequences of assisted suicide. Unlike murder, which

usually encompasses selfish motives and a positive gain for the murderer, PAS remains voluntary

and victimless. PAS is an action that the patient elects to request on his or her own. He or she

possesses the agency—not the doctor. Indeed, Rachels dismisses many of the aspects associated

with murder as irrelevant, claiming that, “…The other factors—murderer’s motive of personal

!45

gain, for example, contrasted with the doctor’s humanitarian motivation—account for the

different reactions to the different cases” (Rachels 2). However, this is one of the many reasons

why the Commonwealth of Massachusetts should revisit this bill, so that the ambiguities

concerning assisted death may be reviewed on a case-by-case basis.

Quite often, those who debate the morality of PAS deal with abstractions and scenarios,

whereas the health care workers and patients possess a closer and deeper understanding of the

ethical interactions involved. David A. Asch and Michael DeKay’s article “Euthanasia Among

US Critical Care Nurses: Practices, Attitudes, and Social and Professional Correlates” describes a

study conducted in South Africa about nurses who have participated in euthanasia, even though

their actions were not necessarily legal. The study shows that 19% of the nurses polled have

participated in euthanasia, specifically critical care nurses (Asch and DeKay 890). They have a

better understanding of the needs, and, more specifically, the pains of the critically and

terminally ill. They better comprehend what the patients are experiencing, the difficulty it is for

the patients to live in such pain, and the reasons why these patients may want to undergo

euthanasia. All of the nurses who performed euthanasia did so out of compassion and believe that

euthanasia is a legitimate response to human pain and suffering.

Moreover, NM Harris, in his article “Management of Death, Dying and Euthanasia:

Attitudes and Practices of Medical Practitioners in South Australia”, comments on self-

determination and autonomy when it comes to euthanasia and uses those ideas as reasoning for

why euthanasia should be legalized. Reiterating why the bill should be put back on the ballot,

Harris states that, “morality presupposes a respect for a person’s autonomy, which requires that

they be allowed to act on the basis of their own desires.” Keeping euthanasia and PAS illegal

!46

means withholding options from patients. Even though most individuals choose not to undergo

euthanasia, they should still have the option for assisted death when appropriate. Although the

issue remains controversial, more and more doctors seem to be accepting the idea of PAS and

euthanasia:

In a recent poll commissioned by the World Federation of Doctors who respect Human Life and

conduced by MORI, nearly two thousand people were approached. Seventy two percent felt that

euthanasia should be made legal. In addition, almost 50% of doctors in Great Britain would be

prepared to consider taking active steps to bring about the death of a patient if it was legal

(Harris 369).

This percentage may not reflect all the physicians who would conduct PAS or prescribe

medications for a patient, but it does reveal that almost ¾ of the people polled respect others’

choices enough to let them make that decision for themselves.

Some opponents of PAS advocate hospice care as a way to manage pain. Yes, hospice

care may be adequate and it may reduce the amount of people who want to undergo PAS, but

there will always be those people who “exercise their right to self-determination by choosing to

have their life prematurely terminated by active and deliberate means. The wishes of such people

must be respected and therefore legislation of active euthanasia is necessary” (Harris, 369). Once

again, CHOICE would like to underscore that PAS remains one alternative amongst many and

that the goal of the proposed bill is to expand the range of care, rather than to infringe on

patients’ rights.

Ultimately, some of the most compelling arguments for the legalization of PAS come

from interviews of those impacted by these debates. As mentioned earlier in our paper, our group

!47

interviewed a Social Worker-Case Manager, Emily Wallace, to get her real-life perspective on the

matter. When asked about her feelings concerning euthanasia, and specifically, PAS, Wallace

responded:

My thoughts on this topic are subjective—based on the particular patient, their disease,

their options and their prognosis. When disease is terminal and/or produces a quality of life that

is unacceptable to the patient, I feel it is unfortunate that such patients are denied this right to end

their life in order to stop the suffering for themselves and their loved ones (Wallace 1).

She also voiced her opinion on the Oregon Death with Dignity Act:

I think that it is an amazing option for individuals who are enduring the tragic events of

debilitating and terminal illnesses. It allows someone control when so much of their life is and

what they have went through as a result of their illnesses is entirely out of their control (Wallace

1).

Additionally, Wallace rejects the idea that PAS undermines the value of life, stating that:

I think that everyone has the right to determine how and what they value in their life. I think

some illnesses and terminal diseases mean that people end up living the last years, months or

days of their life with a quality that is something they have and would never ‘value’. I think in

some circumstances, people should have the right to end their life in order to preserve their own

and their loved one’s quality of life (Wallace 1).

Wallace’s real life experiences and expertise sheds light on the modern-day PAS debate.

