Law and Medical Ethics: Euthanasia and Physician Assisted Death

Topics: Death, Ethics, Euthanasia Words: 4907 Pages: 18

Introduction

Euthanasia (which means “good death” in Ancient Greek) refers to bringing life to an end in a way that eliminates pain. According to the ancient Greeks the transition from life to death ought to be peaceful and noble, not an excruciating experience.¹ The patient’s ‘right to die’ has sometimes received different legal and ethical expressions in different countries. For example, most countries have recognized the right of competent adults to refuse lifesaving treatment irrespective of their clinical state, prognosis or motivation. Most have also decriminalized suicide (of any person), although only very few have decriminalized or legitimized physician assisted suicide and active voluntary euthanasia (of patients only).

Similarly, advance and/or proxy directives are becoming legally, or quasi-legally, binding in many countries.² For instance, legislations that address assisted dying in the Netherlands and Belgium are focused only on physicians. Nevertheless, in Belgium and Switzerland, as well as the UK for sometime, medical organizations stopped opposing new laws that address euthanasia. Currently, they view the subject as chiefly a societal and political subject.³ This is contrary to the viewpoint of Royal Dutch Medical Association, “which continues to play a key role in maintaining the Dutch custom of euthanasia as a medical end-of-life decision since the 1970s.”⁴

The Euthanasia Debate

Discussions of euthanasia become complicated by a) arguments of opponents of euthanasia which are of religious and emotional nature, b) negative image building around this subject, and c) lack of profound attempts of opponents to empathize with or understand persons whose last resort is euthanasia. Religious rules, dogmas and related opinions concerning euthanasia are very deep-rooted in our society and cause taboos. Like the Christian doctrine Islam has prohibited suicide or euthanasia in times of great distress,⁵ because life, death and their certainty have been created by Allah or God (in the Christian doctrine). This might be an additional reason why many professionals (also those who should help and support persons who suffer unbearable and hopeless) are unable to discuss these important matters in an open-minded and unbiased way. Jaspers et al., (2007)⁶ found that in the Netherlands religion had an increasing stronger influence on the perceptions towards euthanasia. Curlin et al., (2008) revealed that 69% of the US physicians object to physician assisted suicide (PAS), 18% to terminal sedation (TS), and 5% to withdrawal of artificial life support (WLS).⁷ Physicians who have stronger religious beliefs are more likely than their counterparts to oppose to both Physician assisted suicide and terminal sedation.

Nearly fifty percent of physicians in the Netherlands try to evade euthanasia or physician assisted suicide due to their own individual beliefs or due to the fact that dealing with the issue is an emotional burden.⁸ However, some philosophers also reject euthanasia as a possibility to terminate unbearable and hopeless suffering. They suggest that euthanasia should be forbidden even in the case of severely suffering newborns (without any hope of improvement and without any chance of a normal life in the future.⁹ ¹⁰ ¹¹ Several criticisms of the Groningen Protocol rest on misunderstandings about how it works or which babies it concerns.¹² ¹³ The authors revealed that many opponents of euthanasia do not have adequate and profound medical knowledge that is required to judge the nature and effects of medical complications of these newborns and medical treatment possibilities (and risks that are paired with treatment).

Physicians do also have problems with terminating life because they see it as their duty to save lives and not to end lives.¹⁴ ¹⁵ They try to avoid (sometimes at all costs) to be involved in decisions that might lead to euthanasia and in this way they believe that they can keep their conscience clean. Nevertheless, these physicians cannot avoid harsh reality and the horrible dimensions of life. The physicians come in this way in conflict with the medical oath which includes the obligation that they should do no harm. In fact, they compel (also legally approved) candidates of euthanasia to stay alive without any proper perspective on improvement. Furthermore, there is hardly suitable medication available in the final stages of various diseases in order to make the patients’ life more bearable. Moreover, most of these patients are also continuously dependent on others (often strange people) and also as a consequence they will suffer from a serious lack of privacy and feelings of decreased dignity.¹⁶

Circumstances under Which Euthanasia Can be Performed

In clinical ethics, it is widely acknowledged that “removing a patient from a life-saving device when the patient makes the request is ethically acceptable.”¹⁷ Such a practice is referred to as voluntary passive euthanasia. On the other hand, voluntary active euthanasia, for instance administering a deadly drug overdose to a patient with the motive of putting an end to that patient’s life, is ethically unacceptable, as is assisted suicide, which entails the provision of lethal drugs or injection to a patient. Nevertheless, supporters of voluntary active euthanasia and assisted suicide assert that “the difference between killing and allowing to die has serious flaws and that there lacks an actual distinction between actively bringing someone’s life to an end and simply letting them die.”¹⁸ The author suggests that the distinction between active and passive euthanasia is only practical and useful when it is beneficial to the patient’s well-being and it should be mainly targeted towards finding the most effective strategy which could lead to relief from his/her unbearable suffering and enduring agony.

