physician assisted suicide

Physician Assisted Suicide and The Art of Care

Abstract:

In an age of managed care, rationing of care, and technological care, there is The Art of Care. We live in a society that has been given various choices to “self-determine” one’s destiny in dying as one has been able to “self-determine” one’s destiny in life itself. We have medicines and technological capabilities, and areas of the country allowing us to hasten or postpone one’s dying. The purpose of this position paper is to outline the legal, ethical, religious, and philosophical ramifications involved in Physician Assisted Suicide (PAS) and how affects of such decisions effect those connected to this issue.

The pros for PAS are:

· People should have the right to die with dignity

· People should have the right to die with their senses intact

· People should have the right to die free of pain

· People should have the right to take charge of futile care

The cons for PAS are:

· Slippery-slope effect, or acceptable and unacceptable euthanasia

· No policy is able to effectively govern the scope of the right to die

· True wishes are hard to discern due to communication challenges

· Playing God

I am simply giving an overview, and not, a detailed analysis on this issue. My intent is to surface the issues in PAS and move toward a philosophy of care that can minimize people’s fear of death by the utilization of a type of care = The Art of Care. The Art of Care will help people gain inner strength that can enable him or her to cope with the external losses happening to their body. At the end of this paper, I hope to outline practical ways people can help terminal patients cope with a dying body from a place inside them that remains steadfast – their soul.

Introduction:

It was Karl Barth who said that “it is for God and God alone to make an end to human life” and that God gives life to us “as an inalienable loan.” (1) It is my belief that we are given meaning and hope in all life situations. This instinct to survive and find value in all of our existence leads me to trust that there is much to learn in all phases of our life. Our ability to trust our Creator’s divine guidance and plan to make us more soul than body at the end of life is just as important as other aspects of living as well. We may do well to trust more and control less. It appears that maturity teaches us all to let go and follow a path inside us that does not always make sense to us externally. As we do, we begin to follow insight. To see from within what cannot be seen from without is our soul’s longing to be known and to surface in our lives.

In On Liberty, John Stuart Mill cautions, “A person should be free to do as he likes in his own concerns, but ought NOT to be free to do as he likes in acting for another, under the pretext that the affairs of the other are his own affairs. (2) Autonomy is so important to us that science, as well as religious communities strive to honor and respect it. For within autonomy is the ability for one to discern for him or herself one’s needs, values, and destiny. This is a movement into the art of care (science and religion) can work together in forging a healing response on the level of soul when physical cure is no longer possible.

On the other side of this issue, it is evident that the Oregon ’s Death with Dignity Act has had its impact on America . Some people want this service available even if it is not chosen by a great number of people. The Oregon ’s Death with Dignity Act has been used very sparingly and a slippery slope does not appear to be in the present forefront. “In 2001, twenty-one Oregonians chose to end their lives by ingesting a lethal dose of medication prescribed by a physician, accounting for 0.33% of the 6,365 Oregon deaths from similar diseases. The number of Oregonians opting for physician-assisted suicide has remained fairly stable, ranging from sixteen in both 1998, the first year the law was in effect, to twenty-seven in both 1999 and 2000. Clearly, there is no landslide in the making.” (3)

It seems then, that people still want to have some sort of control in their dying and autonomy remains prevalent throughout the issue with PAS. This strong need to determine one’s path in the face of suffering offers us hope, faith, and love in a sense of the self not easily defined without losing the grandeur of a trust within oneself to be led by the same power that brought our lives into being. It is here that we turn to the art of care to help us when curative care no longer has any answers. Here, we begin where we end, in that we trust in the very wisdom that has created us.

Meanings, Levels of Care, and Approaches to Care:

There are three levels to discern in the act of euthanasia:

1. One is a patient who is comatose or brain dead. In these cases the doctor is asked to “pull the plug,” or remove the patient from mechanical life support. These cases are generally not challenged by the general public. It is an act of withdrawing or withholding necessary mechanisms used to sustain a life that cannot sustain itself. It is here that the recognition of one’s personality is gone and the shell of a body is all that remains.

