Assisted Suicide: providing a person with the means to end his or her life.

Active euthanasia: taking a specific action to end a person's life.

Passive euthanasia: withholding or withdrawing life support, nutrition, or water without a person's consent, with the specific intention of ending that person's life.

Doctor-assisted death: this term includes both physician-assisted suicide and active euthanasia performed by a physician.

The Hippocratic Oath (350 B.C.)

· "...I will neither give a deadly drug to anyone if asked for it, nor will I make a suggestion to this effect..."

· "First, do no harm."

· For centuries, the Hippocratic oath has provided important ethical guidelines for physicians.

· Traditionally, doctors have been healers, not killers. Doctors now have more and better treatments for pain than ever before. Why is legalization of doctor-assisted death being considered now?

Social and cultural factors affecting the debate in the 1990's:

· Secularism (God is no longer respected as the only giver and taker of life)

· Moral relativism (the lack of moral absolutes in our society)

· Radical personal autonomy ("my body, my right")

· The growing AIDS epidemic

· Families have fewer children - there are fewer family members to care for sick and aging parents

· The tremendous emphasis on reducing the cost of healthcare

· Oregon "Death with Dignity" Act (Nov. 1994) allows a physician to write a lethal drug prescription for a patient. It was passed by a statewide referendum: 51%-49%.

· It was immediately blocked by a judicial injunction. On March 6, 1996, the 9th Circuit Court of Appeals ruled that Washington state's ban on assisted suicide is unconstitutional. Two days later, a Michigan jury acquitted Jack Kevorkian on charges of assisting in two suicides. (His 2nd such aquittal; he was later aquitted for a 3rd time.)

· On April 4, 1996, The 2nd Court of Appeals ruled that New York state's statutes against assisted suicide are discriminatory and unconstitutional.

· July 1996: Australia's Northern Territory legalizes assisted suicide and voluntary euthanasia. This law was repealed in March 1997.

· May 1997: Colombia legalizes assisted suicide and euthanasia.

· On June 26, 1997, the U.S. Supreme Court overturns both Appeals Courts' rulings (of March 6, 1996 and April 4, 1996, noted in this section) stating that:

1. there is no constitutional right to assisted suicide
2. assisted suicide is not the equivalent of withdrawing life support
3. state bans against assisted suicide are constitutional.

The Court's ruling leaves open the possibility that individual states may legalize assisted suicide.

· On November 4, 1997, by a 60%-40% margin, Oregon's citizens vote against repealing the Oregon Death With Dignity Act.

· Responses to the vote (American Medical News, 11/24/97):

1. Oregon Board of Pharmacy issues an order requiring doctors to stipulate on a prescription form if the prescription is for assisted suicide. Pharmacists need to know so they can choose whether or not to participate.

2. U.S. Drug Enforcement Administration announces that prescriptions dispensed for assisted suicide will violate federal narcotics law because assisted suicide does not fit under any current definition of "legitimate medical purpose".

3. Most Oregon medical insurers agree to pay for assisted suicide procedures (although some limit hospice benefits to only $1,000). Catholic health plans and Medicare will not cover assisted suicide.

4. The law is unclear on the obligation of physicians who refuse to participate in assisted suicide. Do they have a duty to refer patients to a willing physician? Many feel that this would make them morally complicit in the act. The Oregon Medical Association advises that physicians "cooperate" with patient requests to transfer care to another doctor.

5. Physicians request guidance on the best drugs to use for assisted suicide.

6. As of January 1998, one Oregon doctor had announced his or her participation in an act of assisted suicide.

· Better training for physicians in pain management techniques for the terminally and chronically ill.

· Relaxing the narcotic prescribing laws that are inappropriately restrictive.

· Better training in diagnosis and treatment of depression in the terminally ill.

· Make adequate hospice care available to all terminal patients.

· Reimburse physicians for palliative care services just as they are reimbursed for performing other medical procedures.

· Train more full-time palliative care specialists and make their services widely available. This will assure incurable patients that they are getting the very best "comfort care" treatments, i.e., not just for their pain but also for their dyspnea, nausea, diarrhea, constipation, and other discomforts.

