A Background Paper Prepared for
The Premier's Council on The Status of Persons with Disabilities (Alberta)

by
Dick Sobsey,University of Alberta Developmental Disabilities Centre
and
Gregor Wolbring

1995

SUMMARY: This background paper examines the potential advantages and disadvantages of assisted suicide and euthanasia for Canadians with physical and mental disabilities. It does not assume that suicide, assisted suicide, or euthanasia are inherently right or wrong ; instead, it considers the complexities and potential effects for people with disabilities. While individual autonomy, the right to privacy, and the right to control one's own body have been presented as arguments in favor of physician-assisted suicide and euthanasia, this paper presents counter-arguments suggesting that proposed assisted-suicide provisions would put many people's lives in jeopardy.

The debate over assisted suicide and euthanasia is not new. Euthanasia was legalized in Germany more than 50 years ago and decriminalized in Holland about 20 years ago. In Canada, it has been the subject of repeated discussions, including Bills introduced to Parliament, Civil and Criminal Court cases, Law Reform Commission Reports, and Medical Association resolutions. Each of these discussions has concluded that the dangers of permitting the willful destruction of human life by another human being far outweighs any benefits gained by legalization. This background paper agrees with this conclusion and supports Canada's current prohibition against assisting or counselling suicide. It argues that the current prohibition represents an important protection of the right to life for all Canadians. Removing it selectively in regard to the lives of people with illness or disability would provide less protection for these Canadians, and as such, it would represent a fundamental violation of the principle of equal protection for all citizens.

Regardless of illness or disability status, choosing to live or die is a personal psychosocial decision. When others become involved in such decision-making process, the decisions become political, social, and legal decisions, not medical decisions. The involvement of health care professionals in such decisions does not constitute a reasonable due-process protection for people's lives. If assisted-suicide is made legal for some citizens, it must be made legal for all citizens. Legal safeguards, including individual judicial proceedings, should be put in place to ensure that decisions are made autonomously by fully competent and informed individuals who are free from coercion or undue influence. Unless and until such safeguards are put in place for every Canadian, assisted suicide or euthanasia should not be permitted for any Canadian.

This paper suggests that Canadians with disabilities will be most affected by assisted-suicide or euthanasia programs; therefore, people with disabilities are urged to carefully study all proposals and to voice any concerns about proposed legislation. Until and unless concerns are adequately addressed, people with disabilities are urged to work against the passage of any assisted-suicide or euthanasia bill.

THREE VIEWS OF ASSISTED SUICIDE AND EUTHANASIA

Basically, there are three views to consider when discussing assisted suicide and euthanasia: an optimistic view, a pessimistic view, and a realistic view:

An optimistic view Proponents of assisted suicide and euthanasia suggest that people whose disabilities or illnesses become so severe that life holds no promise of pleasure should be able to end their lives as painlessly and with as much dignity as possible. They point out that suicide is already legal in Canada and that some people may be unable to physically carry out their autonomous choice because of their disability. Therefore, they consider helping people to die after they have made a free and informed choice as a reasonable accommodation for people with disabilities. They feel that this would give people with disabilities greater control over their bodies and their lives. They suggest that employing euthanasia and assisted suicide might have secondary benefits for people who choose to remain alive because resources that are wasted keeping people alive against their wills could be redeployed to people who could benefit from these resources. They feel that those who worry about the dangers of euthanasia are paranoid or are religious or philosophical zealots since no one would die without making a free choice.

A pessimistic view Opponents of assisted suicide and euthanasia feel that those who consider these practices to be beneficial are naive. They consider euthanasia and assisted suicide to be nothing more than ways to eliminate people with disabilities, and they suggest that few people will make free and informed choices to die; rather, many people with disabilities will have those choices made for them. They point to the horrors of the Nazi euthanasia program, which led to the slaughter of 250,000 people with disabilities, and to the apparent abuses under the current Dutch system as proof that any law that permits people with disabilities to be killed legally will result, at least to some degree, in another holocaust. They suggest that people with illnesses or disabilities do not need assistance to commit suicide. In fact, the vast majority are quite capable of using the same methods as other Canadians if they choose to die. Even those who are severely debilitated but competent can use the right to refuse treatment or food as a way to kill themselves. They suggest that people with disabilities or illnesses might be coerced into suicide for any number of reasons, for example, to cut health care costs, if assisted suicide and euthanasia were legalized.

A realistic view Assisted suicide and euthanasia may make some people's deaths less painful or unpleasant, but these practices also open the door to abuses. Simple cases, in which there is a clear benefit, are the exception rather than the rule. Suicide is not easily divided into rational and irrational suicides for people with disabilities or for anyone else. While it is unlikely that the horrendous events of the German euthanasia program will be repeated, the current Canadian proposals share too many features with the German program to ignore the tremendous potential for abuse. Information from the Dutch program provides clear examples of abuse, and it illuminates vast gray areas of uncertainty. If a law is brought forward with adequate safeguards to prevent abuse and with a description of some clear benefits, it should be considered. If a law cannot be drafted that substantially satisfies the concerns about abuse, it is far better for society to accept the limitations of the current situation than to play with the fundamental protection of an individual's life.

APPLYING THE PRINCIPLES OF THE PREMIER"S COUNCIL
Euthanasia and assisted suicide need to be considered in light of the five
principles of The Premier's Council on the Status of Persons with
Disabilities:

(1) individual responsibility and personal control

(2) full participation in community life

(3) consistent consultation with consumers

(4) personal contribution and worth

(5) equity of opportunity

Each of these principles requires careful consideration in relation to
proposed assisted suicide and euthanasia legislation.

Individual responsibility and personal control
Euthanasia is not typically consistent with the concept of individual
responsibility and personal control. In Germany, a quarter million people
with disabilities were killed without their consent. Some people in Holland
who have requested to die receive euthanasia, many more do not. In addition,
many are killed without making any request. According to Dutch government
figures, 400 people a year are assisted with suicide, while 1000 people a
year are killed without any explicit request.

Assisted suicide appears to be consistent with the principle of individual
responsibility and personal control, and in some cases it is consistent with
this principle. This is true if a person is fully informed, competent, free
of undue influence, and given reasonable alternatives. In practice, this is
rarely the case. Most people, including people with illnesses or
disabilities, who choose suicide are clinically depressed. Many, if given the
opportunity to commit suicide, will do so shortly after being diagnosed, but
if denied the opportunity, they will be thankful they were not allowed to
make a rash decision. Several studies show that patients are given
information about their illnesses and disabilities in a manner designed to
illicit a response desired by the health care provider. This manipulation
gives the illusion of free choice, while in reality, there is nothing
autonomous about such decisions. In some cases, people with disabilities or
illnesses choose to die because there are no reasonable economic,
residential, vocational, social, or educational alternatives. Offering people
death with dignity while denying access to a life with dignity is no choice.

Several cases and situations in Alberta suggest that some end-of-life
decisions are already being made in a manner that fails to respect personal
autonomy and puts the lives of people with disabilities at risk. Opening the
door further to such potential abuses could be disastrous. Introducing
euthanasia and assisted suicide in the midst of health care cuts is
particularly risky since some unscrupulous individuals might attempt to
encourage more deaths as means to reduce health care costs. Only powerful
procedural safeguards can prevent this type of problem.

Assisted suicide programs are only consistent with the principle of
individual responsibility and personal control if safeguards are in place to
ensure: (1) that the individual is fully informed, (2) that they are provided
with all reasonable living and treatment alternatives, (3) that they are free
from clinical depression or other emotional disturbances that may influence
their decision, and (4) that no substitute consents are accepted in lieu of
the individual's personal request.

Full participation in community life
Neither euthanasia nor assisted suicide is consistent with the principle of
full participation in community life: That is, if a person is dead, then he
or she cannot participate in community life. For some individuals already
isolated from any participation in community life, this principle may be less
relevant.

When people with illnesses or disabilities are experiencing clinical
depression or other emotional difficulties, they should have access to and
participate in counselling or other appropriate treatment. When people with
disabilities are experiencing suicidal thoughts or exhibiting suicidal
behavior, they should have access to and participate in the same suicide
prevention programs that are made available to other citizens. Providing
other citizens with suicide prevention programs while assisting and
counselling people with illness and disability to commit suicide is a gross
violation of the principle of full participation in community life and is
entirely unacceptable. Making it a crime to counsel a person to commit
suicide or to assist in the suicide of a person without a disability while
making it legal to counsel a person with disabilities to commit suicide or to
assist in the suicide of a person with a disability deprives people with
disabilities of equal protection of life and is also a gross violation of
human rights.

This problem could be averted if assisted suicide legislation were based on
safeguards related to ensuring that the decision was voluntary, informed,
rational, but not based on health or disability status.

Consistent consultation with consumers
Any Bill drafted to allow euthanasia and assisted suicide should do so based
on full consultation with the people most likely to be affected. People with
illnesses and disabilities are urged to take part at every opportunity. The
Government must not only invite participation but also facilitate
consultation among people with illnesses and disabilities and between those
people and Government. Continued consultation may be required if and when
new law is brought in to ensure that the law is having desired effects and
abuses are minimized.

Senate hearings on Euthanasia and assisted suicide to date have included
representation from some segments of the disability community, but these have
not been comprehensive or adequate. More needs to be done before any Bill is
drafted. Current discussions are very general. They consider principles, not
specific legislation. However, consultation at later stages is imperative.
In the abstract, it is easy to approve of a law that would give people more
autonomy and control over their lives, but it is the complexity of
accomplishing this without doing more harm than good that needs careful
consideration.

Personal contribution and worth
To the extent that they permit people to control their own fates and preserve
their dignity, euthanasia and assisted suicide are consistent with this
principle. Basing access to assisted suicide on health and disability status,
however, is antagonistic to the concept of personal contribution and worth.
It erroneously implies that only illness or disability is so dreadful that
life is no longer worth living. It perpetuates the myth that people with
disabilities are helpless by portraying them as unable to kill themselves by
any means without the help of others. Therefore, euthanasia and assisted
suicide are only consistent with this principle they are available to all
citizens, not if they are restricted to those with illnesses and
disabilities.

Equity of opportunity
Equal access to suicide has been suggested as an advantage for people with
disabilities, but this argument is totally inappropriate. People with
disabilities can and do kill themselves. Some means become more difficult
with some types of disabilities, but rarely is every form of suicide
impossible for any individual. People without illnesses or disabilities do
not now legally commit suicide with assistance. Canada works to discourage
and prevent people without disabilities from killing themselves. Most people
who do kill themselves resort to such means as guns , hanging, and high
buildings. If we were trying to create equal access, we would be providing
equal access to these things. Physicians attempt to heal their patients
without disabilities, not kill them.

No system of assisted suicide or euthanasia that is based on membership in a
particular group (e.g., illness or disability) can be rationally defended as
providing equal access. Equity of opportunity would only exist if similar
provisions were available to people with and without disabilities who were
dissatisfied with life.

Summary of Principles
Assisted suicide and euthanasia for people with illness or disability is
inconsistent with the principles of equity of opportunity and community
participation. They could be consistent with the principles of individual
responsibility and personal control, depending on how they were applied.
Because of the vital nature of this topic, it is essential that the process
used to determine if and how the law is amended be consistent with the
principle of consultation with consumers.

RECOMMENDATIONS TO
THE PREMIER'S COUNCIL ON THE STATUS OF PERSONS WITH DISABILITIES
1. The Council should remain fully informed and participate fully in
discussions of any proposed amendments. It should continue to consult with
Albertans with disabilities about possible effects.

2. The Council should exercise great caution in considering any changes in
the law that could have negative effects on the protection of life of people
with disabilities.

3. The Council should not endorse any principle to amend legislation without
a specific proposal. Endorsement of any amendment should be considered only
after specific legislation is proposed and its provisions carefully reviewed.

4. The Council must consider potential effects of legislation on those who
cannot articulate for themselves. No proposal that has the potential to lead
to the euthanasia of any individual without competent, voluntary consent
should be supported by the Council.








An Illusion of Autonomy:
Questioning Physician-Assisted Suicide and Euthanasia

BRIEF
Submitted to
The Special Senate Committee on Euthanasia and Assisted Suicide
Winnipeg, Manitoba o 30 September 1994


PURPOSE
The purpose of this brief is to raise concerns about amending Canadian law to
permit euthanasia or assisted suicide. To do so, it discusses the abuses
that have typically surrounded euthanasia and assisted suicide and the
complexities of developing a system that allows people as much autonomy as
possible without putting the lives of many more vulnerable people in
jeopardy. It suggests that the number of people who would competently request
assistance for rational reasons and actually require assistance for suicide
is extremely small. The number of people who might be put in jeopardy is much
larger. Those individuals in greatest jeopardy will include infants and
children with a wide range of disabilities (Schaffer & Sobsey, 1990),
children and adults with developmental disabilities, children and adults with
affective disorders and other mental illnesses, and senior citizens.

IN THE NAME OF HUMANITY


It was a story that touched the feelings of the entire nation.
A woman was losing control over her own body
as she lost ground to a degenerative neurological condition.
Her husband an another close male friend looked on as she begged for help
to release her from her suffering, but the law would not allow them to give
her mercy.
Finally, one brave man defied the law
and permitted her to die with dignity
This is the story that a challenged the nation to change its law in the name
of humanity.

This story may seem familiar to Canadians, but it is not the story of Sue
Rodriguez, and the country is not Canada. It is the central plot of Ich Klage
An (I Accuse), a major motion picture written by a T4 Nazi death-doctor and
produced by the Nazi propagandists to legitimize their euthanasia program.
The film, directed by Wolfgang Libeniener, won international awards for
excellence and attracted an audience of more than 15,000,000, a major success
of its day. At the end of the film, Thomas, the husband who assisted his wife
Hannah to commit suicide, stands before the court accused of homicide and
says,

No! Now I accuse! I accuse the law which hinders doctors and judges in their
task of helping people. I confess... I have delivered my wife from her
sufferings, following her wishes. My life and the lives of all people who
will suffer the same fate as my wife, depends on your verdict. Now, pass your
verdict.