2. Another act of euthanasia involves the use of morphine to hospitalized patients in the painful final stages of her or his life with diseases such as cancer and AIDS.

3. The last category of euthanasia is patients in relatively good health and at the beginning of a terminal illness wishing to end their lives. Such cases as Alzheimer’s and Cancer preclude patients to want information on PAS. This is the most controversial of the three issues involved in euthanasia.(4)

Euthanasia originated from the Greek language meaning “good death.” It is the intentional termination of a life by another person capable of doing so by the request of the person wanting to die. Here are a few terms that one needs to know in PAS that define actions taking place.

Passive Euthanasia is the hastening of a death by means of altering some form of support and letting nature take its course. This can include; removing life support equipment, stopping medical treatment or procedures, stopping food and water consumption which leads to dehydration or starving to death, and withholding CPR (Cardio-Pulmonary Resuscitation). The most common use of PAS is to give patients large doses of morphine to control pain. It is most likely that the pain relief will suppress respiration and cause death earlier than it would have otherwise happened. This is also done on patients who are in a persistive vegetative state or patients not able to regain consciousness due to brain damage.

Active Euthanasia is the use of intentional means to cause the death of a person through a direct action. Dr. Jack Kevorkian, a Michigan physician made this well known in 1998 with a patient who had ALS (Lou Gehrig’s Disease). His patient was afraid of the long suffering involved in ALS and wanted to die a quick and painless death. Dr. Kevorkian injected controlled substances into this patient and caused death. Kevorkian was charged with 1^st degree murder, but the jury found him guilty of 2^nd degree murder in March of 1999.

Physician Assisted Suicide is the provision of information or means to a dying patient with the intent to commit suicide.

Involuntary Euthanasia is the ending of a life without a patient clearly requesting it.

“There are many reasons why patients want to utilize PAS. Some are simply clinically depressed, of which, one’s illness has brought on or one’s emotional and mental processing of their illness has led to suffering in ways beyond the body. Others live in chronic pain-due to lack of healthcare coverage or means to obtain medication. This later group would rather die early and not incur medical expenses on those they leave behind. A serious disorder or disease such as: ASL, Huntington’s Disease, Multiple Sclerosis, AIDS, Alzheimer’s, etc. are just some of the illnesses people would rather avoid losing their independence and finances over. In some ways, this gives people a feeling of control over the process of their lives.” (5)

Philosophical Approaches:

When all is said and done, there are two philosophical approaches to suicide: Thomas Aquinas (circa 1225-1274 CE) condemned all suicide (whether assisted or not) because it goes against one’s natural desire to live, it harms other people, and life is a gift of God and is thus only to be taken by God. Michel de Montaigne (1533-1592 CE) argued that suicide was a matter of personal choice and a human right. (6)

These two philosophies remain issues in 2003. Suicide used to be a criminal act. Now, it is no longer something that carries so much weight. But, assisted suicide does remain a criminal act throughout North America except in the state of Oregon . In Oregon , it is allowed under tightly controlled conditions.

As you can see, there is a theme consistent within both of these approaches. Both reflect the need to go within oneself for personal direction. Although both seem to be opposite ends of the spectrum, each encourage terminal people to find strength in one’s inner being and trust the guidance that is consistent with the person’s personality.

Ethical and Religious Considerations:

Some terminally ill patients are in so much pain that they would rather end their life than to go on suffering and experience a poor quality of life. Because of physical and mental limitations, people in pain have a much different view on living than people with good health. This altered view makes some choose certain courses of care in a debilitating illness he or she may not even consider in a healthy state of being. Many healthcare providers claim that terminally ill people’s pain can be controlled to tolerable levels with good pain management, yet there are tens of millions of patients who do not have access to adequate pain management in the U.S. alone.