· Holistic palliative care should also provide psychiatric support and the offering of pastoral care services to the suffering and dying.

· Helpful mnemonic for addressing requests for assisted suicide - "PPD": Pain Control; Pastoral Care; and Depression dx. and treatment.

· Revising and expanding "generic" living will documents so that they better clarify patients' end-of-life wishes.

1.) The experience of the Netherlands with doctor-assisted death{1}.

• The only "hard data" available on the consequences of legalization

• This data reveals:
  • Assisted suicide leads to euthanasia
  • Euthanasia for the terminally ill leads to euthanasia for the chronologically ill
  • Euthanasia for physical suffering leads to euthanasia for emotional/psychological suffering
  • Voluntary euthanasia leads to involuntary euthanasia
  • Euthanasia for adults leads to euthanasia for newborns, children and adolescents
  • Euthanasia performed by non-physicians (nurses) also becomes a reality
• There is no better example of the "slippery slope"

2.) Legalization of assisted suicide in the U. S. equals legalization of euthanasia.

If we legalize only assisted suicide:

• We will "discriminate" against those patients who are too sick to ask for or swallow a lethal dose; or operate the switch on a death machine. How will they exercise their "right to die"? (Rights must be equally available to all citizens.)

• How will we handle failed cases of assisted suicide if we don't have euthanasia available as a "back-up"? What is an emergency room team to do when faced with this situation? Can they be sued for attempting resuscitation? It has been reported that 20-25% of attempted suicides are failures.{2}

• The Netherlands allows both forms of doctor-assisted death and Australia's Northern Territory allowed both for a short time. Columbia has also legalized both.

3.) In our current medical environment of strict cost-containment, how could we possibly control a physician's strong financial incentive to encourage patients to choose doctor-assisted death if it were legal?

Managed care organizations are now offering financial incentives to doctors who use less monetary resources in the care of their patients. Doctor-assisted death will always be less expensive than compassionate terminal care. It has been called the "ultimate form of cost containment".

American medicine has unfortunately moved from a patient-centered to a profit-centered ethic. It will be very difficult to control doctor-assisted death if it is legalized in this economic setting. It should be noted that the Dutch experience has occurred in a country with universal health care. Such is not the case in America and this could easily make the slope even more slippery.

The majority of Oregon's health maintenance organizations have readily agreed to pay for assisted suicide. The Ethix Corp. announced that they "welcomed broad coverage for assisted suicide in a medical economic system already burdened".{3}

4.) If we define a difference between "rational suicide" and "irrational suicide", how long could the distinction be maintained? Before long, doctor-assisted death would become available to anyone with a suicidal wish. Isn't it discrimination to allow it only for terminal patients with severe physical suffering? What about suffering non-terminal patients and non-terminal patients with severe psychological distress? A recent study revealed that 64% of Dutch psychiatrists believe that physician-assisted suicide can be acceptable for patients whose suffering is based on a metal disorder in the absence of terminal (or even physical) illness.{4} Many opponents of doctor-assisted death feel that a suicidal patient should never be considered "rational".{5}

5.) With all the technology that we now have available for pain control and palliative care, why change the Hippocratic Oath now? If, in addition to healers, physicians also become killers, how will this affect the doctor-patient relationship? Pain can now be controlled in 95% of cancer patients and made manageable in the rest.{6} For cancer patients, there are options other than suffering and doctor-assisted death. These alternatives include hospice and finding another doctor who is more capable of controlling pain and other discomforts. If depression is present, it should be treated.{7} Pastoral care services should always be offered. (The AMA has concluded that "physician-assisted suicide is incompatible with the physician's role as healer".)

6.) We should not expand the indications for justifiable homicide without a very good reason:

• self-defense
• just war
• capital punishment (in some states)

The first 3 all involve an element of self-defense against aggressors. How can we justify killing innocent people, even if they request it? Doctors have enough power already. Legal doctor-assisted death would give more power to doctors, not patients. It would not give patients the "right to die" (they already have the right to die naturally). Rather, it would give doctors the right to kill.