Her experiences are not hypothetical. Rather, they show that PAS is a real-life issue that touches

many people. By taking away options from those patients, the government infringes on their

human rights.

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3.4 Dr. Kevorkian: Sinner or Saint?

Some people’s concern when it comes to euthanasia and PAS is not only personal or

religious, but also from historical cases. In the 1990s, a doctor, Dr. Jack Kevorkian, dubbed “Dr.

Death,” performed euthanasia on countless consenting patients, even though his actions were

illegal. In Ned Stafford’s article on the doctor, he argues that Dr. Kevorkian is not a murderer.

What he did was absolutely ethically appropriate, but it was also not completely ethically

immoral. However, Kevorkian’s actions, practicing a form of treatment that was extremely

illegal, caused the doctor to lose his medical license. Nevertheless, his actions demonstrate that

he respected his patients’ right to die. Stafford suggests that, “to his supporters, Kevorkian was a

humane hero who courageously fought for the rights of suffering people to fulfill their death

wishes.” Although his reputation remains controversial, Kevorkian’s practices raised awareness

concerning the euthanasia question.

3.5 A Case Study: Brittany Maynard

When considering legalizing PAS, reviewing statistics alone remains insufficient. It is

important to hear the stories of the terminally ill patients who would want that option available.

One recent example of an outspoken supporter of PAS was Brittany Maynard. As a young

woman in her twenties who was diagnosed with a rare and terminal form of brain cancer,

Maynard wanted to have the right to die, but lived in a state which did not offer PAS.

Consequently, she moved to Oregon, where PAS is legal. With the help of Compassion and

Choices, a non-profit organization that advocates for patient’s rights and choices pertaining to

end-of-life measures, Brittany took advantage of Oregon’s Death with Dignity Act. Brittany

Maynard can be seen as the face of someone who was affected by PAS being illegal in her home

!49

state. Allowing Brittany to take control of own death did not negatively impact anyone. Her

family might have felt immense feelings of loss and sorrow, but the grief was inevitable,

considering her prognosis.

3.6 Final Thoughts on Ethical Argument

Overall, PAS can be beneficial for society in that it gives consenting adults who meet the

necessary criteria options. The Fenigsens discuss the wrongful acts of euthanasia, but CHOICE

believes that forcing terminally ill patients who experience indescribable pain to extend their

lives is an even crueler action. Most legislators do not understand the agony of the patients, so

why should they control the circumstances of the patient’s life and death? The Fenigsens, in

addition to other critics, believe that doctors performing PAS are going against the Hippocratic

Oath. However, prescribing lethal medication to select terminally ill adults who meet all the

requirements simply seems an extension of a doctor’s goal to serve the needs of the patient and

to help relieve them of pain.

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!51

Final Policy Recommendations



group

CHOICE advocates the legalization of PAS in Massachusetts. We believe that consenting

terminally ill adults experiencing insurmountable pain should have the option to choose a quick

and comfortable death if they meet the requirements for PAS. CHOICE endorses the following

protocol: the patient must be a legal adult diagnosed with a terminal condition, which will lead to

death within six months. If that patient wishes to request PAS, he or she must fill out an

application in writing, including the findings of two physicians and one psychiatrist to ensure

that the patient is mentally and emotionally stable. Furthermore, if the patient meets these basic

requirements, and still wishes to be granted PAS after a thorough explanation of the process, the

physicians must require that the patient notify his or her family. Only after these requirements

have been met will the patient be prescribed the lethal medications involved in assisted suicide.

While CHOICE understands that this proposed policy will not please all opponents of the

referendum, such as those who have religious objections, the specific model CHOICE

recommends intends to incorporate many detractors’ fears. Our group hopes that this new model

illustrates that legalizing PAS does not restrict patients’ choices and still encourages quality

healthcare. Additionally, enabling terminally ill patients to choose PAS in specific cases will not

take the place of palliative care consultations, thus allowing terminally ill patients whether they

wish to die prematurely or continue to live out the remainder as free from pain and with the best

quality of life possible. While there is always the possibility that doctors can misdiagnose the

length of a patient’s remaining life-span, the requirement of having two consulting physicians

minimizes the chance for any mistakes. By writing a less vague policy, and giving a specific

definition of mental competency detailing the mental and emotional stability of the patient, we

hope to clarify the policy for Massachusetts voters. At the same time, by requiring patients

!52

seeking PAS to notify their families, and by demanding that those patients also see a psychiatrist,

we hope to minimize the chance of this last resort being chosen carelessly.