Many religious organizations believe that suffering can be used to purify us. This purification can be for the caregiver and for the patient. It is a time to learn and be aware how the body becomes more soul in the process of transformation associated with dying and death. Christians believe that life is a gift from God and God does not send us any experience we cannot handle. Islam states in the Qur’an, “Take not life which Allah made sacred otherwise than in the course of justice.” And “Since we did not create ourselves, we do not own our bodies.” Orthodox Judaism states that “This is an issue of critical constitutional and moral significance which Jewish tradition clearly speaks to. We believe that the recognition of a constitutionally recognized right to die for the terminally ill is a clear statement against the recognition and sanctity of human life….”(7)

It is clearly evident that religious influence upon PAS deems such an act as going against one’s Creator, and as such, the need to pray and discern the direction of one’s life and dying should be in the consultation of clerical status of one’s own faith. To override such influence would take an autonomous individual whose beliefs have taken him or her from what can be known religiously to what can be known through them by the same force that gave them life. It is here that terminal patients choose a course of action from the core on one’s being transcending his or her belief in their creator (religiously) leading to an active participation of one’s assessed values (personal transformations) that includes their religious influence, but it is not limited to it as well.

U.S. Supreme Court Decisions:

“The Supreme Court rendered its decision on the New York and Washington cases, on June 26, 1997. They found that the average American has no constitutional right to a physician assisted suicide. The vote was 9 to 0, an unusual, unanimous decision. Thus, the New York and Washington laws which ban such suicides are constitutional. On the other hand, the court implied that there is no constitutional bar that would prevent a state from passing a law permitting physician assisted suicide. Oregon has done exactly this. So, the battle must be fought on a state by state basis. Chief Justice Rehnquist wrote: “Throughout the nation, Americans are engaged in an earnest and profound debate about the morality, legality and practicality of physician assisted suicide. Our holding permits this debate to continue, as it should in a democratic society. (8)

This governmental act seems to indicate a core value in the United States that PAS challenges. Autonomy is such a personal choice and value held in high regard in our country. Although there are cases whereby rights do not imply that certain choices are right to choose, these cases are held on a case by case basis as well. Sometimes, futile care just does not make sense. These cases are cared for with sensitivity and time, issues medicine and technology cannot cure.

Pain Relief Promotion Act:

Presently, there are no approved drugs by the Food and Drug Administration for the use of killing patients. Drugs are made to treat illness, and not to end a life.

1996 – July: Bill passes House subcommittee: A bill was passed by the Constitution Subcommittee of the Judiciary Committee of the House of Representatives called the Pain Relief Promotion Act. It was aimed at preventing doctors help patients obtain their doctors assistance in suicide.

1999 – October: Bill passes the House: It was passed by a vote of 271 to 156. Lori Hougens, spokesperson for the National Right to Life movement was pleased. She stated, “Congress has just sent a very strong bipartisan message that the appropriate role of a doctor is to be helping their patient, not pushing them off a bridge…Doctors should not be killing their patients, they should be helping them.” (9)

With this in mind and the history of pain in patients who report degrees of suffering mentioned earlier in this paper, it seems that more work in providing money and resources in the study and application of palliative care methods are in order. We have came a long way in defining and debating PAS, now, to move toward the alleviation of pain may give many hope in their dying through scientific means. Religion attempts to do such in finding meaning in suffering. Science needs to step up to the plate and provide the knowledge and care capable of alleviating suffering. In the year 2003, we call spiritual care methodologies beyond the scope of church affiliation complementary care. On this side of the issue in regards to suffering, science has to catch up to complementary medicine modalities. Thus, it is clear that science and religion has their strengths and pull each other forward. Neither, being the greater of the two without losing what inspires people to care for those who need it most.