If people want more control over the circumstances of their deaths, they should be demanding access to the very best palliative care treatments that are available. Legalizing assisted-suicide will give doctors more power than they are entitled to.

7.) Legalization would put vulnerable groups of people at risk for abuses of doctor-assisted death. These groups include the elderly, the disabled, and the mentally ill. The care of these patients is often expensive, difficult, and frustrating. Inappropriate "quality of life" judgements are often made by others on their behalf. They are seen as a burden to their families and to society and they sometimes see themselves as a burden. For these people, the "right to die" could easily become the "duty to die". The poor could find themselves in a similar situation if faced with a terminal illness.

In a number of studies, the most common reason patients cite for requesting doctor-assisted death is "being a burden" to their families.{8}

8.) What about pharmacists, nurses, technicians, and hospitals that morally oppose the practice of doctor-assisted death? This could become very complicated. And how long will it be before they are threatened with the revoking of their licenses for refusing to render "compassionate" care?

Almost immediately after the Oregon vote on November 4, 1997, the Oregon Board of Pharmacy issued an emergency order requiring doctors to indicate on a prescription form if the script is for assisted suicide.{9} This will allow individual pharmacists to choose whether they want to participate. The Oregon Medical Association has threatened legal action.

"Why must people suffer if they are going to anyway within a short period of time?"

Response: Like living, the reality of dying is that it will often involve a component of suffering. But there is no reason for this suffering to be excessive or inappropriate. With the technology that we now have available for the control of pain and other discomforts, pain that cannot be completely relieved can at least be made tolerable.{10} If a dying patient is suffering, the solution to this problem should be better medical care, not killing the patient. Modern palliative care involves a holistic approach that addresses the physical, psychological, and spiritual dimensions of a patient's suffering.

"Terminal sedation" (see below) is a valid option for those rare patients who do not respond to conventional treatments. A short period of terminal sedation prior to death is a much more dignified option than doctor-assisted death.

The idea that there is compassion in killing is a truly radical notion that goes against the Hippocratic tradition that has guided medicine for more than 2,000 years. The original meaning of the word "compassion" is "to suffer with", and this is what we are called to do as family members and healthcare workers. We are called to share in the patient's suffering and provide as much comfort and support as possible. This includes providing the best palliative care that medicine has to offer. Doctor-assisted death is much closer to abandonment than it is to true compassion.

"Assisted suicide should be made legal for those few hard cases where pain cannot be controlled. Safeguards will prevent any abuses."

Response: The "few" hard cases argument was used to legalize abortion. There are now 1.3 million abortions yearly in the U.S. As for safeguards, they have not worked for abortion in the U.S. and they have not worked in the Netherlands for euthanasia.{11} Cases where pain cannot be controlled are indeed very few.{12} Terminal sedation is a valid and ethical option for these patients. (See below.)

"Doctors already give lethal doses of pain medications to some dying patients; why not just legalize the practice for all dying patients?"

Response: Intention is everything. This is why there are different degrees of murder and manslaughter. If a physician's intention is to relieve a patient's pain, and the patient or patient's family is properly informed and in agreement, then it is ethical to give a potentially lethal dose of pain medication and accept the risks. However, if the intention is to bring about death, then the act is not ethical. Traditionally, this is called the "principle of double effect". It was recently supported by the Supreme Court.{13} In those rare cases where pain cannot be controlled, the principle of double effect allows for "terminal sedation". Terminal sedation consists of giving large, potentially fatal doses of narcotic pain medications such as morphine in order to induce a coma-like state of sedation or even death if breathing should stop from over-sedation. As long as the physician's intention is to relieve pain, the risk of hastening death is acceptable and ethical if the patient (or the patient's family) agrees to take the risk. Organized medicine has accepted this practice as ethical for a very long time. The principle of double effect is invoked almost every time that cancer chemotherapy or emergency surgery is performed. (When a patient is unconscious or otherwise unable to make his/her decisions, these decisions are usually made by the patient's family.)