The film ends at that point, inviting the German people to make their choice
between a cruel and archaic law or a humane step toward a better world. It
challenged the German people to accept assisted suicide and mercy killing,
and as history shows, they took the "humane" step. In doing so, they opened
the door to the ruthless murder of a quarter of a million people with mental
and physical disabilities. Ultimately, the ideas, people, and apparatus
developed to run this assisted-suicide program served as the basis for the
later mass killings of Jews, homosexuals, communists, and many other
minorities. When the war was over, the mass graves were opened. The German
people said that what happened was not what they expected and not what they
had approved. It was not death with dignity or rational suicide; it was mass
murder. Many German people said that they did not know the truth or that they
were poorly informed, and some have suggested that they did not want to know
the truth.

Today, Canada is faced with a similar decision about opening the same door
with the same good intentions. We tell ourselves that we are different, that
we are too civilized to allow the abuses, too sophisticated to be betrayed by
something that appears to be rational and compassionate. We tell ourselves
that we will open the door just enough to let in the rare exceptions, but
never wide enough for malicious or unintended killings. We tell ourselves
that we can keep the issues simple and never be drawn down the slippery slope
into the misapplication of our humanitarian goals.

We look to the current Dutch experience with assisted suicide and euthanasia
for reassurance. We try to focus on what is most positive (the tiny number of
true assisted suicides) and ignore the much larger numbers of people killed
without explicit request or consent. We deny the fact that since the door to
euthanasia cracked open in Holland a decade ago, it has been pried open wider
and wider in order to legitimize more and more deaths. We hope the studies
that claim that most Dutch physicians still practice deception in recording
the details of their euthanasia hide only minor procedural noncompliance. We
ignore studies that demonstrate that senior citizens in Holland report that
they fear entering nursing homes because they believe that they will be
euthanized (Protestant Christian Elderly League, 1993).

These problems must not be glossed over or ignored. For those who oppose
euthanasia, these problems may be reason enough to keep the door tightly
shut; and those who support it must confront these problems. Until and unless
they are adequately addressed, no law should be considered to permit assisted
suicide or any other form of euthanasia. If we ignore these problems, we do
so at our own peril. Whatever follows will be our responsibility. We cannot
dispose of it by saying we did not know.

Hegel, in his Philosophy of History, suggests that "what experience and
history teach is this, that people and governments have never learned
anything from history." Canadians have the opportunity to show that Hegel was
wrong. To do so, we must consider what euthanasia and assisted suicide meant
in Germany five decades ago and what they have come to mean in Holland today.
This brief considers Canada's current debate in light of these events and
what we currently know about suicide, illness, and disability.

INTRODUCTION
Last year, the Supreme Court of Canada narrowly upheld Canada's prohibition
against counselling or assisting suicide and denied Sue Rodriguez the right
to die legally with the aid of a physician. Sue Rodriguez's bravery and
willingness to stand up for her beliefs while her health and abilities
deteriorated as a result of Amyotrophic Lateral Sclerosis (ALS) have been
rightly praised as examples of the strength of the human spirit and
determination. The current debate on euthanasia and assisted suicide is, to a
significant degree, a legacy of her advocacy (Wood, 1994).

Nevertheless, if permitted in Canada, the reality of euthanasia or
physician-assisted suicide will not be the reality envisioned by Sue
Rodriguez. To understand the reality of euthanasia and assisted suicide, it
is necessary to examine similar attempts in other countries and other times
and to consider examples from our own Canadian experience.

Most of this brief focuses on physician-assisted suicide rather than other
forms of euthanasia for the following reasons: Current Canadian discussions
focus primarily on physician-assisted suicide as more acceptable than other
forms of euthanasia, and physician-assisted suicide is the target of current
legislative efforts. As suggested in this brief, assisted suicide also needs
careful consideration because what may appear to be simple and for the
benefit of the patient is, in fact, complex and rarely for the benefit the
patient.

The notion of helping people with terminal or incurable illnesses or with
severe disabilities achieve an easy and painless death appears to be humane
and uncomplicated. An individual is informed about his or her condition and
the prospects for the future. After carefully considering the information,
the individual makes an informed choice to avoid prolonged suffering and to
end his or her life with personal dignity and a sense of control. If the
individual makes a choice to die but is unable to carry out that choice
without assistance, a physician dispenses or administers drugs that cause a
peaceful and painless death. According to this view, because other Canadians
have a right to commit suicide under current Canadian law, people with
illnesses and disabilities should have the same right. If some people are
unable to kill themselves because of their impaired physical abilities,
allowing others to help them would be a reasonable accommodation. Because
people with illnesses or disabilities have rational and valid reasons for
choosing to die, they should be given assistance to commit suicide and not
prevented from exercising a right enjoyed by Canadians without disabilities
or illnesses.

To understand why these notions about assisted suicide are simplistic and
misguided, it is necessary to explore 12 underlying assumptions: [1] People
with illnesses and disabilities would make these decisions themselves, [2]
people with illnesses and disabilities would be well-informed about their
conditions and their future prospects, [3] people with illnesses and
disabilities would be free from undue influence and coercion, [4] people with
illnesses and disabilities are often able to make decisions about suicide but
physically unable to carry out those decisions, [5] access by people with
illnesses and disabilities to physician-assisted suicide would be equivalent
to the right of other Canadians to commit suicide by other means, [6]
Safeguards through the involvement of the health care professionals would be
equivalent to legal due process safeguards for the protection of human life,
[7] there is no reason to suspect that such practices would be based on or
lead to maltreatment or devaluation of people with illnesses or disabilities,
[8] there would be little potential for the abuse of the such
assisted-suicide provisions and there would be no conflict of interest
between health-care and death-making roles of physicians or other health-care
professionals, [9] it would be easy to differentiate murders of people with
illnesses and disabilities from assisted-suicides so that prosecutions could
proceed if and when appropriate, [10] the limits of such assisted-suicide
provisions would be adequately clear to prevent gradual broadening to include
other even less acceptable practices, [11] illness or disability is a more
valid reason for choosing suicide than any other reason, and [12] specific
legislation regarding euthanasia and assisted suicide would reduce ambiguity
and thereby reduce clandestine and inappropriate applications of euthanasia
and assisted suicide.

Unfortunately, according to history, experience, and research, none of these
assumptions are correct. Instead, these assumptions suggest 12 fundamental
problems with physician-assisted suicide.

PROBLEMS WITH ASSISTED SUICIDE

1. While advocates of assisted suicide suggest that this would provide people
with autonomy and personal control, in many cases, people with illnesses and
disabilities would have these decisions made for them and imposed on them. As
a result, while some people are being denied access to death now, many more
would be denied access to life under physician-assisted suicide. Statistics
from Holland (e.g., olde Scheper & Duursma, 1994), where physician-assisted
suicide has been allowed for a number of years, suggest that more people are
"assisted to die" without any explicit request (N = 1000) than those who
request assisted suicide (N = 400).

2. In many cases, people with illnesses and disabilities would be poorly
informed about their conditions and their future prospects. Therefore, the
decision to engage in assisted suicide could not be made rationally.
Currently, many patients with serious illnesses are poorly informed about
their conditions and prognoses. Without this information, they cannot be
expected to make informed decisions about suicide. Often, people are given
unclear or misleading information about their prognosis or how long they are
expected to live because health care providers simply do not know or are
wrong in their expectations. As discussed later in this brief, studies that
examined the accuracy of medical predictions suggest that physicians rarely
know who will die or when they will die. The only time that physicians can
predict when death will occur with any degree of certainty is when it is so
close that euthanasia would make little difference.

3. People with illnesses and disabilities would be influenced and coerced by
many others and by circumstances. Research shows that the information given
to patients and their families and the manner in which it is presented often
manipulates the decisions about vital matters. In some cases (e.g., the
MacAfee case discussed in this brief), people chose suicide because there is
a lack of appropriate services or inadequate accommodations and not because
of their physical conditions.

4. People with illnesses and disabilities are able to make decisions about
suicide but physically unable to carry out those decisions. In fact, very few
people have disabilities or illnesses that make it impossible for them to
commit unassisted suicide. The great majority of people with illnesses or
disabilities are perfectly capable of committing suicide by the same means
employed by other individuals. Many of those whose physical condition would
make it impossible for them to commit suicide without help are also unable to
make the decision for themselves (e.g., in a coma). Some people with advance
neurological disease or high level spinal cord injuries may be physically
incapable of holding a gun or drowning themselves, but even these individuals
have a right to refuse food or treatment under current law. While such a
method of suicide may be less preferred, it is nonetheless effective. There
may be cases where no method is available to a fully competent person, but if
such cases exist, they are extremely rare.

5. Access by people with illnesses and disabilities to physician-assisted
suicide would be vastly different to the right of other Canadians to commit
suicide by other means. While suicide is legal in Canada, the government
deliberately controls many dangerous drugs and devices that might be employed
in suicide in an effort to discourage it. Discomfort with the means that are
available acts as an important deterrent to suicide for all Canadians.
Providing deadly drugs, medical expertise, and personal assistance to one
segment of society while denying it to another segment of society goes beyond
the intention of equal access and provides differential encouragement for
suicide.

6. Safeguards through the involvement of the health care professionals would
not be equivalent to legal due process safeguards. While most physicians and
other health-care professionals are ethical and humane individuals, there is
no reason to believe that their inclination, training, or experience prepares
them to exercise life and death power more wisely than any other group of
individuals. The involvement of vast numbers of physicians in selecting
victims for gas chambers during World War II provides a grim reminder that
being a physician is in itself no guarantee that an individual will act
morally to protect life. The fact (discussed later in this brief) that large
numbers of Dutch physicians continue to falsify death certificates, defy
procedural safeguards, and go beyond the limits of legalized euthanasia,
engaging in a wider and wider circle of death-making practices, suggests that
better safeguards would be required for any Canadian legislation legalizing
physician-assisted suicide.

7. There is reason to suspect that such practices would be based on devalued
views of people with disabilities and serious illness. Studies of violence
against people with disabilities indicate that they are commonly the targets
of violence, that crimes against them are perceived as less serious than
similar crimes against other citizens, and that negative and ambivalent
attitudes about people with disabilities that suggest that their lives have
less value are at the root of these problems (Sobsey, 1994). The belief that
illness and disability are valid and rational reasons for suicide and that
other social and interpersonal problems are not rational reasons reflects
society's fundamentally biased attitudes toward disability. If our society
chooses to legitimize this myth through a categorical discrimination in
suicide law (i.e., permitting assistance only for people with illnesses and
disabilities), it will reinforce and strengthen these biases.

8. There would be great potential for the abuse of assisted-suicide
provisions, and often, there would be an inherent conflict of interest
between the health-care and death-making roles of physicians and other
health-care professionals. The interests of health-care providers, families,
and patients are often in conflict. For example, cost control has often
entered into discussions on euthanasia (e.g., Emanuel & Emanuel, 1994).
Hospitals and other institutions may be predisposed to encourage physicians
to gain the consent of some patients as cost-control measures. If patients'
deaths are to hastened to save money, this is triage and not mercy killing or
assisted suicide.

9. It would be difficult to differentiate murders of people with illnesses
and disabilities from assisted suicides. The difference between homicide and
assisted suicide depends on intentions and other subtle factors that are
difficult to prove absolutely. When this is combined with the application of
assisted suicide only to people with illness or disability, it means that
people with illness or disability in Canada would not have equal protection
of their lives, which is a fundamental breach of the Charter of Rights and
Freedoms.

10. The limits of such assisted-suicide provisions could not be constructed
clearly enough to prevent gradual broadening to include other even less
acceptable practices. If assisted suicide was limited to cases where there
were no signs of clinical depression, there was no potential conflict of
interest, and a fully competent person made a decision for his- or herself,
it would rule out more than 99% of the actual cases requiring assisted
suicide. If it is permitted in such cases, the reality of the practice will
be a slippery-slope on which society approves of rare instances of
"assisted-suicide" but gets nonvolunatry euthanasia and outright homicide.

11. Specific legislation defining appropriate and inappropriate conditions
for euthanasia will not end ambiguous or inappropriate uses of euthanasia or
assisted suicide. Current legal (#164# 241(b) Criminal Code) and ethical
(Hippocratic Oath clearly prohibits any form of counseling or assisting
suicide) prohibitions are quite clear, but even so, they have not eliminated
difficult decisions. Creating legal and ethical exceptions will only increase
the ambiguity and provide a greater rationale for other illegal and unethical
exceptions.

12. Illness or disability is no more rational a reason for choosing suicide
than any other reason. Our belief that we should prevent most suicides while
encouraging and assisting suicide for some individuals represents our own
biased views of illness and disability. For example, an individual convicted
of the murder of a child may face life in prison and social disgrace. Such an
individual faces a poor quality of life and may express the wish to commit
suicide. Yet society does not endorse suicide for convicted criminals and
takes an active role in preventing suicides in prison. Suicidal prisoners are
often deprived of belts and even shoelaces to prevent hanging. Why should we
label the suicide of such a prisoner as irrational and try to prevent it
while we label the suicide of an individual with illness or disability as
rational and offer assistance to carry it out?



EUTHANASIA

While this paper is primarily concerned with assisted suicide, a particular
form of euthanasia, it seems necessary to include some general comments about
euthanasia. The primary meaning of euthanasia is a peaceful death with
minimal suffering, regardless of whether death is natural or deliberate. Only
more recently, according to Oxford English Dictionary, the word has gained
another meaning, which is used in this brief: that is, deliberately causing
death to end suffering. This meaning has been further extended in the
twentieth century to refer to the deliberate killing of people with chronic
illnesses or disabilities with or without their consent and regardless of
whether they are suffering.