Survey of Physicians:

Dr. Diane Meier of Mount Sinai School of Medicine in New York , NY gave a survey of 1,902 doctors inquiring about the use of PAS. The poll centered around those dealing with aging patients and dying patients. The following are areas patients usually request PAS:

· 6.4% of those who responded admitted to helping at least one patient commit suicide

· The real number is probably much higher because most physicians will not admit to helping someone commit suicide – this would be a criminal act.

Patients gave many reasons for wanting to die:

· 79% cited discomfort other than pain

· 53% cited loss of dignity

· 52% cited fear of uncontrollable symptoms (10)

As you can see from this survey, there are “some” cases beyond medical knowledge to care for people’s pain in an adequate way. This is not to imply that PAS is the answer. It is an indicator just how much more study is needed in the area of palliative care. Adequate care for the terminally ill is a priority we must find resources for, so we can care for each other at the end of life as we do at birth and through maturity.

Hospice Program: Suicide Policy:

“Hospice has a philosophy of care and a program of skilled pain and symptom management aimed at diminishing physical, emotional, mental, and spiritual pain. Hospice does not hasten or postpone death. In essence, Hospice staff does not participate in actions that solely support a patient’s intent to commit suicide.

Procedures:

1. If a patient intends to commit suicide, staff does the following:

A. Encourage the patients to talk about what brought him/her to this decision;

B. Assess the patient for increased pain and suffering, depression, suicidality, competency, impaired thinking, confusion, dementia, and manipulation by others.

C. Tell the patient that information needs to be shared with family, doctor, and hospice staff.

D. Confirm with pt/family that hospice does not assist in suicide.

E. Notify the Nursing Coordinator and Hospice Coordinator

F. Present this information to the interdisciplinary team and decide on a plan of care which may cause further exploration into this issue by a psychiatrist, psychiatrist nurse or a psychologist. An increase of supportive care would be initiated as well.

G. Notify Doctor as needed on updates.

2. When a patient requests Hospice staff for help in committing suicide, we will do the following:

A. Reconfirm with pt/family the Hospice policy against assisted suicide.

B. Inform supervisors, the interdisciplinary team, patient’s doctor, etc…of the patient’s intent and any concrete plans.

C. Continue to monitor and follow the plan of care and reassess it as changes develop.

Used by permission, Emerson Hospital (11)

Closing Remarks:

“The Hippocratic oath, which forbids killing by physicians, began in ancient Greece at the time of Socrates. It is often considered the origin of medical ethics, but that common impression was disputed in 1931 by Ludwig Edelstein, an historian of medicine. (12) On March 26, 1998, the first KNOWN legal, PAS happened in America . This case occurred in Oregon . A physician gave a woman with terminal breast cancer lethal drugs that were legally prescribed. Many doctors did not like this new role of physicians, but many citizens thought it was a good thing.

There are no easy conclusions to be made on PAS. There are a great number of people who are for and who are against PAS. The debate was not determined by the government stating that a democratic society needs to determine for him or herself the direction of his or her life and death, thus, sending this issue into individual states to determine the direction of their citizens. One thing is clear; the United States of America continues to uphold autonomy and the individual rights of Americans to determine the course of his or her life. And, it seems that PAS will not be an issue that will be determined in the near future.

*My central argument in this paper is NOT to persuade you to be for or against PAS. Research indicates that there are as many good reasons for it as against it. It is for each of us to decide for ourselves the direction of our lives. Anyone who has had children or watch children grow knows autonomy is alive and well within us all. This guiding force inspires us to love, let go, and embrace again life in all its transitions. As we mature, we realize that it is not the experiences of our lives that give us meaning and value: rather, it is the expressions within these experiences that give us life.

The expressions of living are the flow of life moving through us and not from us allowing us to know the true meaning of autonomy. It could be said that our autonomy is our soul’s code. It may just be our authentic self drawing our attention inside us to be heard. This voice is a message of hope in dying that allows those who care for a dying patient to listen to his or her own authentic voice. Perhaps, more attention placed on what can be known through us (The Art of Care) and what we know (Science) will enable us to forge a bridge between two fields of care that are after a similar goal.