Ultimately, CHOICE seeks to persuade Massachusetts voters to adopt PAS for terminally

ill patients who meet rigorous criteria for a very specific situation. We feel that the version of

PAS that we endorse differs significantly from both the Netherlands and Oregon models by

seeking to clarify ambiguities, which raised concerns in Massachusetts voters twice previously.

By addressing these concerns, we feel able to wholeheartedly recommend Massachusetts

adopting PAS as one of many choices available to eligible terminally ill patients.

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!54

Appendix



Interview with Emily Wallace

1. What is your profession and medical title? I am a medical social worker in an emergency

department at a hospital. My title is “Social Worker-Case Manager”

2. What state do you practice in and what state(s) are you certified in? I practice in Colorado

and am currently certified in both New York and Colorado.

3. What are your thoughts on physician-assisted suicide? My thoughts on this topic are

subjective – based on the particular patient, their disease, their options and their

prognosis. When disease is terminal and/or produces a quality of life that is unacceptable

to the patient, I feel it is unfortunate that such patients are denied this right to end their life

in order to stop the suffering for themselves and their loved ones.

4. Have you ever practiced or witnessed physician-assisted suicide? No.

5. What do you think about Oregon’s Death With Dignity Act? I think it is an amazing option

for individuals who are enduring the tragic effects of debilitating and terminal illnesses. It

allows someone control when so much of their life and what they have went through as a

result of their illness is entirely out of their control.

6. How do you define euthanasia? The intentional ending to end your life to release yourself

form pain and suffering.

7. What are your general opinions on euthanasia? That each situation has to be considered on

an individual basis to determine the appropriateness of it. I believe there should be a

reasonable amount of suffering and quality of life lost in order for someone to qualify for

this. I do not think it should be a right of everyone, as we also have to consider mental

health, social support, etc. when someone expresses a desire to intentionally end their life.

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8. Have you ever been asked by a patient to euthanize them (or, in your case, have patients ever

asking if this was an option)? If so, what led them to ask this? I have had several patients ask

but none, do I believe, seriously thought this was an option but more of a statement they

have made when frustrated with their illness and their circumstances. It usually goes like,

“I wish this would end already.”, “I have no life. I am in pain. I can’t do anything, I am a

burden to my family, I wish this would all just end already”.

9. As a medical professional, how do you diagnose pain? Were trained to learn this or is it

instinctual? As a medical social worker, I do not diagnose pain as this is up to the treating

physician or physician’s assistant. In the hospital, they use imaging, pain scales, touch and

more diagnostics to identify and diagnose pain.

10. What is your take on legalizing physician-assisted suicide in your state (if it has not been

already legalized)? I believe it should be legalized but only if there was a firm protocol

established that sets guidelines for how someone qualifies for this option and how it is

determined that they are appropriate – both physically and psychologically.

11. Do you believe individuals should have the right to die? Yes and no. Given the rate of the

suicidal ideations that I see, it would worry me if everyone had the “right to die” as I feel

we would lose many, too early, who have the chance to get better with the right help. As I

have mentioned above, I think this is subjective – depends on the person, their disease, etc.

12. Do you think assisted suicide undermines the value of life? I think everyone has the right

to determine how and what they value in their life. I think some illnesses and terminal

diseases mean that many people end up living the last years, months or days of their life

with a quality that is something they have and would never “value”. I think in some

!56

circumstances, people should have the right to end their life in order to preserve their own

and their loved one’s quality of life.

13. Based on what you’ve seen as a medical professional, how do family dynamics change when

an individual in their family has less than 6 months to live and is terminally ill? Have family

members ever inquired on physician-assisted suicide? I have never heard a family member

inquire about this – I think because most are aware that this is not legal here in Colorado. I

have seen family dynamics change when faced with terminal illness in that grudges are

dropped and sins forgiven. Often the ones who you think would be “more emotional” are

less than what you “expected” and vice versa. Family member’s roles change –for instance,

the daughter who may have been the “child” and always cared for, is now caring and

comforting her mother as they watch her father die. Some family members become angry

and many cycle through the stages that Elizeabth Kubler Ross discusses – anger, denial,

bargaining, depression, acceptance – in no particular order and maybe many stages at

once. Grief and facing terminal illness is never predictable – you never know what you see,

how someone will cope, etc.

14. Is it more common for someone with a family to endure the pain of a terminal disease to live

longer, and for those who have no one ask for assisted suicide? I don’t think so. I think it is

such a personal experience that it is hard to distinguish such differences. I do see a lot of

people WITH a great deal of family support want it all to “end” because they worry about

being a burden to their family, or they don’t want their loved ones to remember them as

weak, or sick, or lifeless – they want them to remember them as who they were before the

illness.

!57

Interview with Sandy Shadgoo

1. What is your profession and medical title? Acute pediatric registered nurse CNII, public

health nurse, and registered nurse.