While the intention of minimizing or ending suffering necessarily plays a
central role in all of these definitions, intentions are rarely singular or
apparent. For example, Quill (1993) in describing his own motivations for
prescribing lethal medications to a terminally ill patient identifies at
least seven separate intentions. The Nazi euthanasia program in the 1930s and
1940s provides an extreme example of the problem with ambiguity of intention.
Although it was described as euthanasia and an attempt to end suffering, the
eugenic and economic intentions were also apparent. While many discussions
centered on the humane intentions of easing suffering, the increasing need
for hospital beds in war time and the shortage of physicians aggravated when
Jews were no longer allowed to practice medicine were powerful motivators for
the practice of euthanasia (Sobsey, 1994). Nevertheless, with specific orders
from Hitler, the program claimed to provide "final medical assistance" to
those judged "incurable" by physicians authorized to end their suffering
(Gallagher,1990).

These various meanings of euthanasia point out that any discussion of
euthanasia must define the limits of the term. As used here, the term
euthanasia refers to the deliberate killing of a human being (or other living
creature where so specified), whether effected by action or inaction, with
the primary intent of minimizing and ending that individual's suffering.
Euthanasia can be further divided into three categories: voluntary
euthanasia, involuntary euthanasia, and nonvoluntary euthanasia.

Voluntary euthanasia takes place when an individual personally chooses to end
his or her own life in order to end suffering with or without the assistance
from others and dies as result of this voluntary choice. As such, it is
essentially the same as suicide and will be discussed under that heading
below.

Involuntary euthanasia occurs when an individual is killed against his or her
will but with the primary intent of ending his or her suffering. This brief
strongly opposes all forms of involuntary euthanasia. Regardless of the real
or professed intentions of those responsible for killing a person against his
or her will, such killings clearly constitute murder and should be prosecuted
as murder.

Nonvoluntary euthanasia occurs when an individual is killed with the intent
of ending his or her suffering, when that individual neither gives informed
consent nor specifically indicates any objection. This frequently occurs when
an individual's ability to understand or discuss his or her condition and
alternatives is severely impaired, such as when an individual is in a coma.
This includes situations where substituted consents are given by guardians,
family members, or other substitute decision makers.

Triage is a system for classifying patients into three groups: (1) Those who
require little or no treatment because they have mild medical conditions that
should improve with or without treatment, (2) those who are unlikely to
survive with or without treatment, and (3) those for whom treatment is likely
to substantially improve outcome. Under a triage system, patients who are
least likely to benefit because of poor prospects for survival may receive
the lowest priority for treatment, receive no treatment, or even, in a
radical approach, be killed. Triage should not be confused with euthanasia;
it allows or causes people to die for the benefit of others or even as a
cost-saving measure, not for the benefit of the individual who dies. If
triage is to be implemented, it should be specifically discussed and debated
as a practice implemented for the benefit of someone other than the person
who dies. It should never be permitted to be introduced under the pretense of
euthanasia.

This brief is against all forms of involuntary euthanasia and nonvolunatry
euthanasia. These practices constitute murder under the Criminal Code of
Canada, and they should remain illegal. Recent efforts to legalize euthanasia
suggest (1) that people with disabilities and incurable illness have such
poor quality of life that killing them is doing them a favor, (2) that
because new medical technology is keeping so many people alive society is
faced with a new and increasing burden, and (3) that families of people with
disabilities should be relieved from their burden of stress. Each of these
arguments are misguided myths or deliberate propaganda (Sobsey, 1993).

The belief that people with disabilities have an unbearable quality of life
is not supported by research. In one powerful study, Bach and Campagnolo
(1992) found that respiratory dependent polio survivors rated their own
quality of life just as high as their caregivers without disabilities, but
the caregivers felt that these people had a lower quality of life. This
clearly demonstrated that health-care professionals' ratings of the quality
of life of people with disabilities is inaccurate.

In addition to the health profession's inaccurate view of quality of life, it
is believed that caring for people with disabilities strains society's
economic resources. Even if it were true that people with disabilities were
placing a strain on our economic resources, this would not be an appropriate
justification for euthanasia. The very existence of such an argument betrays
the fact that those who make it are not primarily concerned about the best
interest of the individual who might qualify for euthanasia. Nevertheless,
the belief that new lifesaving medical technology is creating an ever
increasing number of people with disabilities, which in turn places a burden
on society, is also a myth (Orelove & Sobsey, 1994). While it is true that
many people survive who would have died without modern medical treatment, and
many of those do have significant disabilities, research demonstrates that
medical science is reducing disability at an even faster rate. Vaccines have
drastically reduced the number of people disabled by polio, rubella,
pertusis, and other diseases. The lifesaving techniques that keep premature
infants alive also reduce the number who are disabled. More infants live, but
fewer survive with disabilities. The widespread use of prenatal testing and
genetic counselling has also reduced the number of people born with
disabilities. The only segment of the population with disabilities that
appears to be expanding is the elderly, and even this is based on the
outdated and inaccurate notion that everyone past a given age is disabled.
Today, in Canada, we have many more people living into their 60s and 70s than
ever before, but today, in Canada, people who are in their 60s and 70s are
also healthier than their predecessors.

While it is not true that caring for people with disabilities strains
society's economic resources, it is true that some families experience stress
due to the illness or disability of a family member. However, the frequency
and extent of the stress experienced by families is vastly exaggerated
(Sobsey, 1990; Glidden, 1993) and based on negative stereotypes of people
with disabilities. Furthermore, killing the family member associated with the
source of stress is unlikely to be a successful strategy for reducing family
stress. Family stress is not and should never be a rationale for killing
family members without disabilities, and neither should the presence of a
disability in a family member.

ASSISTED SUICIDE

Canada has identified suicide problem among its youth, and we have responded
"how can we prevent it?" Canada has identified a suicide problem among
Aboriginal Peoples,and we have responded "how can we prevent it?" Canada has
identified a suicide problem among people with disabilities, and we have
responded "how can we assist them to kill themselves?"

Assisted suicide refers to an individual taking his or her own life with the
aid of another individual. Physician-assisted suicide refers to an individual
taking his or her own life with the aid of a physician. Rational suicide
refers to suicide that results from a voluntary and competent decision by an
individual that future prospects do not justify continued living. Irrational
suicide refers to suicide that results from depression, anger, rage, fear, or
an emotional disorder.

Usually, proposals for assisted suicide suggest certain safeguards to
minimize misapplication and to help differentiate between assisted suicide
and murder. Quill, Cassel, and Meier (1992) present these typical safeguards:

oThe patient must have an incurable disease or disability that produces
mental or physical suffering, but need not be terminal.
oIllness or disability should be in advanced stages before euthanasia can be
provided.
oThe physician must determine that the suffering does not result from
inadequate treatment and should make all reasonable attempts to control pain.
oThe patient must ask to die and demonstrate certainty of decision.
oThe physician must be certain that depression or other conditions are not
distorting the patient's judgement.
oThe physician must exhaust all reasonable treatment alternatives.
oThe physician who normally treats the patient would assist with the suicide.
oAn independent physician should be consulted and agree that assisted suicide
is appropriate.
oThe patient and the two physicians involved should sign a witnessed consent
form.

Most discussions of assisted suicide consider assistance for rational suicide
but argue against irrational suicide. Nevertheless, the arbitrary distinction
between rational suicide and irrational suicide fails to recognize that all
suicide decisions include both cognitive (rational) components and affective
(irrational) components. Therefore, in reality, no suicide can be described
as wholly rational or irrational; each is somewhere on a continuum between
the two.

This brief is opposed to most forms of assisted suicide. It suggests that
legalization of assisted suicide would allow a small number of people who
have made rational choices to kill themselves with less pain or distress, but
it points out that this practice would legitimize a much larger number of
wrongful deaths. It also argues that rather than reducing the difficult legal
and ethical questions surrounding end-of-life decisions, legalization of
assisted suicide would open much broader and more difficult questions. Since
current discussions of assisted suicide and euthanasia fail to specify the
details of proposed legislation, it is necessary to consider a wide range of
possibilities. Table 1 illustrates some of the assumptions that underlie
various plans for euthanasia and the realities that undermine those
assumptions. Each of these points is discussed in this brief, and they are
grouped here primarily as a summary of information. In general, while
allowing for a wide range of possibilities, the analysis, predictions, and
recommendations in this brief are based on a program of assisted suicide and
euthanasia similar to the one currently in place in Holland.

Who would make end of life decisions? Would they have all the necessary
information? Would they be free from coercion?
Research suggests that many end-of-life decisions as well as many other vital
medical decisions are made by physicians and not their patients. The
"illusion of patient choice" has been discussed frequently in the
professional medical literature. Orenticher (1992), in reviewing several
studies, found that many physicians were uninformed about their patients
choices, exerted influence over patients choices to make them agree with
their own preferences, and simply ignored their patients' choices even when
they knew them, making their own decisions about treatment and ending
treatment according to their own attitudes and preferences. Even when
patients and their families are the nominal decision-makers, they often are
manipulated by the information given to them and the manner in which it is
presented. For example, studies have shown that physicians discussing heart
surgery with the parents of patients generally start out with a
predisposition to talk them into or out of the surgery. The same studies
indicate that these parents typically make choices consistent with the
physician's biases (Crane, 1975; Silverman, 1987). In simple language,
physicians talk parents of children without disabilities into consenting to
lifesaving surgery and talk parents of children with disabilities out of
consenting to lifesaving surgery. Such medical discrimination has been a
major problem for people with disabilities. Until there is assurance that
such medical discrimination no longer exists, giving physicians greater power
over the lives and deaths of their patients is a dangerous practice.

In research conducted at the University of Alberta, we reviewed 36 medical
records of healthy people with severe developmental disabilities for whom "Do
Not Resuscitate (DNR)" orders had been considered. None of these patients had
any acute severe health problems. Of these 36, none of them had a request for
the DNR order initiated by the family. The request was initiated by the
attending physician in 100% of the cases. In our opinion, the DNR requests
were inappropriate (there appears to be no legal basis for DNR orders for
these patients) and arbitrary (the same request was sent to all of the
families at the same time, regardless of the patient's current health
status). While only two families (6.7%) of 30 families who responded refused
consent to the implementation of DNR, all these patients' charts were
labelled "Do Not Resuscitate." Thus, it was the physician and not the patient
or the family who played the dominant role in this vital decision.

While patients have a clear right to be fully informed about their health
status, they are often poorly informed, especially in the case of
life-threatening illness. In many cases, families are informed by physicians
and the physicians and families make the decision about what and when to tell
the patient. Decisions to withhold information are often defended on the
basis of protecting the patient. This situation creates an obvious problem:
That is, it would be impossible for patients to make rational decisions about
suicide based on medical conditions about which they are not adequately
informed. In a recent poll of Canadians, it was found that 33% still believe
that physicians should withhold information about the conditions of their
patients, even if that information is essential to making vital decisions
(Singer, Choudhry, & Armstrong, 1993). The less obvious but perhaps more
catastrophic problem is that the decisions by families and physicians to tell
patients will, in many cases, be combined with the decision by families and
physicians to ask the person to consent to assisted suicide.


Table 1. Realities of euthanasia
Hypothetical case Reality of euthanasia
Autonomous decision oDecision rests mostly in the hands of physicians and
lawyers.
oIf decisions were truly autonomous, illness or disability would not be a
precondition.
Informed decision oMany people with serious illnesses are never fully
informed about their condition.
oDeception is commonly practiced and recommended in some training programs.
Free from influence oStudies show physicians give the information that will
elicit the decision they want.
Free from coercion oEconomic factors and lack of humane programs often push
people to suicide.
Rational decision o Suicide is not more or less rational for people with
illness and disability than it is for people without disabilities.
o Depression and other mental disorders are commonly present in suicide.
oPeople with medical problems commonly experience depression.
o The desire for suicide in patients with terminal illness or chronic
disabilities is rare in the absence of clinical depression.
Competent decision maker oMost people euthanized in Holland are not assisted
suicides, and many never make a direct request for euthanasia.
No other treatment available oIn many cases where euthanasia is applied in
Holland, physicians admit other reasonable treatments were available but not
tried.
Require assistance oVery few people who are competent to request suicide
actually require assistance to complete the act.
oAssistance generally means making more preferred forms of suicide available.
oMost people with illnesses or disabilities who contemplate suicide do so at
early stages when they are as capable as anyone else of committing suicide.
Last stages of disease oMost people who consider suicide because of a medical
condition do so in the early stages of the disease and rarely consider it in
the late stages.
Equal access and accommodation oOther citizens are discouraged from suicide,
not assisted to kill themselves.
oEasy methods of suicide are often prohibited in order to prevent suicide. If
suicide is to be assisted, it should be assisted for all, not prevented for
some while assisted for others.




Such discussions about who would actually make the decisions regarding
physician-assisted suicide remain somewhat abstract without real data, which
are impossible to collect until and unless physician-assisted suicide is put
into practice. However, data from Holland, where physician-assisted suicide
is permitted, provide a useful guide. As shown in Figure 1, Dutch government
estimates suggest only 400 people (14.8%) actually consented to assisted
suicide, while 1300 (48.1%) received euthanasia after making some request or
advanced directive, and 1000 (37.0%) more received euthanasia without any
request (van Delden, Pijnenborg, & van der Maas, 1993). Since the current
Dutch guidelines are similar to those suggested for Canadian law, and since
Canada's population is about one and a times that of Holland, we could expect
these numbers to be increased by about 150% in Canada.


FIGURE 1. Assisted Suicide cases in Holland. These numbers could be expected
to translate to about 600 truly voluntary assisted suicides in Canada, 1950
voluntary euthanasias, 1500 nonvoluntary euthanasias, and 12,900 cases of
requests for assisted suicide that will be denied each year in Canada.

Another 8600 people requested euthanasia, but their requests were vetoed by
their doctors. These figures do not include approximately 5800 people who had
died because treatment was withheld or about 5000 more whose deaths were
hastened by medication given primarily to control pain. Thus, actual assisted
suicides represented a very small proportion of all these deaths. In fact,
the 1000 nonvoluntary euthanasia cases outnumbered actual assisted suicides
by 2.5 to 1.