It is my hope that the art of care which is the spirit of any movement will inspire healing and will continue to be the guiding force in this issue. If we were to spend more time in creating better care and responding to the needs of suffering patients in a caring way, I can’t help but wonder if physician assisted suicide would be more of an option sparingly considered. In my work with Hospice patients over the last 12 years, I have noticed people who are free of pain go on and make the best of their days. Hospice does not postpone or hasten one’s dying. We are a service that provides management of pain issues mentally, emotionally, physically, and spiritually.

There is a saying in Hospice that we do not add days to one’s life, but we do add more life to one’s days. There is much to learn in life AND in our dying. As a patient begins to die, a flood of memories fills their heart, mind, and soul. This inner life or one’s soul awakens a powerful force of nature. Here, a dying patient becomes more soul than body, giving way, to a presence of awareness inside us all.

This awareness fills those who care for a dying patient with a sense of sacredness. It helps all of us involved in caring for a dying patient to embrace what cannot be touched with human hands. In so doing, we connect to an eternal awareness inside each other that has been with us all along. It is the soul’s longing to be known, blessed, cared for, and loved. PAS cuts off this process of living to the end. And, dying patients have so much to share with us during this process of dying into life eternal.

In my work with dying patients, I have been taught the ART OF CARE. The art of care is a willingness to bear the burdens of another person until they die. This heartfelt connection with a fellow human being allows us to realize that what is the most sacred to us is often the most human. Over time, we connect deeply into the creative order around us. It is not easy to let go. With care, love, and support, a dying patient can let go of the known world and open up to the mysterious world known as the soul. It is a sacred place – not made with human hands. As such, through prayer, letting go, and opening up to guidance from within, we find a spirit inside us that has led us into the world, through it, and has the creative intelligence to lead us home. It is the center of creation itself and perhaps, the heart of our Creator as well.

A Physician Assisted Suicide Alternative:

Having said the above conclusions, I want to further my thoughts in what I mean by THE ART OF CARE in dealing with people who are considering PAS. The following thoughts are considerations and concerns. My hope is to offer an alternative approach to people and extend the discussions beyond care of the body, and into care of the soul. Because I have served for over 12 years now in palliative care, you will hear a bias in this direction adding the element of soul care, or the art of care. In the following brief essay, I want to outline what I believe is a quality of care that speaks to caring in an artful way awakening one’s soul in the dying process.

We live in a time where PAS is an option, and thus, what has entered our consciousness is the epitome of personal autonomy. We have found another way to indulge ourselves in another “right.” In a society where such rights often supersede responsibility, the avoidance of pain – be it emotional, mental, or physical – is put above all else. In our society, pleasure is preferred to principle. Yet what we become as a result of our challenges develops our character. We become better people. We feel better about ourselves. And we relate better to others when character is honored.

I am aware of many people making choices in favor of PAS, and these choices reflect character from their point of view. But the purpose of this rendition inside this paper is to clarify an alternative. Physical and emotional pain has a way of leading us to peace.

In pain, we are born. In various degrees of pain, we leave this world. When we are in pain, we look for external ways to get through it. When we foresee no relief from pain apart from death, we tend to look inward for guidance. For this reason, the following are spiritual concerns I want to raise concerning PAS.

PAS avoids the natural process of life we call dying. In the name of compassion, PAS claims to promote mercy. It is an attempt to restore a body’s state of equilibrium or peace. It is an attempt to ease pain to a body in great “dis-ease.” And it is in these times of discomfort that we reach beyond our mind and body for hope.

In the midst of despair, we cry out for hope – a hope that will sustain us through our pain, guide us deeper into and through our suffering, remind us of our central focus, elicit the Sacred’s care in the face of pain, and lead us from pain to peace.