Terminal sedation – “Terminal sedation refers to the use of sedation as palliation in dying patients with a terminal diagnosis”.¹⁹ Even though terminal sedation has garnered broader legislative and moral support, the act is still an ethically controversial issue, especially because some people argue that it speeds up the dying process. However, some research studies have shown that terminal sedation does not speed up the death process or that even if it does, it does not speed the process in a predictable manner. Even so, it is apparent that carrying out terminal sedation together with removal of life-supporting devices and treatments like fluid and nutrition can speed up the death process considerably. This is referred to as early terminal sedation (ETS).²⁰ The use of ETS in palliative care has been ethically justified and therefore it appears that ETS can be both ethical and legal. Nevertheless, existing literatures emphasize that terminal sedation is limited only to patients who are in an imminently dying condition and thus the use of the practice in other situations is unethical. ²¹ Thus, many medical and ethical professionals believe that even ETS is not allowed in patients who suffer unbearable, long-lasting and without any perspective on improvement. In this way these unenviable patients (who are dependent of these professionals) are pre-destinated to a prolonged process of agony and dying that should be experienced by these patients preferably in fully consciousness.

It is not allowed for a human being to choose for a self-organized and premature death. This argument is often strongly inspired by religious doctrines. Professionals who use this argument believe that there might be always a way for patients to endure severe suffering. Obviously, there is no place in their imagination for real unbearable and hopeless suffering. They believe that every form of euthanasia or assisted suicide (in very severe and perspective-less suffering even when it is legally approved) is always wrong (Biggar, 2004).²² Biggar mentioned that these patients must still be able to value the good around them and stay in life and bear their responsibility. How does Biggar know (and all those professional who have the same opinion) that the good around the suffering patients is good enough for counterbalancing the long-lasting and continuous agony? These professionals believe that life is a gift and that we have the obligation to take life as it is, and even when we have bad luck we should drink the beaker as empty as possible without possibility to escape our fate.

One of the arguments against euthanasia is that the legalization of euthanasia or assisted suicide has the potential of demoralizing society’s value for the sacredness and purity of life (Biggar, 2004; Boer, 2007; Dyck, 2002; Gorsuch, 2006; Keown, 2002).²³ ²⁴ ²⁵ ²⁶ ²⁷ However, this statement cannot be proved. In contrary, in many ancient high standard civilizations was euthanasia approved (such as Japan, China and India; Scofield, 1989) as a consequence of deep respect for life that was linked to a sophisticated system of obligations and morality.²⁸ In these cultural settings the practice of euthanasia was characterized by a) recognition of basic obligations (such good care for the suffering and dying person), and b) respect for life (and related dignity of the suffering person)²⁹. In fact, the spiritual life was regarded as superior to the human body, which was only regarded as the carrier of the spirit. Death of the body did not mean that the spirit died, in contrary by means of euthanasia the spirit of the person becomes free (physical suffering interferes with spiritual activities). Furthermore, the argument that is used by Biggar and others is apparently an expression of irrational fear and lacks logical foundation.

According to their opinion patients have the obligation to suffer unbearable painbecause otherwise euthanasia could undermine the society’s respect for life. But, why should people lose their respect for life as a result of a merciful act of relieving patients from their unbearable and hopeless suffering? In fact, euthanasia in such hopeless cases is rather an act of respect for the autonomy and dignity of human beings. To end the life of our pets when they suffer severely is considered as normal and an act of humanity. Even when the life of human beings is considered as being more valuable and “holy” compared with the life of animals, it is unclear why an act of merciful ending of unbearable and lasting suffering should be regarded as unethical and unsuitable for human beings.³⁰

Physician Assisted Suicide

Physician assisted suicide occurs when a patient is given the means to end their own life, feeling that they can no longer continue to live with their condition. This type of intervention is forbidden by the Suicide Act 1961. Whereas today the taking of one’s own life is not a crime, it is a crime to “aid, abet, counsel or procure the suicide of another or an attempt by another to commit suicide” (Suicide Act 1961, sec. 2.1). Assisted suicide is prohibited whether performed by a relative, friend or nurse prescriber and carries a maximum jail term of 14 years. The aim is to protect vulnerable people pressured into killing themselves by unscrupulous family or friends. For example, in R v. McShane (1977) a daughter was found guilty of trying to persuade her 89-year-old mother, who was residing in a nursing home, to kill herself so that she could inherit her mother’s estate. The police obtained incriminating evidence of the daughter by using a hidden camera at the nursing home that showed the daughter handing her mother drugs, hidden in a packet of sweets, and pinning a note on her mother’s dress telling her not to ‘bungle it’.³¹

