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

!3
choice
group
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

!4
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
choice
group

!5
Introduction
choice
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

!10
Chapter 1The Netherlands & Oregon
group

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
!11

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 LegalAspects
choice
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
!25

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
!26

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
!27

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
!28

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
!29

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
!30

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
!31

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
!32

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
!33

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
!34

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
!35

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
!36

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.
!37

!38
Chapter 3 EthicalAspects
group
choice

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.
!39

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
!40

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
!41

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
!42

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:
!43

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
!44

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.
!48

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.
 
!50

!51
Final Policy Recommendations
choice
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.
!53

!54
Appendix
group

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.
!55

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

!66
Glossary
Ehis Osifo | Madison Palms | Nona Haller | Robert Baillargeongroup
choice

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

• 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)
!68

!69
Bibliography
group

Almagor-Cohen, Raphael. “The Guidelines for Euthanasia in the Netherlands:
Reflections on Dutch Perspectives.” Ethical Perspectives. 9:1 (2002): 3-20. 7 Apr.
2015.
Angell, Marcia. “A Method for Dying with Dignity.” Boston Globe. 29 Sep. 2012.
Web. Accessed 7 Apr. 2015.
Angell, Marcia. “The Supreme Court and Physician-Assisted Suicide—The Ultimate
Right.” The New England Journal of Medicine. 336 (1997): 50-53. 7 Apr. 2015.
Arestad, Kim C. “Vacco v. Quill and the Debate Over Physician-Assisted Suicide: Is
The Right to Die Protected by the Fourteenth Amendment?” N.Y.L Scholarly
Journal of Human Rights. 15 (1998-1999): 511-540. 5 Apr. 2015.
Bernabei, Roberto, et al. “Management of Pain in Elderly Patients with Cancer.” The
Journal of the American Medical Association. 279.23 (1998): 1877-1882. 29 Mar.  
2015.
Bever, Lindsay. “Brittany Maynard, as promised, ends her life at 29.” The
Washington Post. 2 Nov. 2014. Web. Accessed 7 Apr. 2015.
Bilsen, Johan, et al. “Changes in Medical End-of-Life Practices During the
Legalization Process of Euthanasia in Belgium.” Social Science and Medicine.  
64.4 (2007): 803-808. Web. Mar. 31 2015.
Bolt, Eva. “Can Physicians Conceive of Performing Euthanasia in Case of Psychiatric
Disease, Dementia or Being Tired of Living?” Journal of Medical Ethics 10
(2015): 1-7. Web. Accessed March 29, 2015.
!70

Capstone Official Final Paper

Recommended

Recommended

More Related Content

Similar to Capstone Official Final Paper

Similar to Capstone Official Final Paper (16)

Capstone Official Final Paper