The problem is that people want immediate results to ease present pain. This is understandable. Yet I can’t help but believe PAS has evolved out of an alternative to faith; rather than, being inspired by faith in a power greater than ourselves. If you think about it, our lives are in the hands of skilled doctors and nurses who care for us. These healthcare practitioners are gifted. They are gifted by a power greater than themselves. Some may call this genetic or dna patterns given at birth, but as we age, we come to know that all things are beyond even the person with the greatest of knowledge.

PAS addresses outcomes of care that relieve physical pain, but the effects of this care raise doubts and questions and a lack of spiritual resolution. PAS undermines contemplation, character, and faith at the end of life. This is not to say that some cases may require scientific intervention such as terminal sedation to ease the burden of pain. I just want to say that I am not convinced PAS offers much in the way of soul care at a time in life that is just as vital as living. Often, it is not until we lose our roles, expressions of personalities, and ability to act on our character that soul is revealed in our dying. As the mind and body’s expressions fade in dying, our dying loved ones lead us to care for them in a gentle awareness beyond these exterior expressions – to their spirit. It is in this place that souls meet creating invisible bonds we never forget.

PAS cuts off spiritual reflection at the end of life. PAS claims to provide comfort and care for the mind and body. Yet we are more than a mind and a body. We are interconnected with a sacred universe. This dimension of our being is cut off in PAS, and the Sacred is not given opportunities to grow through one of its greatest challenges. We are transformed through life’s challenges. Why then do we not extend this into dying? Death is a part of living and therefore I question the holistic nature of PAS.

PAS is not just a moral and legal debate. PAS keeps us from exploring life until we die. Often our spirit encourages us to remain engaged in life when no apparent hope can be found. This is where we find our greatest capacities for faith. Spirit has a natural process of revealing life. We evolve into this world, we evolve through it, and we evolve out of it. We each come from somewhere, and we are each going somewhere. Along the way, we engage in experiences and become a part of those experiences. Nothing really dies on this level of awareness for we become aware that we are more than a body.

PAS interrupts this natural flow. It is usually based on the fear of pain and being a burden to others. The focus at this point is on avoidance. Instead, we could be integrating courage in the face of adversity. Furthermore, we may even be losing out at the end of life on a possible gift by our Creator.

We are not guaranteed a life free from suffering, but we can be freed from our suffering. This hope cannot be found in a pill. This hope goes much deeper. If we choose PAS, we cut off this hope revealed to us at birth. It is the eternal dance of spirit manifested in the cycles of life. Here, we are reminded that life must continue no matter what transformations in physical reality occur. In this deeper part of us, it is more vital to be engaged in life than to withdraw from it. Otherwise, no one would have learned to crawl or walk just after birth. In spirit, we transcend our fears, and we are reborn into the eternal dance of life not defined by pain.

What I am referring to in this last paragraph is the identification with our essence. Remember as a child the first time you rode a bike. You first saw others do it. Then, you imagined yourself doing it. Then, you got on your bike and tried. At first, you fall off. But, inside you are saying to yourself, if I try hard enough, maybe I can do it. You may ride for a moment and notice you are riding a bike and fall again. And then, you reach deep inside yourself to a place that no longer identifies with your body. You tell yourself that no matter what happens to my body, I will get on that bike and ride it. It is like magic in this moment because you get on this time and ride everywhere. There is something inside each of us that knows how to draw on this source of strength for abilities beyond our own capacities. It is this part of us that knows how to be engaged in the Art of Care as well.

PAS is a choice between control and surrender. PAS is a choice to end what does not belong to us. It is a choice to consider personal needs over collective conscious development of humanity. In the dying process, a person’s mind and body deteriorate, moving their attention inward. In a sense, terminal patients are making connections with their inner life. This is the private part of us we commune with daily. It is our communication with the subtle aspects of who we are. It is a vital source of strength and courage. From this part of us, we draw forth memories in our past, anticipation of the future, and bring destiny into our present awareness.