There has long been a debate over the morality of physician assisted suicide (PAS), both in philosophical literature and in the media. Arguments against PAS come in a variety of forms. One of the most common forms of argument cites the possible negative consequences of the practice as a reason not to legalize it. These assertions are reliant on research studies’ predictions about the future and therefore their potency relies on how probable it is that the claims will come true. Physicians in the Netherlands have actively practiced PAS since 1977 and have done so legally since 1992.³² The data show that most of the aforementioned empirical predictions have not come to pass. However, it is not clear that the Netherlands can serve as a good test case for the empirical claims, for two reasons. First of all, the Netherlands has a socialized medical system. All citizens have adequate health care coverage, including rehabilitative and nursing home care. Some of the more dire predictions about PAS are less likely to occur against this backdrop than they would be in a free market health care system such as that in the United States. Secondly, the Netherlands legalized active euthanasia at the same time it legalized PAS. Active euthanasia and PAS differ in an important respect: in cases of PAS, the patient him or herself is the instigator of death, whereas in cases of active euthanasia, the physician is the instigator of death. Given this, certain dire predicted consequences of the legalization of PAS are more likely to occur in the Netherlands than they would be in a situation where only PAS is legal.³³

Voluntary and Non-Voluntary Euthanasia

Voluntary euthanasia may be defined as the ending of someone’s life at his or her competent request, with his or her consent and in his or her best interests, non – voluntary euthanasia as the ending of someone’s life without reference to his or her wishes, but when it is in that person’s best interests, in a situation where he or she is incompetent to give or refuse consent, and involuntary euthanasia as the ending of someone’s life either against his or her expressed wishes or without regard to his or her wishes when competent, supposedly in his or her best interests.³⁴ Attempts to pass laws in other parts of the world to allow physician-assisted suicide and voluntary euthanasia considered their use only after a request from a competent adult. The fear of the slippery slope is, however, a realistic worry, for, if to allow voluntary euthanasia would lead ultimately to involuntary euthanasia, which has no moral or legal difference from murder, then this argument does require satisfactory responses. The ethics of medicine have long emphasized the restoration of health and that the killing of the sick by doctors as wrong.

Drawing the Line between PAS and Refusal of Treatment

Legal and ethical commentators often explain the distinction between withdrawal of life-sustaining treatment and assisted suicide by citing a difference of causation.³⁵ ³⁶ Withdrawal of life support is seen to enable the patient to die by “letting nature take its course.”³⁷ Death in such situations is therefore as a result of the essential illness and rather than the withholding of treatment. In assisted suicide, ingestion of lethal medication prescribed by a physician causes death. However, withdrawal of life-sustaining treatment occurs in different contexts. For imminently dying patients whose lives are temporarily being prolonged by life support, it is reasonable to assume that death is caused by the disease, not by withdrawal of treatment. In these cases, regardless of treatment, death will soon occur; therefore, continued treatment serves more to prolong dying than to preserve life. Some have argued in favour of recognizing that withdrawal of life support causes death by presenting the following scenario.³⁸ Consider a ventilator-dependent patient who was not seeking death, and suppose that a person plotting the death of that patient maliciously withdrew him or her from the ventilator.

The perpetrator would be charged with murder and could not successfully argue that the underlying disease, not the action of “pulling the plug,” caused the patient’s death.³⁹ The same treatment-terminating act causes both this hypothetical death, which is engineered by a malicious perpetrator, and the deaths of competent patients who refuse continued life-sustaining treatment. It is important to note, however, that causation in fact is not the same as causation in the law. Although a clinician’s withdrawal of life-sustaining treatment may in fact contribute causally to the deaths of patients who refuse such treatment, it does not follow that the clinician is morally or legally culpable for wrongful killing. The intentions involved in end-of-life decisions are complex and may be ambiguous. In many cases, clinicians who withdraw treatment do not intend to bring about death. In addition, death does not always necessarily result when a life-sustaining treatment is stopped.⁴⁰

In some cases, however, the physician intends to help the patient escape an irreversibly intolerable condition by withdrawing life-sustaining care. Does this intent make the action similar to assisting in suicide by prescribing lethal medication? Both patient and physician may see treatment withdrawal that results in death as a way to make the best of a bad situation. However, when prescribing lethal medication at the request of a dying patience, the physician may or may not intend that the patient use it to end life. The intent in some cases may be to provide the patient with the security of a self-administered means of ending life in response to intolerable suffering; this security may help the patient endure. However, regardless of the nuances of intent, a physician who complies with a patient’s request for a prescription of lethal medication is responsible for assisting in suicide if the patient takes the medication to end his or her life. Given this complexity, the potential for ambiguity, and the difficulty of specifying clinicians’ intentions, appeal to intention otters no basis for a clear moral distinction between withdrawing life-sustaining treatment and physician-assisted suicide.⁴¹