In fact, this estimate almost certainly overestimates the percentage of cases
in which patients autonomously chose assisted suicide for two reasons. First,
75% of the Dutch cases of euthanasia are not reported as such (despite the
legal requirement to do so), and "26% of Dutch physicians went so far as to
say that they would not, under any circumstances, be willing to report a case
of euthanasia despite the legal requirement" (Ciesielski-Carlucci & Kimsma,
1994, p. 152). Unless we assume that physicians are as likely to report
illegal cases as legal cases, we would have to assume more illegal
(involuntary) cases go unreported. Second, even for the 400 who volunteered
for assisted suicide, this report gives no information about any coercive
circumstances that may have influenced their decisions, how well-informed
they were about their actual condition and prognosis, or how competent they
were to make their decisions. If any of the volunteers were coerced or had
incomplete or inaccurate information, this would further reduce the number of
volunteers for assisted suicide. In view of our findings in regard to DNR
orders and the work of Crane (1975) and Silverman (1987), which suggests that
physicians are often the real decision makers, it seems extremely likely that
many of the 400 volunteers were strongly influenced by others. In view of the
information presented in this brief on the relationship between illness,
depression, and suicide, on the lack of complete information commonly given
to patients with serious illnesses, and on the undue influence of physicians
in end-of-life decisions, it is likely that more than half of the 400
voluntary cases were not fully voluntary.

There is good reason to question whether all the Dutch volunteers were
competent to make the decision about suicide. For example, this year, the
Dutch Supreme Court ruled that mental illnesses, including chronic
depression, constitute disabilities for which assisted suicide is
appropriate. It is difficult to see how a person could be so severely
mentally ill that he or she would be better off dead and yet be rational
enough to make the decision to die, especially since 64% of all people who
commit suicide suffer from a major uncomplicated affective disorder
(typically depression), and an additional 13% suffer from major affective
disorders complicated by alcoholism (Buda & Tsuang, 1990). Estimates of the
number of people in the general population with major affective disorders
range from 6.1% to 9.5% of the population, which would translate to about
1,600,000 Canadians (Buda & Tsuang, 1990).

Many cases involve substitute consent. In such cases, the decision for
"voluntary assisted-suicide" is made by another person appointed as guardian
or substitute decision maker. Such individuals are typically entrusted to
make decisions for people who cannot make them for themselves. End-of life
decisions are commonly made by such individuals. In a Wisconsin case, for
example, it was ruled that a guardian could choose to let a comatose patent
die even though the patient had never indicated a preference for this
decision at any time in his life (In the matter of Guardianship of L. W.,
1992). Thus, while the argument is made on behalf of those who are personally
requesting assisted-suicide, most "assisted suicides" will in fact be
nonvoluntary.

Are people with disabilities and chronic illness capable of making decisions
about suicide but unable to commit suicide without help? Would
physician-assisted suicide make suicide equally available to all Canadians,
regardless of disability status?
It has been argued that people with disabilities might be capable of deciding
to commit suicide, but physically unable to carry out the act. This provides
the basis for a constitutional argument that people with disabilities should
be provided assistance to commit suicide in order to have equal control over
their lives. This argument requires careful consideration.

It is clear that some people are capable of making informed decisions about
suicide but physically unable to act on this decision without assistance. The
number of people in this category, however, is very small, and the exact
number depends on the method of suicide. Figure 2 indicates common methods of
suicide for the general population. Although drugs and gas are often
considered easier methods of suicide, they are used in only 20% of cases. In
a study of young, presumably healthy college students, poison and drugs
accounted for 20% of suicide deaths, and gas accounted for another 14%; the
other 66% of suicides used less preferred methods, including firearms (30%),
hanging (17%), jumping (15%), and other means, such as drowning, slashing
wrists, vehicle crashes, fire, or electrocution (4%).


FIGURE 2. Methods of suicide. Only about 10% of people committing suicide use
poison or drugs, and this includes many methods that cause slow and painful
deaths. Most people who commit suicide use less preferred methods such as
guns and hanging.

Ironically, some of the methods that have been suggested for euthanasia may
seem more acceptable because they are seen as medical and not because they
actually produce less suffering. For example, potassium chloride injection,
mentioned in Special Senate Committee on Euthanasia and Assisted Suicide
Bulletin Number 3 as a substance requested for euthanasia, is among the
agents considered "unacceptable and absolutely condemned for use" as an
euthanasia agent (American Veterinary Medical Association, 1993, p. 239) with
animals because it is inhumane and causes respiratory arrest before
unconsciousness. Gunshot and electrocution are considered far less inhumane
methods of euthanasia.

Most people who commit suicide do not have access to easy means or
assistance. While suicide is legal in Canada, the government deliberately
controls many dangerous drugs and devices that might be employed in suicide
as a part of its suicide prevention program. Experts estimate that further
restriction of access to guns, dangerous drugs, and high places would reduce
youth suicide by about 18% (Rosenberg, Eddy, Wolpert, & Broumas, 1989). In
fact, restricting access to the common means to commit suicide is an
important component of suicide prevention programs (Lester & Leenaars, 1993).
One study showed that suicide by firearms decreased significantly in Canada
after Bill C-51 restricted firearms, and suicides by other means failed to
rise in response. Reduced access and discomfort with the means that are
available act as important deterrents to suicide for all Canadians. Providing
deadly drugs, medical expertise, and personal assistance would make suicide
much easier for those with this access. This goes beyond the intentions of
equal access and provides differential encouragement for suicide, which is
illegal under Canadian law.

Providing drugs and physician assistance would not give people with
disabilities equal access to suicide; instead, it would provide them with
encouragement to commit suicide when other citizens are discouraged.
Mislabeling this as accommodation and equal access has no basis in reality.
Suicide assistance for one segment of the population while other segments get
suicide prevention is both discriminatory and dangerous.

Would the requirement for physician involvement provide adequate safeguards?
Can physicians be expected to act rationally? Can physicians be trusted to
serve the best interests of their patients?
Physician-assisted suicide puts decisions about killing patients in the hands
of physicians. In most proposals, consultation with or review by a second
physician would be required in order to provide a safeguard against
inappropriate use of physician-assisted suicide. Such proposals place
enormous trust in physicians to act responsibly and in the best interests of
their patients. Is it reasonable to expect physicians to exercise this
responsibility properly?

The answer to this question is that some, probably most physicians would
exercise this responsibility wisely, but it is certain that some would not
act responsibly. How many physicians would act irresponsibly or irrationally
remains to be seen. Nevertheless, since proposed plans would give all
physicians the power to assist suicides, even a small minority could be
associated with large numbers of inappropriate deaths.

Substance abuse and psychiatric problems are not uncommon among physicians.
For example, studies of female physicians showed 39% to 51% had a history of
primary affective disorder (a problem commonly linked to suicidal thoughts
and actual suicide), a rate far exceeding females in the general population
(Holmes & Rich, 1990). The rate of suicide for female physicians is four
times as high as for controls of the same age and gender (Holmes & Rich,
1990). Studies of male physicians are less conclusive. Rates of suicide for
physicians as a whole appear to be about three times the rate for the
population as a whole, although these rates may not be significantly elevated
when compared to a sample matched for gender, age, ethnic origin, and
socioeconomic status (Holmes & Rich, 1990). Drug abuse is a frequent problem
among some groups of physicians (e.g., anesthesiologists, who are a likely
group to be involved in physician-assisted suicide procedures, [Holmes &
Rich, 1990]). Psychiatrists, a group likely to be involved in end-of-life
decisions also have a particularly high rate of suicide (Holmes & Rich,
1990).

Narcotic abuse among health-care professionals represents a particular
problem because it has not been uncommon for health care discouraged. divert
some of their patients pain-killing medication for their own use. Often, the
result is failure to adequately control the patient's pain. It would be
unfortunate if these same professionals were involved in their patients'
decisions to commit suicide.

The chronic problem of the sexual exploitation of patients by physicians and
other health care providers reveals further reason to question the adequacy
of physicians to safeguard the interest of patients (Shapiro, 1987; Smith &
Bisbing, 1988). Research suggests that as many as 10% of physicians engage in
the sexual exploitation of patients, in spite of ethical, professional, and,
in many cases, legal sanctions against this behavior. These physicians
selfishly ignore the harm done to their patients and act in their own
self-interest. Is it reasonable to expect them to exercise greater altruism
and responsibility when deciding who to assist with suicide?

Physicians roles in the Nazi T4 euthanasia program during the 1930s and 1940s
indicate how poorly medical involvement serves as a safeguard. Approximately
250,000 people with disabilities were "euthanized" during this program. Every
one of these people died as a result of a direct order from one of hundreds
(probably thousands) of physicians who reviewed their files and certified
that their life was truly "not worth living." Karl Brandt, the physician who
headed the program, never denied his involvement when tried after the war,
but he did deny that there was anything wrong with the program. He insisted
that the "underlying motive was the desire to help individuals who could not
help themselves and were thus prolonging their lives of torment" (quoted in
Metscherlich & Mielke, 1962, p. 266). The T4 program was legal and
legitimized by physicians who used such terms as "final medical assistance in
the case of incurable invalids" (quoted in Metscherlich & Mielke, 1962, p.
239). When objections were raised about the election of Hans Sewering, a
physician who is known to have sent more than 200 handicapped children to
their deaths as part of the Nazi euthanasia program, to head the World
Medical Association in 1992, Sewering indicated that he had never broken the
law (Leaning, 1993).

Similarly, the conduct of some Dutch physicians under the current
"assisted-suicide" program appears irresponsible. Fenigsen (1989) describes a
Dutch physician who was convicted of homicide after admitting to killing five
elderly patients without their consent. He was suspected in about 20
homicides of patients in "De Terp" old-age Home in the Hague, where the
secret killing of patients was exposed in 1985. Witnesses testified that some
of the individuals killed were not ill or debilitated but were only senile or
uncooperative with the staff. Many other patients were threatened with
euthanasia whenever they showed any sign of being uncooperative. Patients
were killed with difficult to trace insulin overdoses. This doctor pleaded
guilty to five murders and was found guilty for three murders. A citizens
committee was formed to support the physician, and the Board of Physicians
declared its alarm that this conviction might inhibit physicians or make them
feel insecure in carrying out other euthanasia actions. A higher court
dismissed the guilty pleas and declared him innocent; the punishment was
abolished, and a civil court awarded the physician 300,000 guilders (about
$200,000 Canadian) for his trouble.

In another case, aides at a Dutch nursing home who were killing patients
indicated that they were engaging in this practice because the physician was
too slow to euthanize patients (Fenigsen, 1989). The court refused to convict
them because they appeared to have humane motives. Ironically, the murder of
nursing home patients by staff is not uncommon. It has occurred in many
countries (including those that do not allow euthanasia), and it is
frequently defended as mercy killing (Sobsey, 1994). In reality, it rarely,
if ever is done as an of mercy. For example, the husband of Cathy Wood, an
American nurse's aid convicted of murdering patients at the Alpine Manor
nursing home in Michigan, wrote the judge and defended her acts:

How much did she really take? All of the victims weren't even living. They
enjoyed nothing, experienced nothing and were going to die. The families at
the times of death were relieved at the end of the suffering. (Ken Wood,
quoted in Cauffiel, 1992. p. 485)

Cathy's own admission that "we did it because it was fun" (Cathy Wood, quoted
in Cauffiel, 1992. p. 485), the fact that some of the patients killed were
healthy and happy, and the fact that the patients were chosen by their names
(Cathy Wood and her accomplices were trying to spell out "Murder" with the
patients' initials) raises questions about her altruism (Sobsey, 1994).

Health care providers who murder patients are not that uncommon. They are
among the most frequent and certainly the most prolific serial killers that
plague our society (Sobsey, 1994). Euthanasia and assisted suicide can
provide a smokescreen for their activities. Giving these people a license to
kill legally is not an attractive prospect.

A survey among two random samples of Dutch doctors (52% had actually applied
some form of euthanasia) revealed that 7% had defied the requirement that all
other reasonable treatment be tried before euthanasia, 12% of physicians had
ignored the requirement to consult with other physicians, and 26% of the
physicians who applied euthanasia falsified the cause of death. This would
translate to about 1000 cases per year of hidden cases of euthanasia. The
authors conclude that most family physicians follow the rules most of the
time (Van der Wal, van Eijk, Leenen, & Spreeuwenberg, 1992). Following most
of the rules most of the time may not be adequate grounds for giving
physicians the license to kill.

Would assisted suicide be based on devalued views of people with
disabilities? Would assisted suicide bring about further devaluation and
abuse?
The proposition that physician-assisted suicide is a rational act is false.
This proposition depends on the fundamental assumption that suicide results
from a poor quality of life and that people with health problems and
disabilities always have a lower quality of life than people without health
problems or disabilities. It depends on the assumption that a rational
consideration of quality of life is the motivation for suicides. It depends
on the assumption that the course and prognosis of an illness or disability
is predictable and can be accurately forecast.

As stated earlier in this brief, the stereotype of people with chronic
illnesses and disabilities suffering endlessly is not justified by research.
Like all other members of society, people with chronic illnesses and
disabilities experience a full range of emotions. Some are distressed,
perhaps even suicidal, but others with the same illnesses and disabilities
are enjoying life. People without disabilities also experience a full range
of emotions. Some are distressed, and some are suicidal, while others are
enjoying life. Suicide is no more or less rational for members of either
group. People choose to commit suicide because they experience isolation,
boredom, anger, betrayal, humiliation, or a variety of other negative
emotions. The belief that disability or illness is a rational reason to
commit suicide is based only on negative ideas about illness and disability.