Some proponents of doctor-assisted death call terminal sedation "undignified"--a death without dignity. They feel that death by assisted suicide or euthanasia is somehow more dignified. This has certainly not been the case with many of the assisted suicides performed by Jack Kevorkian where bodies have been left in cars next to hospitals or morgues.

"Suffering patients deserve to have this choice. You may not agree with doctor-assisted death but you can't force your morality on society."

Response: Issues of life and death cannot be arbitrary matters of "choice". Legalization of doctor-assisted death will have implications far beyond the individual patient. Although some citizens might feel that they would benefit from legalization, it would put other citizens at risk for coercion and possible involuntary euthanasia. This would be especially true for "vulnerable" citizens such as the elderly, the disabled, and the mentally ill. Laws can be viewed as restrictions on personal freedoms for the good of society as a whole. For this reason, 35 states now have statutes that prohibit assisted suicide.

The involuntary euthanasia that is occurring in the Netherlands{14} gives patients no choice. It is the ultimate absence of choice--the ultimate insult to a patient's autonomy.

Many who favor doctor-assisted death also favor forcing doctors who morally object to it to refer patients to willing physicians. What about the doctor's choice in these situations?

Every American has first amendment rights on this important issue. This includes the right to attempt to persuade others within the limits of the law. This is the very essence of the American political system. It is not "forcing one's morality" on America.

"You are making this a religious issue--you can't force your religion on the rest of society."

Response: None of the objections to doctor-assisted death that I have stated thus far are based on religion. The American Medical Association and more than 40 other medical organizations oppose doctor-assisted death. None of these organizations have religious affiliations and most of them support legal abortion.

Legislation or public policy that happens to parallel religious teachings is not automatically made irrelevant{15}. Our laws against stealing, lying, and murder also coincide with certain religious teachings (the Ten Commandants). It would be absurd to suggest that such laws be eliminated because of this.

"If some suffering patients can die by refusing life-sustaining treatments then why can't other suffering patients die by requesting life-ending treatment?"

Response: These are totally different situations. Patients are removed from life support equipment to respect their wishes regarding unwanted medical care and to allow a natural death if the time has come. The patient does not ALWAYS die: Karen Quinlan lived 9 years after her mechanical ventilation was discontinued. Doctor-assisted death is intended to give the patient no chance at survival. Previous "right to die" legislation (Quinlan, Cruzan) was successful because withdrawing life support was portrayed as being very DIFFERENT from euthanasia. When we remove a patient from a ventilator we do not also remove all oxygen from the patient's hospital room. (The only "right to die" is the right to die NATURALLY.)

The U.S. Supreme Court recognized this difference as "a distinction widely recognized and endorsed in the medical profession and in our legal tradition"{16}. The Court also cited 34 prior legal decisions that upheld this distinction.

"Opinion polls have repeatedly shown that the majority of the American public and the majority of American doctors are in favor of legalization. This is America: give the people what they want."

Response: The issues involved in doctor-assisted death are very poorly understood by the American public. Because of this, the accuracy of various opinion polls has been questioned. If the public strongly favors doctor-assisted death, they why did referendums for assisted suicide fail in both California and Washington and only pass by the narrowest of margins (51%:49%) in Oregon in 1994 (all of these states are very liberal).

It should be noted that certain subgroups of Americans are strongly opposed to doctor-assisted death. These include nursing home patients, the disabled{17}, and some minority groups{18}. The majority of oncology (cancer) physicians{19} are opposed to euthanasia and so are the majority of hospice workers{20}. These are the health care workers that work most directly with the dying. If the majority of physicians favor legalization, then why did the physicians of the Oregon Medical Society recently vote 121-1 to support the repeal of the Oregon Death With Dignity Act? (American Medical News, 5/19/97). In November 1997, the people of Oregon voted NOT to repeal this act by a 60%:40% margin, but no other states have legalized assisted suicide.

The Michigan State Medical Society has changed its position on physician-assisted suicide from "neutral" to "strongly opposed"{21}.

Furthermore, "consensus ethics" is a dangerous practice. It has given us slavery and the Nazi Holocaust. If a majority of Americans were ever to support pedophilia, should we then make it legal?