Euthanasia and Physician Assisted Suicide in the United Kingdom

The Assisted Dying for the Terminally Ill Bill 2005

The proposal made in the Assisted Dying for the Terminally Ill Bill was to make both euthanasia and physician-assisted suicide legal for patients suffering from terminal illness in the United Kingdom. The House of Lords Select Committee met to analyze the Bill and a report was later published. A debate on the Bill was then carried out in Parliament on October 10th 2005.⁴² Both published and verbal evidence supporting the Bill was presented to the Select Committee and represented a wide variety of opinions on assisted dying. Much of the evidence was based on countries and states in which euthanasia and physician-assisted suicide practices are legal such as the Netherlands, Belgium, Switzerland and Oregon. Such evidence addressed the technicalities of bringing life to an end, as well as the legal processes and defence made in these countries. Reasons often given for legislation include evidence of covert euthanasia, the need to regulate end-of-life decision-making and to ensure reporting of the serious act of ending life.⁴³ The Select Committee report was balanced in presenting the evidence it heard and in trying to represent both sides of the argument. The sponsor of the Bill (Lord Joffe) was a member of the Select Committee established to examine the Assisted Dying for the Terminally Ill Bill. Other members came with a wide range of views and so the committee was deeply divided at the outset and remained so to some extent during its proceedings. This is reflected in the report. However, there is a recommendation that palliative care services in the UK must be improved and extended to ensure equity of provision; that is a huge challenge to hospice and palliative care services, who must now urgently consider ways to extend their work to cover areas with poor provision. It is also a challenge to commissioners of services to ensure they meet their ethical obligations to the entire population they serve to ensure that adequate services are there to relieve the suffering of the terminally ill that results from inadequate care.⁴⁴

The Suicide Act of 1961 and Legal Cases

The Suicide Act 1961, Section 2, states that

“A person who aids, abets, counsels or procures the suicide of another, or an attempt by another to commit suicide, shall be liable on conviction on indictment to imprisonment for a term not exceeding fourteen years; and If on the trial on an indictment for murder or manslaughter it is proven that the accused aided, abetted, counselled or procured the suicide of the person the jury may find him guilty of that offence.”⁴⁵

The precedent case that clarifies the refusal of medical treatment, even if such refusal leads to the person’s death is that of Re T. This case concerned the refusal of an adult Jehovah’s Witness to agree to blood transfusion following a stillbirth caesarean section. A declaration was sought and given that it would not be unlawful to give the blood transfusion. This case was influenced by the sudden deterioration of the patient and the suggestion of possible coercion by the woman’s mother in the refusal. The declaration was subsequently upheld in the Court of Appeal. Judgment clarified that a competent adult person has the right to refuse treatment or choose an alternative, even if so doing is likely to lead to the death of the patient. Lord Donaldson MR noted that this was ‘not withstanding that the reasons for making the choice are rational, irrational, unknown or non-existent’ (Re T, p. 653).⁴⁶

Assisted suicide is prohibited whether performed by a relative, friend or a doctor and a person who does so would be liable on conviction to fourteen years in prison. The aim of the prohibition is to protect vulnerable people from being pressured into killing themselves by unscrupulous family or friends. While such protection is laudable the same provisions prevent people who cannot take their own lives because of a debilitating condition from being helped to do so by a friend, relative or health professional. In Pretty v DPP (2001) the House of Lords refused to grant Diane Pretty’s application for a judicial review challenging the decision of the Director of Public Prosecutions, who had refused to give an undertaking that he would not prosecute her husband if he assisted in her suicide at some time in the future.⁴⁷ The European Court of Human Rights later argued that the Suicide Act 1961 was not a breach to the European Convention on Human Rights because: the right to life as protected under Article 2 of the Suicide Act was not inclusive of a right to die at a preferred time; the inhuman and undignified treatment that Mrs. Pretty experienced was not as a result of the government but of the motor neuron illness which she was suffering from; and Mrs. Pretty’s right to respect for her private life under Article 8 was not unconditional.⁴⁸ The right could be restricted by the government passing legislation which had the legitimate aim of protecting vulnerable individuals from being forced into agreeing to be assisted to die.

A medical practitioner who issues a prescription or a nurse who obtains prescription drugs that a patient takes to end his or her life would have acted illegally under the Suicide Act 1961 or, if the practitioner was to administer a lethal substance, this would be actionable as a case of murder. In order to convict a person for murder, much importance is placed on the mens rea, the guilty intent.⁴⁹ If the accused killed the victim intentionally, then the charge will be murder, which carries a mandatory life sentence. The hastening of a person’s death, when the sole motive is to do that, must be charged and punished as the crime of murder. In practice, however, the legal penalties following proven cases of assistance with suicide and mercy killing will usually find minimal sentencing. If the court accepts that the action was a mercy killing, despite there being no such legal charge, a plea of manslaughter is likely to be accepted. Section 23 of the Offences Against the Person Act 1861 considers it a crime to illegally administer or result in the administration by an individual of a lethal drug that has the potential of harming that individual’s life. Such an offence is punishable by a maximum of 10 years imprisonment.⁵⁰