Many years ago, Henry and Short (1954) proposed that suicide was related more
to anger and blame than to quality of life. They suggested that if suicide
were rational it should be more prevalent in societies where quality of life
is generally lower. However, they also predicted that if suicide resulted
from self-blame, with no external person to blame for an individual's
difficulties, suicide would be more common in societies where quality of life
is higher. This theory was tested and confirmed by Lester (1984), and
empirical data confirm that suicide increases as quality of life improves.
Similarly, if we assume that suicide is a sign of low quality of life we
would have to conclude that White American males (22 suicides per 100,000)
are extremely disadvantaged compared to Black American males (12 suicides per
100,000), White American females (5.3 suicides per 100,000), or Black
American females (2.3 suicides per 100,000) (Gelman, 1994).

Finally, if suicide were a rational decision for people with chronic
illnesses and disabilities, we would expect that such rational suicides would
come in the later stages of an illness or when disabilities are most severe.
This is not the case. Studies of suicide in people with a variety of health
problems indicate that suicide is much more likely to occur when symptoms are
mild, in remission, or totally absent (e.g., Marzuk et al., 1988).
Furthermore, the course of illnesses and disabilities are typically
unpredictable. Beyond the basic fact that we will all die sooner or later,
medicine is unable to predict accurately the length of most lives or the
progress of most health conditions. For example, studies of physician's
predictions of patient survival suggest that they often are only slightly
better than chance. As a result, there is rarely any firm information upon
which to base a rational decision to commit suicide.

As a result of these factors, decisions about whose lives are not worth
living and who qualifies for assisted suicide can only be based on negative
stereotypes about people with disabilities. Furthermore, by allowing these
stereotypes to become the basis for assisted suicide, we would legitimize and
reinforce these stereotypes. Many of the problems experienced by people with
disabilities do not result from their physical condition; instead, they
result from systematic marginalization and social discrimination (Sobsey,
1994). People with disabilities are the victims of more crimes than people
without disabilities, they experience educational and vocational
discrimination, and they are among the poorest Canadians. Canada needs to
respond to social problems with social reform. We need to provide a life
worth living, not a final exit for people who can no longer cope with the
abuse. If we responded to any other marginalized group with this kind of
solution, there would be public outrage.

Could we tell murder from mercy?
Assisted-suicide and euthanasia are prohibited by law partly because they
differ from murder only in intent. Society has a strong interest in
protecting its members, and to do so, it must be able to tell the difference
between suicide and murder.

A Saskatchewan case of a farmer who admitted killing his daughter provides an
example of the difficulty inherent in proving intent. While this farmer's
wife was in church, he killed his 12-year-old daughter in the garage and left
her in bed for his wife to discover. When the medical examiner recognized
that the girl had been gassed, the father admitted doing it, but he indicated
that he killed her to release her from suffering because she had cerebral
palsy. Did the daughter want to die? Was her suffering unbearable? Did the
father act to help her, or did he just want to be rid of her? We must either
take his word that his actions were altruistic or reject it. Unfortunately,
there is no objective standard with which to decide his reasons for killing
his daughter.

Procedural guidelines, such as requiring the consultation of two physicians
or recording the patient's consent, provide only a little help in determining
whether an act is murder or assisted suicide. For example, how can we know
that the patient is accurately informed ? Health care providers often
misinform patients. For example, Walton (1985) prepares physicians for
working with patients with Amyotrophic Lateral Sclerosis (ALS) saying,
"Certainly a responsible relative should be told the truth....In order not to
destroy all hope, I prefer to say that the condition progresses slowly up to
point...and may even subsequently improve....Comparatively few patients seem
to be aware of the deception" (p. 376). The fact that physicians routinely
engage in deceptions and even include this tactic in a textbook for new
physicians makes it clear that in many cases the physician and the
responsible family member will manipulate the information given to the
patient in order to get the response they want. If they believe it is time to
end the person's life, they will provide the information in a manner to
ensure that the patient makes a "voluntary" decision to die.

Could the limits of assisted suicide be clearly defined? Would specific
legislation eliminate gray areas of ambiguity?
Current events in Holland show that opening the door to some forms of
euthanasia inevitably increases acceptance of other forms. For example,
Fenigsen (1989) cites the cases of four nurses at the Free University
Hospital in Amsterdam who secretly killed comatose patients. The Empoyees'
Council defended them saying that they had been forced to take these actions
by physicians who were too slow to order euthanasia. The court dismissed the
charges because it found that they acted out of humane considerations.
Although Dutch guidelines clearly restrict euthanasia to physicians, they
have been used to legitimize many other forms of euthanasia. Rather than
provide clear boundaries for the limits of acceptable and unacceptable
euthanasia, the Dutch guidelines have merely created more gray areas.

Physicians often face difficult legal and ethical end-of-life decisions: for
example, when to discontinue treatment and allow patients to die or when to
continue treatment to alleviate pain even though death may be hastened by
this treatment. Assisted-suicide legislation might be defended as providing
clearer boundaries for physicians and assisting them with these gray areas of
practice. In fact, the opposite will occur if physician-assisted suicide is
permitted. Current law and ethical guidelines are very clear. It is illegal
to kill a patient and to counsel or assist with suicide (#164#221[b] Criminal
Code of Canada) Similarly, the Hippocratic Oath is clear: "I will neither
give a deadly drug to anybody if asked for it, nor will I make a suggestion
to this effect" (translated in Edelstein, 1967, p.4). As pointed out by
Edelstein (1967), these words "can mean only that the doctor promises not to
supply the patient with poison if asked by him to do so nor to suggest that
he take it. It is the prevention of suicide, not murder, that is here
implied" (p. 10). The law and ethical guidelines are crystal clear. Creating
some exceptions can only increase ambiguity and provide a rationale for other
illegal and unethical exceptions. Physicians will be faced with more and more
difficult decisions about when these exceptions are appropriate.

Although the problems with ambiguous guidelines and the creation of gray
areas around the fundamental protection of life have resulted in continual
discussions of assisted suicide, Canadians have repeatedly rejected the
notion of assisted suicide. For example, in 1993, the Canada's Law Reform
Commission's Report on Euthanasia, Aiding Suicide, and Cessation of Treatment
(Law Reform Commission of Canada, 1983) warned of the danger in
decriminalizing assisted suicide and euthanasia:

The Commission therefore recommends against legalizing or decriminalizing
voluntary active euthanasia in any form and is in favour of continuing to
treat it as culpabable homicide. (p. 18)

Moreover, there can be other cases in which aiding suicide is done for far
less altruistic motives, and which do warrant a legal penalty.The Commission
agrees with that view and does not recommend that aiding suicide be
decriminalized. (p. 21)

Similarly, the Canadian Medical Association, which represents 80% of Canada's
physicians, sent "a strong message to Ottawa that change [in the assisted
suicide law] is not welcome" (Adolph, 1994, p. A1) by voting against a
proposal that would allow physicians to make up their own minds on assisted
suicide. Only 73 (30.4%) of the 240 physicians who voted supported the
resolution for doctors to make up their own minds, although the vote remained
close because of a large number of abstentions. Nevertheless, the 30.4% of
physicians who voted in support probably overestimates the percentage of
supporters of assisted suicide since they only voted "yes" to making up their
own minds, not "yes" to assisted suicide.

The rejection by Canada's physicians and the Law Reform Commission was the
result of careful analysis and grave concerns. This rejection should not be
dismissed as the rantings of some uninformed special interest group.

Previous bills to legalize euthanasia and assisted suicide in Canada have
failed to gain adequate support, and the Supreme Court of Canada denied Sue
Rodriguez the right to assisted suicide on September 30, 1993. The British
Columbia Court of Appeal had already upheld the prohibition of assisted
suicide in this case in February 1993. While the Supreme Court's decision was
a close and minority members found a basis for allowing access to suicide,
#164# 241(b) of the Criminal Code was upheld, and the decision of the Supreme
Court should be seen as final. The majority decision warns that if exceptions
were made to permit assisted suicide, "there could be no guarantee that
assisted suicide could be limited to those who genuinely wish to die" (Smith,
1993, p. 6). This warning, taken with the experiences of Germany and Holland,
should be clear enough.

Is illness or disability a rational reason for suicide?
Should access to assisted suicide be based on health status?

The man who in a fit of melancholy, kills himself today, would have wished to
live if he had waited a week.
-Voltaire

Terminal illness and permanent disability have been proposed as uniquely
rational reasons for suicide. While it is true that medical conditions are
sometimes associated with suicide, they are no more rational than other
reasons, and they tend to be interwoven with a web of other reasons that are
unrelated to health or disability status.

Depression Clinical depression is associated strongly with suicide and is
commonly linked to state of health. Clinical affective disorders, typically depression,
are present in about three quarters of all people who commit suicide (Black
& Winokour, 1990). Research on suicide has increasingly shown a physiological
component, which is demonstrated by genetic studies, chemical studies, and
brain electrical activity studies (Maris, 1986). Depression and depression
accompanied by substance abuse are the conditions most frequently associated
with the desire to commit suicide. In June 1994, the Dutch Supreme Court
ruled that physicians had a right to assist in the suicide of people with
mental disorders, including depression, and that depression alone, with no
other mental or physical illness, was adequate reason for assisting a person
commit suicide. With a similar law in Canada, the vast majority of people who
are now receiving suicide prevention services would become eligible for
suicide assistance.

While it is worrisome that depression alone is viewed as an illness that can
be "treated" with assisted suicide, it is even more worrisome that depression
is rarely considered as a factor in assisted suicide. It is often simply
assumed that those who are physically ill and wish to die are acting from
rational motives. Nevertheless, depression is a critical factor in serious
illness (Sullivan & Younger, 1994):

Depression is especially common among the medically ill. Studies have
revealed that the most frequent precipitant for depression in the elderly is
physical illness. Furthermore, the rate of depression has been shown to be
higher in those who are severely ill.(p. 975)

The depressive symptoms that are most likely to impair a patient's capacity
to appreciate his or her medical situation accurately are the distorted
assessments of self, world, and future that typify depressive thinking.
Depressive helplessness produces an underestimation of one's possible
effectiveness in the face of serious illness. Guilt and worthlessness may
make one believe that suffering and death are deserved and should not be
forestalled. (p. 976)

Hopelessness is not a reflection of objective information about one's future.
It is a state of mind influenced by attitude as well as biochemical
processes. It is directly associated with depression. If suicide was a
rational decision for people with health problems and disabilities, it would
occur more frequently as the the individual's condition deteriorated, but
this is not the case. Instead, suicide is more likely to occur soon after
diagnosis.

Terminal Illness In reality, cases where the prognosis is a certainty are
exceptional. In most cases, even physicians' most basic predictions about who
will live and who will die are only marginally better than chance. Complex
computer programs have been used to aid in prediction and have improved the
accuracy, but even these make large numbers of errors. The APACHE (Acute
Physiology, Age, and Chronic Health Evaluation) program often can predict who
will live and who will die in the intensive care unit with a slightly better
than 80% accuracy. This mean that even with advanced computer systems about
one prediction in five will be wrong, and this is only a gross prediction of
survival; finer predictions about the state of health or function for those
who do survive are even more difficult. In one example of research on the
accuracy of APACHE (Abizanda et al., 1994) to predict survival of Intensive
Care Unit patients, the program correctly predicted the deaths of 47 (8%)
patients and the survival of 419 patients (74%); but 29 (5%) who were
expected to die survived, and 69 (12%) who were expected to live died. In
other words, if all 86 patents expected to die were euthanized, 29 people
(34%) would have been killed based on a false prediction of death. Other
studies report similar results. One study used advanced techniques to
categorize nonalcoholic liver disease patients into those who would live and
those who would die, and it reported powerful results (p <= 0.001); but when
these results are translated into predictions of individual cases, 12% of the
"survivors" died, and 47% of those predicted to die survived (Schrander-van
der Meer & Vogten, 1992). Such predictions seem like a poor basis for
deciding who should be euthanized.

Cancer Suicide among cancer patients also fails to be associated with more
advanced stages of the disease, but it does seem to be associated with the
use of certain medications and with a pathological fear of cancer (Mackenzie
& Popkin, 1990). This pathological fear of cancer is commonly associated with
clinical depression. One study of 44 terminally ill (43 with cancer) hospice
patients found 33 (77%) had never considered suicide. Of the 10 (23%) who had
thought about suicide, all 10 were found to be suffering from clinical
depression (Brown, Henteleff, Barakat, & Rowe, 1986).

Acquired Immune Deficiency Syndrome (AIDS) Marzuk and colleagues (1988) found
that suicide was 36 times as likely in men with AIDS as in other men of the
same age; but all of the AIDS-related suicides in this study occurred within
9 months of diagnosis, and none of them had advanced forms of the disease.
This suggests that depression and humiliation are likely to be powerful
components in these men's decision to commit suicide. As suggested by
Mackenzie and Popkin (1990), "the contemporary stigmata attached to this
diagnosis may drive some to suicide" (p. 209). The solution to this problem
is changing society's attitudes toward people with AIDS, not driving them to
suicide and then helping them do the job. Certainly, some people with AIDS do
choose suicide during later stages of the disease, but these suicides are
also difficult to defend as inherently rational since these patients show
brain changes that are often associated with memory loss, depression,
personality changes, or even psychosis (Mackenzie & Popkin, 1990).
Furthermore, while AIDS is normally a fatal condition, the course of the
disease and likelihood of death at any specific time are unpredictable. For
example, one study, using highly sophisticated techniques to predict who of
2,113 AIDS patients would die and who would be discharged, concluded that the
system was very helpful because it correctly identified 66% of the patients
who would die (Stitt, Lu, Dickson, & Klimas, 1991).

Epilepsy Suicide appears to be more frequent among people with epilepsy and
brain injury. However, this appears to be associated with brain damage in
some cases and to the side effects of medications commonly used with epilepsy
in other cases. Multiple sclerosis appears to associated with higher rates of
suicide than found in the general population, but it is often associated with
affective disorders and clinical depression. Huntington's Chorea is another
neurological disease that is associated with increased rates of suicide, but
again, it seems related to organic brain damage (Mackenzie & Popkin, 1990).