"I am personally opposed to doctor-assisted death, but I don't want to force my beliefs on other people."

Response: I find your position confusing and morally contradictory. Why do you personally oppose doctor-assisted death? If you feel that it is evil or immoral, then why don't you feel a responsibility to stand up against it? This same kind of attitude allowed the Holocaust to happen. How many good German people were personally opposed to the killing, but...? Since when do Americans tolerate evil and immorality in the name of pluralism? We do not take this approach with other evils such as child abuse and pedophilia. It is a tradition in America for individuals to fight for what they think is right and fight against what they feel is wrong. You must not feel very strongly about this important issue.

"If a woman has a right to an abortion, then a suffering patient has a right to doctor-assisted death."

Response: This is perfect example of the slippery slope of immorality. The right to life is the most fundamental of the human rights. Like legal abortion, legalization of doctor-assisted death will lead to its own slippery slope (just as we have seen in the Netherlands). Many medical organizations that fully support legal abortion are strongly opposed to doctor-assisted death (i.e., the American Medical Association).

The "right" to an abortion is predicated upon the idea that the unborn child is "not a person". How can this be applied to adults with terminal illness{22}? It is worth noting that, at the time of Roe vs. Wade, proponents of abortion scoffed at the prospect of legal abortion eventually leading to legal euthanasia. Closing thought: If a mother can kill her innocent, unwanted daughter for the sake of convenience, then why can't a daughter kill her innocent, unwanted mother for the same reason?

"Legalizing doctor-assisted death will probably result in fewer actual cases of it in the U.S. If patients know that they have the option available, they will be less likely to attempt suicide out of fear when they are in the early stages of an illness."

Response: The data from the Netherlands does not support this contention. In the Netherlands, tolerance of doctor-assisted death has led to more doctor-assisted death{23} {24} {25}.

Note: Although doctor-assisted death is technically "illegal" in the Netherlands, it is endorsed by the government and widely practiced by physicians. No Dutch physician has ever served a prison term for violating euthanasia laws{26}.

(Author: Dr. Keith Simcic, M.D., FACP San Antonio, Texas written January 1998)

(The article below is referenced in the "Debating Points" section.)

Kenneth J. Simcic, M.D.

In November 1994, Oregon passed a law that legalized physician-assisted suicide. In a statewide referendum, the law passed narrowly by 51 percent to 49 percent. Even though implementation of the law was blocked by a judicial injunction that is under appeal, 12 other states have since considered similar legislation.

Texas voters may soon face this difficult issue. Is legalization of assisted suicide a step toward a kinder and gentler society, or is it a major assault on the sanctity of human life?

Those who support legalization of assisted suicide often use the experience of the Netherlands (Holland) to support their case. For more than 15 years, the Dutch government has permitted assisted suicide as well as euthanasia by lethal injection. Some say that Holland has a "model" system for doctor-assisted death that other nations should emulated, but close examination of the facts leads to a different conclusion.

At first, euthanasia in Holland was permitted only if physicians followed strict guidelines. Patients had to be conscious, mentally competent, in unbearable pain and suffering from a terminal disease. A voluntary request for euthanasia was also necessary.

However, the Dutch government did not closely monitor the practice of euthanasia until a nationwide study was performed six years ago. The study revealed that approximately 9,000 Dutch patients requested euthanasia or assisted suicide in 1990. Euthanasia was performed on 2,300 of these patients, while assisted suicide was performed on 400. These 2,700 deaths represent two percent of the 129,000 total deaths reported in Holland during that year.{27}

Closer inspection of the statistics reveals that an additional 1,000 patients had their lives terminated without specifically requesting the termination. Also, 8,000 terminal patients were intentionally given lethal overdoes of pain medication. Fewer than half of the overdosed patients had requested euthanasia {28} {29}.

Perhaps the most disturbing finding of the study was that more than 60 percent of the doctors surveyed admitted to falsifying the cause of death on death certificates after performing euthanasia{30} {31}. This implies that the study grossly underestimated the true incidence of doctor-assisted death in Holland.