In R v. Cox (1992) a consultant rheumatologist had promised a patient that he would not allow her to suffer as the result of her incurable illness. When she reminded him of his promise when she was in considerable and intractable pain he fulfilled his promise and gave her a lethal dose of potassium chloride. When Dr. Nigel Cox admitted administering a lethal dose of potassium chloride to the terminally ill elderly lady who was in terrible intractable pain and begging him to end her life, he was convicted of manslaughter and given a one-year suspended prison sentence. This case was complicated by the cremation of the patient before autopsy. The General Medical Council (GMC) found Dr. Cox guilty of serious misconduct but did not remove him from the medical register after his conviction; he was required to undertake further education in palliative care. Sir Robert Kilpatrick, the president of the GMC, when referring to Dr. Cox, was quoted as saying that: “[you] acted in good faith in what you thought to be the best interests of your dying patient, and… your purpose was to relieve her intolerable suffering by expediting her death.”⁵¹

It is likely that incidents of physician-assisted suicide and euthanasia are not as isolated as many would think or like to think. A questionnaire survey of UK doctors that asked practitioners if they had ever practiced voluntary euthanasia found that, of those doctors who replied 12% admitted that they had.⁵² However, politicians, judges and indeed society steer away from officially condoning or, as seems apparent, controlling euthanasia in the UK. The religious or moral beliefs regarding the sanctity of life held by many can inhibit full and frank discussion of the issues. For instance, Farsides has asked those involved in palliative care to examine their apparent dominant philosophy, which suggests that palliative care is a euthanasia-free zone, and asks if this ideology stifles free debate in this field.⁵³ Although personal beliefs must be respected, should a vocal opinion influence the rights of others who do not have such beliefs? Doctors or nurses who are confronted with a request to help a person to die have a dilemma in that they have legal obligations to consider, for to assist would be illegal yet, from their caring perspective, they may consider that they have a moral obligation to the patient to give assistance. It can be argued that for patients to see their doctor as a potential killer would do little for an effective relationship.⁵⁴

It would seem that doctors have a legal and professional duty not to hasten the death of their patients, but it is equally within their duty of care to prevent pain and suffering. Medication given to relieve suffering, especially opioid pain relief, can hasten death. This is known as the doctrine of double effect. The legality of such an action was clarified by the courts in the case of R v. Bodkin Adams in 1957. When Dr. Adams was accused and subsequently acquitted of murder after his treatment of an elderly stroke victim with opioids, the trial judge noted: “If the first purpose of medicine, the restoration of health, can no longer be achieved there is still much for a doctor to do, and he is entitled to do all that is proper and necessary to relieve pain and suffering, even if the measures he takes may incidentally shorten life,” (p. 365).⁵⁵ In the case of Rodriguez v. A-G of British Columbia, it was considered whether a woman suffering from motor neurone disease should have the right to set up a mechanism that she could use to end her life should she become paralysed. It was clarified, in a Canadian court, that it would be wrong to deny a person choice just in case others who are able to exercise this choice may misuse it.⁵⁶ It is obvious from these cases that both active and passive euthanasia are unlawful in the UK and health practitioners found guilty of such practices can face a murder charge under the Suicide Act of 1961.

In Airedale NHS Trust v Bland (1993)⁵⁷ the House of Lords recognized the concept of medical futility and held that it would be lawful to withhold treatment, in this case artificial nutrition and hydration from a man in a persistent vegetative state, where it was no longer in the patients best interests to continue with that treatment. Lord Mustill concluded the court’s position by stating that: The termination of nutrition or fluid is an error not a deed; therefore, such a termination is not considered to be a criminal offence except for situations in which the physicians are under an obligation to prolong the treatment. It was also held that when Anthony Bland sought medical assistance from the involved physicians, the physicians had to make crucial decisions on his behalf because he was not in a position to make the decisions. The physicians were to make decisions that served Bland’s best interests. However, because there was a likelihood that he could improve, his best interest necessitated the prolonging of the treatments he received in the hope that such treatments would enable him to recover.

Conclusion

Euthanasia and physician-assisted suicide are practices that occur in many countries. Some countries and states such as the Netherlands, Belgium, Switzerland and Oregon have made these practices legal. However in the United Kingdom, euthanasia and PAS remain illegal. The only exception is in cases that involve mentally capacitated patients who refuse treatment or patients who are mentally incapacitated and in an appalling condition such as a persistent vegetative state. Physicians can respect the wishes of patients in the former category to withhold or withdraw treatment. For patients in the latter category, physicians can withdraw treatment as long as they act in the best interests of the patients. Nevertheless, it is advisable for physicians to seek the advice of courts or court declarations before taking such dire actions lest they are caught up with the arm of the law.

Bibliography

Airedale NHS Trust v. Bland (1993) 1 All ER 821

Begley, A. ‘Beneficent voluntary active euthanasia: a challenge to professionals caring for terminally ill patients’, Nursing Ethics, vol. 5, 1998, pp. 294–305.

Biggar, N. Aiming to Kill: The Ethics of Suicide and Euthanasia. Darton, Longman, and Todd Ltd, London, 2004.

Boer, T.A. ‘Recurrent themes in the debate about euthanasia and assisted suicide’, Journal of Religious Ethics, vol. 35, no. 3, 2007, pp. 529-555.