Amyotrophic Lateral Sclerosis (ALS ) ALS or motor-neurone disease results in
the degeneration of nerves that control muscles, but it does not appear to
affect the brain in a manner that would be likely to cause an affective
disorder. The disease results in progressive loss of all motor functions that
eventually lead to death. The course of the disease is unpredictable, and it
may progress rapidly for a period of time and then arrest for a significant
period of time at any stage before another period of progression. Survival
from the time of diagnosis can vary from a few months to many years.
Depression and possible suicide are most likely to ensue shortly after
diagnosis. For example, one patient described his "deep depression" and
dreams about death after receiving the diagnosis. The depression became
deeper as his ALS progressed rapidly and he was given a prognosis of not
living for more than a couple of years. In spite of his depression and the
doctor's negative prognosis, he resisted the urge to commit suicide. This man
made his decision more than 30 years ago, and in those 30 years, he has
completed his doctoral dissertation, married, had children, traveled around
the world, written one of the all-time leading international best-selling
books, become the world's best known theoretical physicist, and made a huge
contribution to humanity's understanding of the universe (Ferguson, 1992).
The man's name is Stephen Hawking. If Stephen Hawking was offered the
assistance to commit suicide three decades ago during his depression, would
he have taken the opportunity? Perhaps not, but if he had, the world might
very well be a different place.

Spinal Cord Injury Suicide has increased substantially among people with
spinal cord injury, but research suggests that many people with spinal cord
injuries demonstrate impulsive and self-destructive behavior before
sustaining their injuries. Nevertheless, most suicides that follow spinal
cord injury occur close to the time of the original injury, suggesting that
depression eases as the individual adjusts to his or her new lifestyle.
Furthermore, the severity of the injury does not predict the likelihood of
suicide.

Larry McAfee, who was paralyzed in a motorcycle accident and asked to be
assisted with suicide, provides a powerful reminder that spinal cord injured
people can adjust to a new lifestyle. The court approved his petition for a
rational assisted-suicide, but disability-rights activists protested,
suggesting that the court's willingness to assist him to die was based on his
disability status, and therefore, people with disabilities did not have equal
protection under the law. They also pointed out that McAfee wanted to die
because he was receiving poor quality care. He was being shuttled from one
nursing home to another, and the solution should have been better care and
not helping him die. By the time the case was settled, McAfee was receiving
better care, happier with his circumstances, and no longer wanted to die
(Shapiro, 1993).

Disabilities Suicide and suicide prevention are important concerns for
people with disabilities. For example, a recent study (Masuda, 1994) by DAWN
Canada (DisAbled Women's Network Canada) indicates that 60% of women with
disabilities have contemplated suicide, and 28% have attempted it; however,
the report suggests that discrimination and abuse were among the reasons
attempted suicide and suicide and not necessarily the result of a woman's
physical condition. Canada should be able to find a better answer than
assisted suicide to help ease the plight of these individuals.

The boundaries between rational and irrational suicide for people with
chronic illnesses or disabilities remain illusive for the people who would
volunteer for suicide and for those who would endorse and assist their
decisions. This is not a case of small gray areas of uncertainty; instead,
the majority of cases fall into a vast area of ambiguity.

A NOTE ON ANIMAL EUTHANASIA

It has been argued that we "put dogs to sleep to end their suffering" and
"why not show the same mercy for human beings?" The truth is that we do put
some dogs are put to sleep to end their suffering. But, many more are killed
because they are abandoned, because those responsible for them don't want to
pay for their medical treatment, because they are sacrificed for
experimentation or because we do not like the way they behave. It is
intention of mercy that legitimizes all the other reasons. This kind of mercy
should never be extended to human beings.

Advocates for euthanasia have suggested that suffering animals are put to
death and people should be given the same dignity. If such an analogy is
used to defend the mercy killing of humans, it is important to understand the
reality of veterinary euthanasia, which is a much crueler truth. Very few
animals are killed solely to end incurable suffering. Many are killed because
they are merely unwanted, because they are no longer considered appealing,
because their behavior is unacceptable, or because the people responsible for
their care cannot or do not want to pay for treatment that would save their
lives or ease their pain (Cohen & Sawyer, 1991; American Veterinary Medicine
Panel on Euthanasia, 1993). All of these intentions are lumped together under
the category of veterinary euthanasia. For example, the American Veterinary Medicine
Panel on Euthanasia (1993) discusses euthanizing "healthy and unwanted
animals. "

Statistics from the Edmonton Society for the Prevention of Cruelty to Animals
(SPCA) for 1993 indicate something about the reasons for euthanizing animals:
Of 17,147 companion animals (dogs and cats) admitted, 44% (7,559) were
euthanized; and of those euthanized, 836 (11%) were young healthy animals
killed simply because no one wanted them, 1437 (14%) were old healthy animals
killed because they were unwanted, 2036 (27%) were killed because their
behavior was unacceptable, and 3,250 (43%) were killed because of poor health
or injury. According to the report, however, "many" of the 43% euthanized
because of "poor health or injury" could have been cured and adopted if they
had received treatment.

Common acceptable methods of animal euthanasia include microwave irradiation,
decapitation, gunshot, electrocution, and penetrating captive bolt (American
Veterinary Medicine Panel on Euthanasia, 1993). Other methods in use but
"unacceptable" include drowning, bleeding, strychnine, cyanide, freezing, and
rapid decompression. There are few legal safeguards regarding animal
euthanasia: For example, Soave and Crawford (1981), in their text on
veterinary law, simply recommend that veterinarians be sure to get the
owner's signature on a consent form, make sure the person consenting is the
real owner, and do not destroy animals at the request of minor children
without parental consent. The notion of applying these practices to humans
is absurd. Again, it is the rare exception (i.e., the animal with untreatable
suffering) to kill an animal to release it from agony, but this rationale is
used to legitimate the common practice (i.e., the healthy unwanted animal
killed because it is unwanted).

CONCLUSIONS
Involuntary euthanasia and nonvoluntary euthanasia, including euthanasia with
substitute consent, are fundamentally unacceptable practices. Since they
would not be under the control of the individual who is killed, they cannot
be defended as increasing autonomy or personal choice. They would be
impossible to implement in a manner that ensured that they were in the
interest of the individuals whose lives were most directly affected. In
short, there is tremendous potential for abuse.

Assisted-suicide or voluntary euthanasia would increase voluntary decision
making and control over one's person for a small number of individuals;
nevertheless, it does not constitute a civil rights issue of equal access
since most people with disabilities who are able to make choices are also
able to kill themselves by some means, even though these generally represent
less preferred methods. Society generally attempts to discourage and prevent
suicide for all its members, and it should respond in the same way when
people with disabilities contemplate suicide.

The number of people with terminal illnesses and disabilities who would make
truly voluntary decisions to end their lives would be extremely small. In
order to extend this freedom to this small number of people, many more people
would have their lives and care put in jeopardy. Based on the experiences
with the Dutch and German euthanasia programs, it is likely that opening this
door will permit more involuntary and nonvolunatry deaths than truly
voluntary suicides. Putting so many people at risk for the possible benefit
of a much smaller number is unacceptable.

If strict safeguards for physician-assisted suicide were applied and enforced
(i.e., requiring a waiting period to ensure that the decision is consistent
and not an impulsive reaction to a diagnosis; ruling out people with clinical
depression or other confounding conditions, at least until treated; providing
access to counsellors; keeping records of the information given to patients
to ensure their is no undue influence; requiring consultation with a second
physician prior court approval), the number of physician-assisted suicides in
Canada would remain small (e.g., under 200 per year). If loose guidelines are
employed, the number of euthanasia deaths will be much larger and increase
over time (e.g., 2000-5000 a year within 10 years of legalization), but most
will not be truly voluntary and would remain illegal under stricter
regulations.

The health-care system should never be used as a substitute for the
due-process protection of human life. If there are any cases that require
special consideration to obtain assistance to commit suicide, these case
should be heard in court, ensuring a high level of protection for the lives
of all Canadian citizens.

Suicide by individuals with illnesses or disabilities is no more or less
rational an act than it is for other citizens. The view that suicide is
rational for people with illnesses or disabilities but irrational for other
Canadians is based on a devalued and prejudicial view of people with
disabilities.

PREDICTIONS

The following predictions are made about what will happen if assisted suicide
is legalized for people with illnesses and disabilities in Canada:

1. A small number of people (e.g., 500 per year) will ask for and receive
euthanasia. Even among this small number, questions will arise about how many
were free of clinical depression, fully informed, and insulated from coercion
and undue influence.

2. A much larger number of people (e.g., 3000 per year) for which no
voluntary consent exists will be killed.

3. Law and guidelines will be routinely violated, but prosecutions of
violators will be rare or nonexistent.

4. Cases will arise in which the intent to murder appears apparent, but
prosecutors will refuse to prosecute or defendants will be acquitted because
of the assisted-suicide defense.

5. People with disabilities and illnesses will report fear of involuntary
euthanasia, threats of involuntary euthanasia, and pressure to end their
lives.

6. People with disabilities and illnesses will come to view the practice as
fundamental and life-threatening discrimination.

7. Physicians will report even more ethical and legal difficulty dealing with
end-of-life decisions than previously existed.

8. There will be increasing pressure to legalize nonvoluntary and involuntary
euthanasia.

9. Evidence will arise that some health care providers are attempting to
encourage suicide as a cost-control measure or public health measure. For
example, some health care providers will attempt to influence people with
AIDS to accept suicide in order to eliminate the risk of infecting others and
to save money.

10. Eventually, any law that provides assistance for people with illnesses or
disabilities to commit suicide while discouraging and prohibiting assisted
suicide for other citizens will be found to violate Canada's Charter of
Rights and Freedoms.

RECOMMENDATIONS

Involuntary and nonvolunatry euthanasia should not be legalized in Canada.
Legalization of assisted suicide should be considered with great caution only
if the following safeguards can be met:

1. Disability or illness should not be a consideration in legitimizing
assisted suicide. If assisted suicide is legalized, it must be legal for all
citizens with or without disabilities. Legal safeguards should be in place to
determine that the person is fully competent, free of clinical depression and
other mental disorders, has made a consistent decision over time, and is free
from undue influence and pressure. Consistent with the principle of autonomy,
the individual's reason for choosing to die should not be considered
legitimate or illegitimate. If such safeguards are not adequate enough to
protect all citizens, they are not adequate enough for people with illnesses
or disabilities.

2. Physicians and health care providers should not become the guardians of
access to assisted suicide. If law allows assisted suicide, the courts should
be the decision makers, providing safeguards against the abuse of these
provisions. In any case of assisted suicide heard by the court, an advocate
for prevention should be included.

3. If physicians are involved in suicide decisions or acts, they should not
be the same physicians that have treated the individuals whose lives they are
now involved in ending.

4. Suicide among people with illnesses and disabilities should be viewed as a
public mental health concern like other suicides in Canada. It should be a
subject of research and prevention programs.

5. Physicians and other health care providers should become more involved in
suicide prevention programs. Canada should work to reduce its status as
having the third highest rate of suicide in the world among young people.

6. More specific laws and guidelines need to be developed regarding the use
of pain medication for people whose lives may be shortened by its use. It is
recommended that individuals undergoing such treatment should be given a
choice both at the early stages of treatment and at the time of
administration of any life-threatening medication.

7. More specific laws and guidelines need to be developed on withholding
medical treatment. These guidelines should be developed to help define what
constitutes heroic care or extraordinary efforts, which need not be used in
every case. They should also be designed to identify medical discrimination
and inappropriate withholding of care.

8. Prosecutors should prosecute cases of illegal euthanasia whether they are
committed as an act of commission or omission.