Despite these findings, no further restrictions were placed on euthanasia. As a result, Holland has tumbled off its slippery slope and into a moral free-fall. For instance, in 1991, a Dutch psychiatrist gave a lethal dose of barbiturates to a severely depressed 50-year-old woman at her request. The woman had recently suffered a bitter divorce and the deaths of her two children, one from cancer, the other from suicide{32}.

The Dutch Supreme Court found the doctor "guilty," but exempted him from any penalty. The court ruled that there was no distinction between physical and emotional suffering in euthanasia. (No Dutch doctor has ever served a prison term for violating euthanasia laws.{33})

In July 1992, the Dutch Pediatric Association announced that it was issuing formal guidelines for the physician-assisted suicide of severely handicapped newborns. Just eight months later, a physician gave a lethal injection to a three-day-old handicapped baby{34}. The physician was acquitted because he obtained the consent of the parents and followed the official guidelines for adult euthanasia. It has since been reported that at least 10 Dutch babies are euthanized every year. A recent report also indicates that a growing number of older children with cancers and degenerative diseases are having their lives ended through euthanasia and that doctor-assisted death is gaining wider acceptance among adolescent patients and their physicians{35}.

Holland's most recent development involves a 38-year-old Dutch nurse who gave a lethal injection at the request of a friend suffering from AIDS{36}. Dutch law requires that a physician perform euthanasia, and the nurse was found guilty of violating this law. However, she was given only a two-month suspended sentence, and she is appealing the decision. With these rulings, the liberal Dutch courts have now nearly eliminated any formal legal restriction on any doctor (or nurse) killing any patient for any reason.

It is ironic that euthanasia was first allowed in Holland to give people more control over how they die. Instead, Dutch people have less control than ever over the circumstances of their death. Some have even resorted to carrying "Passport for Life" wallet cards to protect themselves from involuntary euthanasia should they become comatose or mentally incompetent.

One should remember that Holland's slide into involuntary euthanasia and euthanasia for non-terminal patients has occurred in a country that has universal health care. The slope could prove even more slippery in a country like our own where families and third-party payers might be burdened financially in caring for the sick, the disabled and terminally ill{37}.

Holland's experiment with physician-assisted death has become a tragic failure. If we learn from this tragedy, we can avoid the same mistake.

Endnotes

1 Simcic KJ. Lessons from the Netherlands. Lone Star Citizen. April 1996, 8(4):1.

2 Gianelli DM. Once again, Oregon voters ponder fate of assisted suicide. American Medical News. 8/25/97:9. Shapiro JP. & On second thought ... Oregon reconsiders its pioneering assisted-suicide law. U.S. News & World Report. 9/1/97:58-60. & Gianelli DM. Dutch euthanasia expert critical of Oregon approach. American Medical News. 9/15/97:10.

3 Monod P. Insurance companies making a financial killing off assisted suicide. Today's Catholic. 1/2/98:17.

4 Groenewoud JH, van der Wal G, et al. Physician-assisted death in psychiatric practice in the Netherlands. N Engl J Med 1997; 336:1795-1801. & Ganzini L, Lee MA. Psychiatry and assisted suicide in the United States. N Engl J Med 1997; 336:1824-26.

5 Ibid, Ganzini L, Lee MA.

6 Hammack JE, Loprinzi CL. Use of Orally Administered Opiods for Cancer-Related Pain. Mayo Clinic Proc 1994; 69:384-90.

7 Foley KM. Competent Care for the Dying Instead of Assisted Suicide. N Engl J Med 1997; 336: 54-8.

8 Emanuel E. Euthanasia: Historical, Ethical, and Empiric Perspectives. Arch Intern Med 1994; 154:1890-1901.

9 Gianelli L, Lee MA. Psychiatry and assisted suicide in the United States. N Engl J Med 1997; 336:1824-26.

10 Hammack JE, Loprinzi CL. Use of Orally Administered Opiods for Cancer-Related Pain. Mayo Clin Proc 1994; 69:384-90.

11 Simcic KJ. Lessons from the Netherlands. Lone Star Citizen. April 1996, 8(4):1. Gianelli DM. Dutch data indicate doctor-assisted death on the rise. American Medical News. 1/13/97:4.