Bosshard, G., Broeckaert, B., Clark, D., Materstvedt, L.J., Gordijn, B., & Muller-Busch, H.C. ‘A role for doctors in assisted dying? An analysis of legal regulations and medical professional positions in six European countries’, Journal of Medical Ethics, vol. 34, no. 1, 2008, pp. 28-32.

Brock, D.W. ‘Voluntary active euthanasia’, in: Brock DW, ed. Life and Death. Cambridge University Press, New York, 1993.

Callahan, D. The Troubled Dream of Life’ In Search of a Peculiar Death. Georgetown University Press; Washington, D.C., 1993.

Cellarius, V. ‘Terminal sedation and the imminence condition’, Journal of Medical Ethics, vol. 34, no. 2, 2008, pp. 69-72.

Chervenak, F.A., McCullough, L.B., & Arabin, B. ‘Why the Groningen Protocol should be rejected’, Hasting Center Report, vol. 36, no. 5, 2006, pp. 30-33.

Churchill, L.R., & King, N. ‘Physician assisted suicide, euthanasia, or withdrawal of treatment?, BMJ, vol. 315, 1997, pp. 137–38.

Curlin, F.A., Nwodim, C., Vance, J.L., Chin, M.H., & Lantos, J.D. ‘To die, to sleep: US physicians’ religious and other objections to physician-assisted suicide, terminal sedation, and withdrawal of life support’, American Journal of Hospice and Palliative Medicine, vol. 25, no. 2, 2008, pp. 112-120.

Dieterle, J. ‘Physician assisted suicide: A new look at the arguments’, Bioethics, vol. 21, no. 3, 2007, pp. 127-139.

Dimond, B. ‘Not for resuscitation instructions: the law for adult patients in the UK’, British Journal of Nursing, vol. 13, no. 16, 2004, pp. 984-986.

Dyck A. Life’s Worth: The Case against Assisted Suicide. Eerdmans, Michigan, 2002.

Farsides, B. ‘Palliative care: a euthanasia-free zone’, Journal of Medical Ethics, vol. 24, 1998, pp. 149–50.

Fenigsen, R. ‘Other people’s lives: Reflections on medicine, ethics and euthanasia’, Issues in Law & Med, vol. 25, no. 2, 2009, pp. 169-181.

Finlay, I., Wheatley, V., & Izdebski, C. ‘The House of Lords Select Committee on the Assisted Dying for the Terminally Ill Bill: Implications for Specialist Palliative Care’, Palliative Medicine, vol. 19, 2005, pp. 444-453.

Georges, J.J, Onwuteaka-Philipsen, B.D., & van der Wal, G. ‘Dealing with requests for euthanasia: A qualitative study investigating the experience of general practitioners’, Journal of Medical Ethics, vol. 34, no. 3, 2008, pp. 150-155.

Gorsuch, N.M. The Future of Assisted Suicide and Euthanasia. Princeton University Press, Princeton, 2006.

Griffith, R. ‘Euthanasia: Is there a case for changing the law?’ British Journal of Community Nursing, vol. 12, no. 6, pp. 273-277.

Griffith, R. ‘Euthanasia and assisted suicide: current law and attempts at reform’, Nurse Prescribing, vol. 5, no. 7, 2007, pp. 315-318.

Griffiths, P. ‘Physician-assisted suicide and voluntary euthanasia: Is it time the UK law caught up?’ Nursing Ethics, vol. 6, no. 2, 1999, pp, 107-117.

House of Lords Select Committee on Medical Ethics. Report of the Select Committee on medical ethics 1994, HL Paper 21. HMSO, London, 1994.

Jaspers, E., Lubbers, M., & de Graaf, N.D. ‘Horrors of Holland: Explaining attitude change towards euthanasia and homosexuals in the Netherlands, 1970-1998’,

International Journal of Public Opinion Research, vol. 19, no. 4, 2007, pp. 451-473.

Keown, J. Euthanasia, ethics, and public policy: An argument against legalisation. Cambridge University Press, Cambridge, 2002.

Kodish, E. ‘Paediatric ethics: a repudiation of the Groningen Protocol’, Lancet, vol. 371, no. 9616, 2008, pp. 892-893.

Lindemann, H., & Verkerk, M. ‘Ending the life of a newborn: The Groningen Protocol’, Hasting Center Report, vol. 38, no. 1, 2008, pp. 42-51.

Martens, W.H.J. ‘They shoot horses, don’t they? How valid are the arguments of opponents against euthanasia?’ Medical Law, vol. 28, 2009, pp. 739-754.

Martens, W.H.J. ‘Recommendation of the Groningen Protocol for euthanasia in newborns with unbearable suffering and unacceptable quality of life’, Medicine and Law (In Press).

McHale, J., & Fox, M. Health care law: text cases and materials. Sweet and Maxwell, London, 1997.

Medical Ethics Alliance. Written submission to the House of Lords Select Committee on the Assisted Dying for the Terminally Ill Bill. Medical Ethics Alliance, Worcester, 2004.