REFERENCES
Abizanda, R., Balerdi, B., Lopez, J., Valley, F. X., Jorda, R., Ayestaran,
I., & Rupert, C. (1993 ). Failure of prediction of rsults with APCHE II:
Analysis of prediction errors of mortality in critical patients [Spanish].
Medicina Clinica. 102(14), 527-31.
Adolph, C. (1994, August 17). Doctors say no to aiding suicides. The Edmonton
Journal. p. A1.
Bach, J. R., & Campagnolo, D. I. (1992). Psychosocial adjustment of
post-poliomyelitis ventilator assisted individuals. Archives of Physical and
Medical Rehabilitation, 73(October), 934-939.
Black, D. W. (1990). Suicide and psychiatric diagnosis. In S. J. Blumenthal
& D. J. Kupfer (Eds.), Suicide over the life cycle: Risk factors, assessment,
and treatment of suicidal patients (pp. 135-153). Washington, DC: American
Psychiatric Press.
Brown, J. H., Henteleff, P., Barakat, S., & Rowe, C. J. (1986). Is it normal
for terminally ill patients to desire death? American Journal of Psychiatry,
143, 208-211.
Cauffiel, L. (1992), Forever and five days. New York: Zebra Books.
Cohen, S. P., & Sawyer D. C. (1991. Suffering and euthanasia. Problems in
Veterinary Medicine. 3(1), 101-109.
Crane, D. (1975). The sanctity of social life. New York: The Russell Sage
Foundation.
Edelstein, L. (1967). The Hippocratic oath. In O. Temkin & C. L. Temkin
(Eds.), Ancient medicine: Selected papers of Ludwig Edelstein (pp. 4- 62).
Baltimore: Johns Hopkins Press.
Edmonton Society for the Prevention of Cruelty to Animals. (1993). Edmonton
SPCA 1993 Shelter Statistics. Edmonton: Author.
Emanuel, E . J., & Emanuel, L. L. (1994) The economics of dying: The illusion
of cost savings at the end of life. New England Journal of Medicine, 330(8),
540-544.
Fenigsen, R. (1989). A case against Dutch euthanasia. Hastings Center Report,
19(1), 22-30.
Gallagher, H. G. (1990). By trust betrayed: Patients, physicians, and the
license to kill in the Third Reich. New York: Henry Holt & Co.
Gelman, D. (1994, April 18). The mystery of suicide. Newsweek, pp. 45-47.
Glidden, L. M. (1993). What we do not know about families with children who
have developmental disabilities: Questionnaire on resources and stress as a
case study. American Journal of Mental Retardation, 97, 481-495.
Holmes, V. F., & Rich, C, L. (1990). Suicide among physicians. In S. J.
Blumenthal & D. J. Kupfer (Eds.), Suicide over the life cycle: Risk factors,
assessment, and treatment of suicidal patients (pp. 599-618). Washington, DC:
American Psychiatric Press.
In the matter of Guardianship of L. W., 167 Wis 2d 53, N.W. 2d, April 1 1992.
Law Reform Commission of Canada. (1983). Euthanasia, aiding suicide and
cessation of treatment [Report No. 20]. Ottawa: Author
Leaning, J. (1993, February, 6). German doctors and their secrets. New York
Times, p. I 21.
Lester, D. (1984). The association between quality of life and suicide and
homicide rates. The Journal of Social Psychology, 124, 247-248.
Lester, D., & Leenaars, A. (1993). Suicide rates in Canada before and after
tightening firearm control laws. Psychological Reports, 72, 787-790.
Marzuk, P. M., Tierney, H., Tardiff, K., Gross, E. M., Morgan, E. B., Hsu, M.
A.,& Mann , J. J. (1988). Increased risk of suicide in persons with AIDS.
Journal of the American Medical Association, 259, 1333-1337.
Mackenzie, T. B., & Popkin, M. K. (1990). Medical illness and suicide.
Suicide among physicians. In S. J. Blumenthal & D. J. Kupfer (Eds.), Suicide
over the life cycle: Risk factors, assessment, and treatment of suicidal
patients (pp. 205-232). Washington, DC: American Psychiatric Press.
Maris, R. (Ed.). (1986). Biology of suicide. New York: Guilford Press.
Masuda, S. (1994). DAWN Canada' Safety Net\Work Suicide and Abuse Project
report. Vancouver: DAWN Canada.
olde Scheper, T. M. J. J., & Duursma, S. A. (1994). Euthanasia: The Dutch
experience. Age and Ageing, 23, 3-8.
Orelove, F. P., & Sobsey, D. (1991). Educating children with multiple
disabilities: A transdisciplinary approach (2nd ed.). Baltimore: Paul H.
Brookes.
Orentlicher, D. (1992). The illusion of patient choice in end-of-life
decisions. Journal of the American Medical Association, 267(15), 2101-2104.
Protestant Christian Elderly League. (1993). Elderly people on the leash [In
Dutch]. Rijssen: Author.
Quill, T. E. (1993). The ambiguity of clinical intentions. New England
Journal of Medicine, 329(14), 1039-1040.
Quill, T., Cassel, C. K., Meier, D. E. (1992). Care of the hopelessly ill:
Proposed criteria for physician-assisted suicide. New England Journal of
Medicine, 327(19), 1380-1384.
Rosenberg, M. L., Eddy, D. M., Wolpert, R. C., & Broumas, E. P. (1989).
Developing strategies to prevent youth suicide. In C. R. Pfeffer (Ed.),
Suicide among youth: Perspectives on risk and prevention (pp. 203-225).
Washington, DC: American Psychiatric Press.
Schaffer, J., & Sobsey, D. (1990). A dialogue on medical responsibility. In
L. H. Meyer, L. Brown, & C. Peck (Eds.). Critical issues in the lives of
people with severe disabilities (pp. 601-606). Baltimore: Paul H. Brookes.
Schrander-van der Meer, A. M., & Vogten, A. J. (1992). Estimation of survival
probability in cirrhotics. Evaluation of a computer model applicable for
decision-making. Netherlands Journal of Medicine, 40(3-4), 183-189.
Shapiro, E. T. (1987). Sex in the MD's office. Hastings Center Report, 17(3),
11-12.
Shapiro, J. P. (1993). No pity: People with disabilities forging a new civil
rights movement. New York: Times Books.
Silverman, D. (1987). Communication and medical practice: Social relations in
the clinic. London: Sage Publications.
Singer, P. A., Choudhry, S., & Armstrong, J. (1993). Public opinion regarding
consent to treatment. Journal of the American Geriatrics Society, 31(2),
112-116.
Smith, J. T., & Bisbing, S. B. (1988). Sexual exploitation by health care and
other professionals (2nd ed.). Potomac, MD: Legal Medicine Press.
Smith, M. (1993). The Rodriguez Case: A review of the Supreme Court of Canada
decision on assisted suicide. Ottawa: Library of Parliament [Catalog No.
YM32-2/349E].
Soave, O., & Crawford, L.M. (1981). Veterinary medicine and the law.
Baltimore: Williams & Wilkins.
Sobsey, D. (1990). Too much stress on stress? Abuse & the family stress
factor. Newsletter of the American Association on Mental Retardation, 3(1),
2, 8.
Sobsey, D. (1993) Disability,discrimination, & the law. Health Law Review,
2(1), 6-10.
Sobsey, D. (1994). Violence and abuse in the lives of people with
disabilities: The end of silent acceptance? Baltimore: Paul H. Brookes.
Stitt, F. W., Lu, Y., Dickinson, G. M., & Klimas, N. G. (1991). Automated
severity classification of AIDS hospitalizations. Medical Decision Making,
11(4 Suppl.), 41-45.
Sullivan, M. D., & Younger, S. J. (1994). Depression, competence, and the
right to refuse lifesaving medical treatment. American Journal of Psychiatry,
151(7), 971-978.
van Delden, J. J., Pijnennorg M., & van der Maas, P. J. (1993). Report from
the Netherlands dances with data. Bioethics, 7(4), 323-329.
van der Wal, G., van Eijk, J. T., Leenen, H. J., & Spreeuwenberg, C. (1992).
Euthanasia and assisted suicide. II. Do Dutch family doctors act prudently?.
Family Practice. 9(2):135-40.
Walton, J. (1985). Brain's diseases of the nervous system (9th ed.). Oxford:
Oxford University Press.
Wood, C. (1994, February 28). The legacy of Sue Rodriguez. Maclean's, pp.
22-25.