12 Hammack JE, Loprinzi CL. Use of Orally Administered Opiods for Cancer-Related Pain. Mayo Clin Proc 1994; 69:384-90.

13 Annas GJ. The Bell Tolls for a Constitutional Right to Assisted Suicide. N Engl J Med 1997; 337:1098-1103.

14 Simcic KJ. Lessons from the Netherlands. Lone Star Citizen. April 1996, 8(4):1.

15 Marker R. Euthanasia: Answers to Commonly Asked Questions (in "Euthanasia: Implications for Hospice" published by the International Anti-Euthanasia Task Force, P.O. Box 760, Steubenville, OH 43952; Phone" (614)282-3810)

16 16 Annas GJ. The Bell Tolls for a Constitutional Right to Assisted Suicide. N Engl J Med 1997; 337:1098-1103.

17 Willing R, Castaneda CJ. Protesters see no mercy in assisted suicide. USA TODAY. 1/9/97:3A.

18 Foley KM. Competent Care of the Dying Instead of Assisted Suicide. N Engl J Med 1997; 336:54-8.

19 Emanuel E, Fairclough DL, Daniels ER, Clarridge BR. Euthanasia and Physician-assisted Suicide: Attitudes and Experiences of Oncology Patients, Oncologists, and the Public. Lancet 6/29/96; 347:1805-10.

20 Marker R. Euthanasia: Answers to Commonly Asked Questions (in "Euthanasia: Implications for Hospice" published by the International Anti-Euthanasia Task Force, P.O. Box 760, Steubenville, OH 43952; Phone" (614)282-3810)

21 Gianelli DM. Michigan doctors change stance on assisted suicide. American Medical News. 5/19/97.

22 Annas GJ. The Bell Tolls for a Constitutional Right to Assisted Suicide. N Engl J Med 1997; 337:1098-1103.

23 Gianelli DM. Dutch data indicate doctor-assisted death on the rise. American Medical News. 1/13/97:4.

24 Van Der Mas PJ et al. Euthanasia, Physician-Assisted Suicide, and Other Medical Practices Involving the End of Life in the Netherlands, 1990-1995. N Engl J Med 1996; 335:1699-1705.

25 Spanger M. Mental Suffering as Justification for Euthanasia in the Netherlands. Lancet 6/25/94; 343:1630.

26 Simcic KJ. Lessons from the Netherlands. Lone Star Citizen. April 1996, 8(4):1.

27 Van Der Mas PJ, Van Delen JJM, Pijnenborg L, Looman CWN. Euthanasia and Other Medical Decisions Concerning the End of Life. The Lancet 9/14/91. 338:669-674.

28 Shapiro JP, Bowermaster D. Death on Trial. U.S. News and World Report 4/25/94, 31-39.

29 Jochemsen H. Euthanasia in Holland: an Ethical Critique of the New Law. Journal of Medical Ethics, 1994; 20:212-217.

30 Jochemsen H. Euthanasia in Holland: an Ethical Critique of the New Law. Journal of Medical Ethics, 1994; 20:212-217.

31 Orlowski JP, Smith ML, Zwienen JV. Pediatric Euthanasia. American Journal of Diseases of Children, 1992; 146:1440-46 (page 1441, 1443).

32 Spanjer M. Mental Suffering as Justification for Euthanasia in Netherlands. The Lancet 6/25/94; 343:1630.

33 Dutch Group Favors Distancing Doctors from Euthanasia. American Medical News 9/11/95.

34 Spanjer M. Terminating Life of Severely Handicapped Dutch Baby. The Lancet 4/15/95; 345:975.

35 Orlowski JP, Smith ML, Zwienen JV. Pediatric Euthanasia. American Journal of Diseases of Children, 1992; 146:1440-46 (page 1441, 1443).

36 Spanjer M. Nurses Cannot Assist Suicide in the Netherlands. The Lancet 4/1/95; 345:849.

37 Terry PB. Euthanasia and Assisted Suicide. Mayo Clinic Proceedings 1995; 70:189-92 (page 191).