2. What state do you practice in and what state(s) are you certified in? California.

What are your thoughts on physician-assisted suicide? I do not agree with it because there are

so many things you can do in palliative care to keep a patient comfortable. I believe that life

is given and taken by God and that it is not up to man to make that choice, even with a

terminal illness.

3. Have you ever practiced or witnessed physician-assisted suicide? No.

What do you think about Oregon’s Death With Dignity Act? I do not believe or agree with it.

How do you define euthanasia? A terminally ill patient ending their life before it is their time

simply due to a man-given diagnosis.

4. What are your general opinions on euthanasia? I disagree with it.

5. Have you ever been asked by a patient to euthanize them? If so, what led them to ask this? I

have not been asked.

6. As a medical professional, how do you diagnose pain? Were trained to learn this or is it

instinctual? Pain is anything that the patient says it is. I was trained in nursing school.

What is your take on legalizing physician-assisted suicide in your state (if it has not been already

legalized)? I do not agree with it, again because of my own spiritual belief that life is given

and taken by God.

7. Do you believe individuals should have the right to die? I believe that a patient should have

a death with dignity and without pain, but I do not believe that they should choose to kill

!58

themselves, because they never know when something can turn in their favor and for them

to live.

8. Do you think assisted suicide undermines the value of life? Yes because again, life is

something that is given by God, and no human being can say how long a person can live,

including that individual himself or herself.

9. Based on what you’ve seen as a medical professional, how do family dynamics change when

an individual in their family has less than 6 months to live and is terminally ill? Have family

members ever inquired on physician-assisted suicide? Usually, as a nurse, when a patient of

mine does get that diagnosis, I always support the family and tell them that these diagnoses

are never set in stone. As a practicing health care professional, I have seen that they are not

set in stone. As medical professionals, we take an oath to preserve life, not to end it, and as

much as I can, I help families try to preserve life, but no, families have never inquired on

physician-assisted suicide—it has always been asking about what the medical professional

can do to add more time for the individual.

10. Is it more common for someone with a family to endure the pain of a terminal disease to live

longer, and for those who have no one ask for assisted suicide? I do not believe that it has to do

with an individual or their families—I think it has to do with the individual and how strong

their minds are. As a health care professional, I try my best to strengthen their minds.

!59

Figure 1.

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Figure 2.

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Figure 3.

Figure 4.

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Figure 5. Figure 6.

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Figure 7. Figure 8.

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Figure 9.

Figure 10.

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Figure 11.

Figure 12.

!65

!66

Glossary


Ehis Osifo | Madison Palms | Nona Haller | Robert Baillargeongroupchoice

Active Euthanasia: “In active euthanasia a person directly and deliberately causes the patient's

death.” (BBC News)

Coroner: an officer, as of a county or municipality, whose chief function is to investigate by

inquest, as before a jury, any death not clearly resulting from natural causes. (dictionary.com)

Dutch Criminal Code Section 293: The new statutory rules will not make any substantive

changes to the grounds on which life may be terminated on request or on which assistance with

suicide are permitted. The requirements of due care have however been formulated in somewhat

more detail. Under Section 293 (2) of the Criminal Code the physician must:

• be convinced that the patient's request was voluntary, well-considered and lasting;

• be convinced that the patient was facing unremitting and unbearable suffering;

• have informed the patient concerning the latter's situation and prospects;

• have reached the firm conclusion with the patient that there was no reasonable alternative

solution to the patient's situation;

• have consulted at least one other independent physician, who has examined the patient and

who has formed a judgment concerning the requirements of due care as referred to in a-d

above;

• have carried out the termination of life in a medically appropriate fashion. (The World

Federation of Right to Die Societies)

Passive Euthanasia: “In passive euthanasia they don't directly take the patient's life, they just

allow them to die.”

This can be by withdrawing or withholding treatment:

!67

http://dictionary.com

• Withdrawing treatment: for example, switching off a machine that is keeping a person alive, so

that they die of their disease.

• Withholding treatment: for example, not carrying out surgery that will extend life for a short

time. (BBC News)

Physician Assisted Suicide: “Physician-assisted suicide refers to the physician providing the

means for death, most often with a prescription. The patient, not the physician, will ultimately

administer the lethal medication.” (The World Federation of Right to Die Societies)

Voluntary Euthanasia: “Voluntary euthanasia occurs at the request of the person who

dies.” (BBC News)

Non-Voluntary Euthanasia: “Non-voluntary euthanasia occurs when the person is unconscious

or otherwise unable (for example, a very young baby or a person of extremely low intelligence)

to make a meaningful choice between living and dying, and an appropriate person takes the

decision on their behalf.” (BBC News)

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!69

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