Miller, F., Fins, J., & Snyder, L. ‘Assisted suicide compared with refusal of treatment: A valid distinction?’ Annals of Internal Medicine, vol. 132, no. 6, 2000, pp. 470-475.

Murphy, D.M., & Princhard, J. ‘Euthanasia in severely ill newborns’, New England Journal of Medicine, vol. 252, 2005, pp. 2353-2355.

Nuyen, A.T. ‘Levinas and the euthanasia debate’, Journal of Religious Ethics, vol. 28, no. 1, 2000, pp. 119-135.

Pellegrino, E.D.’ Doctors must not kill’, Journal of Clinical Ethics, vol. 3, 1992, pp. 95-102.

Quill, T.E. ‘The ambiguity of clinical intentions’, New England Journal of Medicine, vol. 329, 1993, pp. 1039-40.

Re T (adult refusal of treatment) (1992) 4 All ER 649

R v. Bodkin Adams (1957) Crim LR 365

R v. Cox. The Times, September 22, 1992: (1992) 12 BMLR 38

R v. McShane (1977) Crim LR 737

Rodriguez v. A-G of British Columbia (1993) 3 WWR 553

Rose, T. ‘Physician-assisted suicide: Development, status, and nursing perspectives’, Journal of Nursing Law, vol. 11, no. 3, 2007, pp. 141-151.

Schopenhauer, A. ‘On suicide’. In: Parerga and paralipomena, vol. 2. (306-311). Oxford University Press, Oxford, 1974.

Scofield, G. ‘The Living Will’. In: R. Kastenbaum R, Kastenbaum B. (Eds.) Encyclopedia of death. Oryx Press, Phoenix, 1989.

Sen, M., & Shaikh, S. ‘Death and dying in Islam: Psychological and spiritual perspectives’. In: Chariar V, Chatterjee SC, Patnaik P. (Eds.), Discourses on aging and dying. (97-114). Sage Publications, New Delhi, India, 2008.

Shaw, D. ‘The body’s unwarranted life support: A new perspective on euthanasia’, Journal of Medical Ethics, vol. 33, no. 9, 2007, pp. 519-521.

Snell, J. ‘Dr Cox: the nurse’s story’, Nursing Times, vol. 88, no. 41, 1992, p. 19.

The House of Lords Select Committee on Euthanasia. House of Lords Paper 21-1. HMSO, London, 1994.

Vacco v. Quilt, 117 S Ct. 2293 (1997).

Ward, B., & Tate, P. ‘Attitudes among NHS doctors to requests for euthanasia’, BMJ, vol. 308, 1994, pp. 1332–34.