It takes great courage, faith, and hope to face each day. These are spiritual qualities describing the inner life of a soul. We have to be committed to them and make the most of any challenge. Behind these qualities are powers greater than ourselves. They do not contain energy that restores a dying patient’s body (although this should always be held as a possibility). Yet, courage, faith, and hope do hold an energy that leads to a moment of insight.

Here, we move from our perceptions and emotions surrounding transition from one life experience to another, thus yielding our whole body and mind into our Creator’s will. In this moment, a person is graced with the feeling of being loved that sustains a person’s dying. Their spirit will have an anchor, a reason, and a focal point filled with vitality and trust. It is spirit directed by our Creator. It is an energy of spiritual maturity preparing the soul for a journey that will never die. (This last section is from an article I wrote through Healing Ministry Journal, Vol.5, No.6, November/December 1998 – adaptions to this article…June 2003).

Suggestions for the Art of Care in alleviating suffering in the terminally ill patient:

Many people are left alone when news that he or she is dying – just show up.

Do not fear talking openly to someone about their dying.

Talk about God or one’s higher power.

Listen without judgment to a dying patient tell you their story.

Allow yourself to learn something from a dying patient.

Offer very little advice.

Remember, it is a patient’s death - not ours.

These very few suggestions are simple insights into The Art of Care and the path each of us will be destined to travel throughout life and especially at the end. Where these suggestions lead no one knows, but they are insights that engage each of us in our greatest potential of artful care. As we listen attentively with an open heart to our dying loved one's, this union of shared sorrow and shared joy may be just enough to encourage a dying loved one to live fully as they can until they die. This will not completely remove incredible pain for dying patients, but at least their pain will be cared for on a level only souls can embrace. And to me, this is the deeper level of suffering AND care no one should be without. And, when we live fully from birth to death, we can leave this world with a "whole" or "full" perspective of the life we were given at birth.

Web Sites and Books on PAS:

· Euthanasia.com

· Deathwithdignity.org

· Compassionindying.org

· “Bioethics in a Liberal Society” by Max Charlesworth (1993)

· “Is life sacred?” by Geoffrey Drutchas (1999)

· “The Good Death: The new American search to reshape the end of life” by Marilyn Webb (1997)

· “Last rights: The struggle over the right to die” by Sue Woodman (1998)

Notes:

1. K. Barth, Church Dogmatics, Vol.III: The Doctrine of Creation, Part 4, ed. B>W.

Bromily and T.F. Torrance, tr. A.T. Mackay et al. (Edinburgh: T.&T. Clark, 1961),404,425

2. J.S. Mill, On Liberty , ed. C.V. Shields (Indianapolis, Ind.: The Bobbs-Merrill Co, Inc. 1956),127.

3. Daniel E. Lee, “Physician-Assisted Suicide: A Conservative Critique of Intervention,”

Hastings Center report 33, no. 1 (2003): 17-19

4. Right TO DIE….http://www.geocities.com/HotSPrings/3872/euth.htm

5. Euthanasia and PAS.......http://www.religioustolerance.org/euth1.htm

6. “Suicide, The Internet Encyclopedia of Philosophy,” http://utm.edu/research/iep/s/suicide.htm

7. religioustolerance.org

8. religioustolerance.org

9. Jeff Johnson, “Pain relief promotion act passes house,” Family news in focus at: family.org/cforum/fnif/news/a0008306.htm1.

10. “Doctor-assisted Suicide Not Rare in U.S. , Study Finds,” Reuters News Agency, 1998-Apr-23.

11. Copyright: 1998 by The National Hospice and Palliative Care, Org. Item Number 714556; ISBN 0-931207-53-3

12. Ludwig Edelstein, Ancient Medicine: Collected Essays of Ludwig Edelstein, O.

Temkin and L. TEmkin, eds., Johns Hopkins University Press, Baltimore , MD , 1967.

Sam Oliver

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