Footnotes

Scofield G. The Living Will. In: R. Kastenbaum R, Kastenbaum B. (Eds.) Encyclopedia of death. Phoenix, AZ: Oryx Press, 1989.
Kodish E. Paediatric ethics: a repudiation of the Groningen Protocol. Lancet 2008; 371(9616): 892-893.
Martens, WHJ. They shoot horses, don’t they? How valid are the arguments of opponents against euthanasia? Medical Law, 2009; 28: 739-754.
Bosshard G, Broeckaert B, Clark D, Materstvedt LJ, Gordijn B, Muller-Busch HC. A role for doctors in assisted dying? An analysis of legal regulations and medical professional positions in six European countries. Journal of Medical Ethics 2008; 34(1): 28-32.
Sen M, Shaikh S. Death and dying in Islam: Psychological and spiritual perspectives. In: Chariar V, Chatterjee SC, Patnaik P. (Eds.), Discourses on aging and dying. (97-114). New Delhi, India: Sage Publications India, 2008.
Jaspers E, Lubbers M, de Graaf ND. ‘Horrors of Holland’: Explaining attitude change towards euthanasia and homosexuals in the Netherlands, 1970-1998. International Journal of Public Opinion Research 2007; 19(4): 451-473.
Curlin FA, Nwodim C, Vance JL, Chin MH, Lantos JD. To die, to sleep: US physicians’ religious and other objections to physician-assisted suicide, terminal sedation, and withdrawal of life support. American Journal of Hospice and Palliative Medicine 2008; 25(2): 112-120.
Georges JJ, The AM, Onwuteaka-Philipsen BD, van der Wal G. Dealing with requests for euthanasia: A qualitative study investigating the experience of general practitioners. Journal of Medical Ethics 2008; 34(3): 150-155.
Chervenak FA, McCullough LB, Arabin B. Why the Groningen Protocol should be rejected. Hasting center Report 2006; 36(5): 30-33.
Kodish E. Paediatric ethics: a repudiation of the Groningen Protocol
Murphy DM, Princhard J. Euthanasia in severely ill newborns. New England Journal of Medicine 2005; 252: 2353-2355.
Lindemann H, Verkerk M. Ending the life of a newborn: The Groningen Protocol. Hasting Center Report 2008; 38(1): 42-51.
Martens WHJ. Recommendation of the Groningen Protocol for euthanasia in newborns with unbearable suffering and unacceptable quality of life. Medicine and Law (In Press).
Curlin et al.
Georges
Fenigsen, R. Other people’s lives: Reflections on medicine, ethics and euthanasia. Issues in Law & Med, 2009, 25(2): 169-181.
Shaw D. The body’s unwarranted life support: A new perspective on euthanasia. Journal of Medical Ethics 2007; 33(9), 519-521.
Shaw
Griffith, R. Euthanasia: Is there a case for changing the law? British Journal of Community Nursing, 12(6), 273-277.
Cellarius V. Terminal sedation and the “imminence condition”. Journal of Medical Ethics 2008; 34(2): 69-72.
Cellarius
Biggar N. Aiming to Kill: The Ethics of Suicide and Euthanasia. London: Darton, Longman, and Todd Ltd, 2004.
Biggar
Boer TA. Recurrent themes in the debate about euthanasia and assisted suicide. Journal of Religious Ethics 2007; 35(3): 529-555.
Dyck A. Life’s Worth: The Case against Assisted Suicide. Grand Rapids, Mich.: Wm. Eerdmans, 2002.
Gorsuch NM. The Future of Assisted Suicide and Euthanasia. Princeton, N.J. and Oxford: Princeton University Press, 2006.
Keown, J. Euthanasia, ethics, and public policy: An argument against legalization. Cambridge: Cambridge University Press, 2002.
Scofield
Nuyen AT. Levinas and the euthanasia debate. Journal of Religious Ethics 2000; 28(1): 119-135.
Schopenhauer A. (transl. Payne EFJ). On suicide. In: Parerga and paralipomena, vol. 2. (306-311). Oxford: Oxford University Press, 1850/1974.
R v. McShane (1977) Crim LR 737
Dieterle, J. Physician assisted suicide: A new look at the arguments. Bioethics, 21(3), 2007, 127-139.
Rose, T. Physician-assisted suicide: Development, status, and nursing perspectives. Journal of Nursing Law, 2007, 11(3), 141-151.
McHale J, Fox M. Health care law: text cases and materials. London: Sweet and Maxwell, 1997: 870.
Vacco v. Quilt, 117 S Ct. 2293 (1997).
Callahan D. ‘The Troubled Dream of Life’ In Search of a Peculiar Death.’ Washington, DC” Georgetown Univ. Pr; 1993:76-82,
Pellegrino ED. Doctors must not kill. J Clin. Ethics. 1992, 3: 95-102
Brock DW, Voluntary active euthanasia, in: Brock DW, ed. Life and Death. New York- Cambridge Univ Pr, )993 208-13,
Miller, F., Fins, J., & Snyder, L. Assisted suicide compared with refusal of treatment: A valid distinction? Annals of Internal Medicine, 2000, 132(6), 470-475.
Quill TE, The ambiguity of clinical intentions. N Engl. J Med. 1993:329, 1039-40.
Griffith, R. Euthanasia and assisted suicide: current law and attempts at reform. Nurse Prescribing, 2007, 5(7), 315-318.
Finlay, I., Wheatley, V., & Izdebski, C. The House of Lords Select Committee on the Assisted Dying for the Terminally Ill Bill: Implications for Specialist Palliative Care. Palliative Medicine, 2005, 19, 444-453.
House of Lords Select Committee on Medical Ethics. Report of the Select Committee on medical ethics 1994, HL Paper 21. London: HMSO, 1994.
Medical Ethics Alliance. Written submission to the House of Lords Select Committee on the Assisted Dying for the Terminally Ill Bill. Worcester: Medical Ethics Alliance, 2004.
Griffiths, P. Physician-assisted suicide and voluntary euthanasia: Is it time the UK law caught up? Nursing Ethics, 1999, 6(2), 107-117.
Re T (adult: refusal of treatment) (1992) 4 All ER 649
Dimond, B. Not for resuscitation instructions: the law for adult patients in the UK. British Journal of Nursing, 2004, 13(16), 984-986.
Churchill LR, King NMP. Physician assisted suicide, euthanasia, or withdrawal of treatment. BMJ 1997; 315: 137–38.
The House of Lords Select Committee on Euthanasia. (House of Lords Paper 21-1.) London: HMSO, 1994.
Begley A-M. Beneficent voluntary active euthanasia: a challenge to professionals caring for terminally ill patients. Nursing Ethics 1998; 5: 294–305.
R v. Cox. The Times, September 22, 1992: (1992) 12 BMLR 38
Ward B, Tate P. Attitudes among NHS doctors to requests for euthanasia. BMJ 1994; 308: 1332–34.
Farsides B. Palliative care – a euthanasia-free zone. J Med Ethics 1998; 24: 149–50.
Snell J. Dr Cox: the nurse’s story. Nursing Times 1992; 88(41): 19.
R v. Bodkin Adams [1957] Crim LR 365
Rodriguez v. A-G of British Columbia [1993] 3 WWR 553
Airedale NHS Trust v. Bland (1993) 1 All ER 821