SUGGESTED READINGS ON EUTHANASIA
Abrams, R. C. (1988). Dementia research in the nursing home. Hospital and
Community Psychiatry, 39(3), 257-259.
Annas, G. J., & Glantz, L. H. (1986). Rules for research in nursing homes.
New England Journal of Medicine, 315(18), 1157-1158.
Anzia, D. J., & la, P. J.??? (1991). An annotated bibliography of psychiatric
medical ethics. Academic Psychiatry, 15(1), 1-17.
Arboleda, F. J. (1991). Ethical issues regarding research on prisoners.
International Journal of Offender Therapy and Comparative Criminology, 35(1),
1-5.
Barry, R. (1992). The paradoxes of "rational death." Society, 29(5), 25-28.
Battin, M. P. (1991). Euthanasia: The way we do it, the way they do it
[Special Issue: Medical ethics: Physician-assisted suicide and euthanasia].
Journal of Pain and Symptom Management, 6(5), 298-305.
Benson, B. A., & Laman, D. S. (1988). Suicidal tendencies of mentally
retarded adults in community settings. Australia and New Zealand Journal of
Developmental Disabilities, 14(1), 49-54.
Brent, S. B., Speece, M. W., Gates, M. F., & Kaul, M. (1993). The
contribution of death-related experiences to health care providers' attitudes
toward dying patients: II. Medical and nursing students with no professional
experience. Omega Journal of Death and Dying, 26(3), 181-205.
Brock, D. W. (1992). Volunatry active euthanasia. Hastings Center Report,
22(2), 10-22.
Brown, G. W. (1990). Rule-making and justice: A cautionary tale. Mental
Retardation, 28(2), 83-87.
Carson, R. (1992). Washington's I-119. Hastings Center Report, 22(2), 7-9.
Clements, C. D. (1992). Systems ethics and the history of medical ethics
[Special Issue: Statewide Grand Rounds]. Psychiatric Quarterly, 63(4),
367-390.
Clouser, K. D. (1991). The challenge for future debate on euthanasia [Special
Issue: Medical ethics: Physician-assisted suicide and euthanasia]. Journal of
Pain and Symptom Management, 6(5), 306-311.
Connery, J. R. (1986). The ethical standards for withholding/withdrawing
nutrition and hydration. Issues in Law and Medicine, 2(2), 87-97.
Cranford, R. E. (1992). The contemporary euthanasia movement and the Nazi
program. In A. L. Kaplan (Ed.), When medicine went mad: Bioethics and the
holocaust (pp. 201-210). Totawa, NJ: Humana Press.
Crisci, C., Guariglia, M., Gargano, F., & Caruso, G. (1992). Italian
neurologists and euthanasia: A poll. Italian Journal of Neurological
Sciences, 13(5), 425-427.
Davis, A. J., Davidson, B., Hirschfield, M., Lauri, S. et al. (1993). An
international perspective of active euthanasia: Attitudes of nurses in seven
countries. International Journal of Nursing Studies, 30(4), 301-310.
Degkwitz, R. (1985). Medizinisches Denken und Handeln im Nationalsozialismus
[Medical thinking and way of acting in the national socialist era].
Fortschritte der Neurologie, Psychiatrie, 53(6), 212-225.
Erez, E. (1986). Randomized experiments in correctional context: Legal,
ethical, and practical concerns. Annual Meeting of the Academy of Criminal
Justice Sciences (1986, Orlando, Florida). Journal of Criminal Justice,
14(5), 389-400.
Fenigsen, R. (1989). A case against Dutch euthanasia. Hastings Center Report,
19(1), 22-30.
Finger, P. (1990). Die Sterilisation geistig Behinderter nach 1905 BGB in der
Fassung eines Entwurfs des Betreuungsgesetzes (BtG) [The sterilization of the
mentally handicapped according to Paragraph 1905 BGB (civil code) in a draft
of the Betreuungsgesetz]. Praxis der Kinderpsychologie und Kinderpsychiatrie,
39(4), 132-138.
Finkel, N. J., Hurabiell, M. L., & Hughes, K. C. (1993). Right to die,
euthanasia, and community sentiment: Crossing the public/private boundary.
Law and Human Behavior, 17(5), 487-506.
Fletcher, J. (1986). Geriatric psychiatry: The case of the MI, DNR, ECT, NG,
and DOD. Psychiatric Annals, 16(7), 411-413.
Fletcher, J. (1988). The courts and euthanasia. Law, Medicine and Health
Care, 15(4), 223-230.
Foley, K. M. (1991). The relationship of pain and symptom management to
patient requests for physician-assisted suicide [Special Issue: Medical
ethics: Physician-assisted suicide and euthanasia]. Journal of Pain and
Symptom Management, 6(5), 289-297.
Gers, D. (1984). "Lernbehinderte" fruher und heute-Eine Unterrichtseinheit
[Learning handicapped past and present: A historical description].
Behindertenpadagogik, 23(2), 98-125.
Gibbens, T. C., & Robertson, G. (1983). A survey of the criminal careers of
hospital order patients. British Journal of Psychiatry, 143, 362-369.
Glare, P. A., Krech, R. L., & Walsh, T. D. (1991). "Character of terminal
illness in the advanced cancer patient: Pain and other symptoms during the
last four weeks of life": Comment. Journal of Pain and Symptom Management,
6(7), 408-409.
Goldberg, R. T. (1987). The "right" to die: The case for and against
voluntary passive euthanasia. Disability, Handicap and Society, 2(1), 21-39.
Goldney, R. D. (1986). Arthur Koestler: Was his suicide rational? 13th World
Congress of the International Association for Suicide Prevention (1985,
Vienna, Austria). Crisis, 7(1), 33-38.
Gomez, C. F. (1991). Regulating death: Euthanasia and the case of the
Netherlands. New York: The Free Press.
Goodwin, O., Zouhar, M. S., & Bergman, R. (1982). Hysterical seizures in
adolescent incest victims. In J. Goodwin (Ed.), Sexual abuse: Incest victims
and their families (pp. 101-108). Littleton, MA: John Wright-PSG Inc.
Hanks, R. S., & Settles, B. H. (1989). Theoretical questions and ethical
issues in a family caregiving relationship [Special Issue: Aging and family
caregivers]. Journal of Applied Social Sciences, 13(1), 9-39.
Helmchen, H. (1990). The unsolved problem of informed consent in dementia
research. Psychiatria Fennica, 21 pp.???
Hendin, H., & Klerman, G. (1993). Physician-assisted suicide: The dangers of
legalization. American Journal of Psychiatry, 150(1), 143-145.
Ho, R., & Penney, R. K. (1992). Euthanasia and abortion: Personality
correlates for the decision to terminate life. Journal of Social Psychology,
132(1), 77-86.
Holden, J. (1993). Demographics, attitudes, and afterlife beliefs of
right-to-life and right-to-die organization members. Journal of Social
Psychology, 133(4), 521-527.
Horan, D. J. (1986). Failure to feed: An ethical and legal discussion. Issues
in Law and Medicine, 2(2), 149-155.
Hubbard, R. (1985). Prenatal diagnosis and eugenic ideology. Women's Studies
International Forum, 8(6), 567-576.
Huber, R., Cox, V. M., & Edelen, W. B. (1992). Right-to-die responses from a
random sample of 200. National Hospice Organization (1991, Seattle,
Washington). Hospice Journal, 8(3), 1-19.
Hume, J. (1991). The unremembered holocaust: How doctors ran a programme to
kill people with disabilities (Part I). New Zealand Disabled, 11(5), 61-63.
Hume, J. (1991). The unremembered holocaust: German doctors' "mercy" killings
of people with disabilities (Part II). New Zealand Disabled, 11(6), 64-65.
Humphry, D. (1986). The case for rational suicide. Center for Applied
Biomedical Ethics Conference: Non-natural death. Coming to terms with:
Suicide, euthanasia, withholding or withdrawing treatment (1986, Denver,
Colorado). Euthanasia Review, 1(3), 172-176.
Humphry, D. (1986). Mercy denied to Roswell Gilbert. Euthanasia Review, 1(1),
13-19.
Hunter, E. (1993). The snake on the caduceus: Dimensions of medical and
psychiatric responsibility in the Third Reich. Australian and New Zealand
Journal of Psychiatry, 27(1), 149-156.
Huyse, F. J., & Van, T. W. (1993). Euthanasia policy in the Netherlands: The
role of consultation-liaison psychiatrists. Hospital and Community
Psychiatry, 44(8), 733-738.
Jennings, B. (1991). Active euthanasia and forgoing life-sustaining
treatment: Can we hold the line? [Special Issue: Medical ethics:
Physician-assisted suicide and euthanasia]. Journal of Pain and Symptom
Management, 6(5), 312-316.
Kaminer, Y., Feinstein, C., & Barrett, R. P. (1987). Suicidal behavior in
mentally retarded adolescents: An overlooked problem. Child Psychiatry and
Human Development, 18(2), pp.???.
Katz, J. (1992). Abuse of human beings for the sake of science. In A. L.
Kaplan (Ed.), When medicine went mad: Bioethics and the holocaust (pp.
233-270). Totawa, NJ: Humana Press.
Kennedy, M. (1989, March). Sexual abuse: A survivor's story. Soundbarrier,
pp. 10-11.
Kerwin, J., & Shaffer, D. R. (1991). The effects of jury dogmatism on
reactions to jury nullification instructions. Personality and Social
Psychology Bulletin, 17(2), 140-146.
Klagsbrun, S. C. (1991). Physician-assisted suicide: A double dilemma
[Special Issue: Medical ethics: Physician-assisted suicide and euthanasia].
Journal of Pain and Symptom Management, 6(5), 325-328.
Koenig, H. G. (1993). Legalizing physician-assisted suicide: Some thoughts
and concerns. Journal of Family Practice, 37(2), 171-179.
Kuhse, H., & Singer, P. (1985). Should the baby live? The problem of
handicapped infants. Oxford: Oxford University Press.
Kuhse, H., & Singer, P. (1989). The quality/quantity-of-life distinction and
its moral importance for nurses. First Victorian State Conference on Nursing,
Law and Ethics: Matters of life and death (1988, Melbourne, Australia).
International Journal of Nursing Studies, 26(3), 203-212.
Kuhse, H., & Singer, P. (1993). Voluntary euthanasia and the nurse: An
Australian survey. International Journal of Nursing Studies, 30(4), 311-322.
Latimer, E. J. (1991). Ethical decision-making in the care of the dying and
its applications to clinical practice [Special Issue: Medical ethics:
Physician-assisted suicide and euthanasia]. Journal of Pain and Symptom
Management, 6(5), 329-336.
Lauter, H., & Meyer, J. E. (1982). Mercy killing without consent: Historical
comments on a controversial issue. Acta Psychiatrica Scandinavica, 65,
134-141.
Lauter, H., & Meyer, J. E. (1984). Active euthanasia without consent:
Historical comments on a current debate. Death Education, 8(2-3), 89-98.
Lavin, M. R., Martin, G., & Roy, A. (1992). Final Exit: The practice of
self-deliverance and assisted suicide for the dying: Comment. New England
Journal of Medicine, 326(13).PP????
Lavin, M. R., Martin, G., & Roy, A. (1993). Final Exit and depressed
patients. American Journal of Psychiatry, 150(7).PP????
Lecso, P. A. (1986). Euthanasia: A Buddhist perspective. Journal of Religion
and Health, 25(1), 51-57.
Lester, D., & Bean, J. (1992). Attitudes toward preventing versus assisting
suicide. Journal of Social Psychology, 132(1), 125-127.
Lester, D., Hadley, R. A., & Lucas, W. A. (1990). Personality and a pro-death
attitude. Personality and Individual Differences, 11(11), 1183-1185.
Levine, C., Dubler, N. N., & Levine, R. J. (1991). Building a new consensus:
Ethical principles and policies for clinical research on HIV/AIDS. Irb??? A
Review of Human Subjects Research, 13(1-2), 1-17.
Lifton, R. J., & Hackett, A. (1990). Physicians, Nazi. In I. Gutman (Ed.),
Encyclopedia of the holocaust (Vol. 3, L-R, pp. 1127-1132). New York:
Macmillan.
Lo, B. (1990). Assessing decision-making capacity. Law, Medicine and Health
Care, 18(3), 193-201.
Lowenthal, B. (1989). Early childhood special educators and the hospital
ethics committee. International Journal of Disability, Development and
Education, 36(1), 29-38.
Lusthaus, E. (1985). "Euthanasia" of persons with severe handicaps: Refuting
the rationalizations. Journal of the Association for Persons with Severe
Handicaps, 10(2), 87-94.
Lynn, J. (1988). The health care professional's role when active euthanasia
is sought [Special Issue: Controversies in palliative care: A thematic
issue]. Journal of Palliative Care, 4(1-2), 100-102.
Macklin, R. (1992). Which way down the slippery slope? Nazi medical killing
and euthanasia today. In A. L. Kaplan (Ed.), When medicine went mad:
Bioethics and the holocaust (pp. 173-199). Totawa, NJ: Humana Press.
Marzen, T. J. (1986). Medical decisionmaking for the incompetent person: A
comprehensive approach. Issues in Law and Medicine, 1(4), 293-317.
Meilaender, G. (1986). The confused, the voiceless, the perverse: Shall we
give them food and drink? Issues in Law and Medicine, 2(2), 133-148.
Meisel, A. (1989). Refusing treatment, refusing to talk, and refusing to let
go: On whose terms will death occur? Law, Medicine and Health Care, 17(3),
221-226.
Meyer, J. E. (1988). "Die Freigabe der Vernichtung lebensunwerten Lebens" von
Binding und Hoche im Spiegel der deutschen Psychiatrie vor 1933 [Release for
elimination of those unworthy of living by Binding and Hoche: The response of
German psychiatry prior to 1933]. Nervenarzt, 59(2), 85-91.
Meyer, J. E. (1988). The fate of the mentally ill in Germany during the Third
Reich. Psychological Medicine, 18(3), 575-581.
Meyer-Lindenberg, J. (1991). The holocaust and German psychiatry. 143rd
Annual Meeting of the American Psychiatric Association: International
scholars lecture series (1990, New York, New York). British Journal of
Psychiatry, 159, 7-12.
Miles, S. H., & August, A. (1990). Courts, gender and "the right to die."
Second International Conference on Health Law and Ethics (1989, London,
England). Law, Medicine and Health Care, 18(1-2), 85-95.
Mitscherlich, A., & Mielke, F. (1962). The death doctors (James Cleugh,
Trans.). London: Elek Books.
Nagi, M. H. (1990). Clinical imperatives versus ethical commitments in
euthanasia: The perspectives of nurses. Loss, Grief and Care, 4(1-2), 99-128.
Nelson, W. A., & Bernat, J. L. (1989). Decisions to withhold or terminate
treatment. Neurologic Clinics, 7(4), 759-774.
Nevins, M. A. (1986). Analysis of the Supreme Court of New Jersey's decision
in the Claire Conroy case. Journal of the American Geriatrics Society, 34(2),
140-143.
Nuernberg Military Tribunals (1946). Trials of war criminals before the
Nuernberg Military Tribunals under Control Council Law No. 10. Volumes I and
II, The Medical Case. Wahington, DC: U.S. Government Printing Office.
O'Rourke, K. (1991). Assisted suicide: An evaluation [Special Issue: Medical
ethics: Physician-assisted suicide and euthanasia]. Journal of Pain and
Symptom Management, 6(5), 317-324.
O'Rourke, K. (1992). Pain relief: The perspective of Catholic tradition.
Journal of Pain and Symptom Management, 7(8), 485-491.
Paulos, S. M. (1985). In re L.H.R. Issues in Law and Medicine, 1(3), 233-236.
Payoffs demanded for participants. (1993, December 29). The Edmonton Journal,
p. B8.
Pfafflin, F. (1987). Bemerkungen zur forensischen Psychiatrie [Observations
on forensic psychiatry]. Recht and Psychiatrie, 5(4), 134-140.
Pope, K. S. (1988). How clients are harmed by sexual contact with mental
health professionals: The syndrome and its prevalence. Journal of Counseling
and Development, 67(4), 222-226.
Post, S. G. (1990). Severely demented elderly people: A case against
senicide. Journal of the American Geriatrics Society, 38(6), 715-718.
Prakasa, R. V. V., Staten, F., & Nandini, R. V. (1988). Racial differences in
attitudes toward euthanasia. Southern Sociological Society Meeting (1987,
Atlanta, Georgia). Euthanasia Review, 2(4), 260-277.
Proctor, R. (1988). Racial hygiene: Medicine under the Nazis. Cambridge, MA:
Harvard University Press.
Proctor, R. N. (1992). Nazi biomedical policies. In A. L. Kaplan (Ed.), When
medicine went mad: Bioethics and the holocaust (pp. 23-42). Totawa, NJ:
Humana Press.
Pross, C. (1991). Breaking through the postwar coverup of Nazi doctors in
Germany. Journal of Medical Ethics, 17(Suppl.), 13-16.
Pynoos, R. S., & Eth, S. (1986). Witness to violence: The child interview.
Journal of the American Academy of Child Psychiatry, 25(3), 306-319.
Quill, T., Cassell, C., & Meier, I. E. (1992). Care of the hopelessly ill:
Proposed clinical criteria for physician-assisted suicide. New England
Journal of Medicine, 327(19), 1380-1384.
Qvarnstrom, U. (1990). Quality of life-Euthanasia. First Open Symposium of
the Nordic Academy of Nursing Science (1989, Vasa, Finland). Scandinavian
Journal of Caring Sciences, 4(1), 7-10.
Risley, R. (1986). What the humane and dignified death initiative does.
Euthanasia Review, 1(4), 221-225.
Rodriguez: Autonomy & vulnerability must both be protected (1993). Abilities,
16(Fall), 77-78.
Rollin, B. E. (1987). Euthanasia and moral stress. Loss, Grief and Care,
1(1-2), 115-126.
Roscam, A., & Henriette, D. (1988). Dying with dignity, and euthanasia: A
view from the Netherlands [Special Issue: AIDS]. Journal of Palliative Care,
4(4), 70-74.
Rosenthal, G., & Bar, O. D. (1992). A biographical case study of a
victimizer's daughter's strategy: Pseudo-identification with the victims of
the Holocaust. Journal of Narrative and Life History, 2(2), 105-127.
Rosner, F., Rogatz, P., Lowenstein, R., Risemberg, H. M. et al. (1992).
Physician-assisted suicide. New York State Journal of Medicine, 92(9),
388-391.
Roumasset, E. G. (1991). Early experiences, affect organization, and
separation anxiety in adolescent females with the self-mutilation syndrome.
Dissertation Abstracts International, 51(10), 5039B-5040B.
Rudisill, J. R., & Merriman, P. S. (1987). Attitudes toward death and dying
among second-year medical students. Death Studies, 11(6), 437-445.
Rue, V. M. (1985). Death by design of handicapped newborns: The family's role
& response. Issues in Law and Medicine, 1(3), 201-225.
Sacks, M. H., & Kemperman, I. (1992). Final Exit as a manual for suicide in
depressed patients. American Journal of Psychiatry, 149(6).PP??
Sarason, S. B. (1986). And what is the public interest? American
Psychologist, 41(8), 899-905.
Scharfetter, C. (1984). Ein Anliegen der Menschheitserziehung: Delegierte
Destruktivatat [An objective of education of mankind: Delegated
destructiveness]. Schweizer Archiv fur Neurologie, Neurochirurgie und
Psychiatrie, 134(2), 279-293.
Schmidt, G. (1985). Vom Rassenmythos zu Rassenwahn und Selektion [From racial
myth to racial psychosis and persecution]. Nervenarzt, 56(7), 337-347.
Scofield, G. R. (1991). Privacy (or liberty) and assisted suicide [Special
Issue: Medical ethics: Physician-assisted suicide and euthanasia]. Journal of
Pain and Symptom Management, 6(5), 280-288.
Seidelman, W. E. (1989). In memoriam: Confrontation with evil. Hastings
Center Report, 19(6), 5-6.
Seidelman, W. E. (1992). "Medspeak" for murder. In A. L. Kaplan (Ed.), When
medicine went mad: Bioethics and the holocaust (pp. 271-279). Totawa, NJ:
Humana Press.
Seiden, R. H. (1986). Self-deliverance or self-destruction? Euthanasia
Review, 1(1), 48-56.
Sengstock, W. L., Magerhans Hurley, H., & Sprotte, A. (1990). The role of
special education in the Third Reich. Education and Training in Mental
Retardation, September, 225-236.
Sengstock, W. L., & Ruttgardt, S. E. (1994). Rebuilding special education in
Germany after World War II. Education and Training in Mental Retardation and
Developmental Disabilities, 29(1), 69-81.
Shapiro, J. P. (1993). No pity: People with disabilities forging a new civil
rights movement. New York: Times Books.
Sherlock, R. (1987). Preserving life: Public policy and the life not worthy
of living. Chicago: Loyola University Press.
Shuman, C. R., Fournet, G. P., Zelhart, P. F., Roland, B. C. et al. (1992).
Attitudes of registered nurses toward euthanasia. Death Studies, 16(1), 1-15.
Smith, J. D. (1989). On the right of children with mental retardation to life
sustaining medical care and treatment: A position statement. Education and
Training in Mental Retardation, 24(1), 3-6.
Solomon, M. Z., O'Donnell, L., Jennings, B., Guilfoy, V. et al. (1993).
Decisions near the end of life: Professional views on life-sustaining
treatments. American Journal of Public Health, 83(1), 14-23.
Somander, L. K. H., & Rammer, L. M. (1991). Intra- and extrafamilial child
homicide in Sweden 1971-1980. Child Abuse & Neglect, 15, 45-55.
Sonnenblick, M., Friedlander, Y., & Steinberg, A. (1993). Dissociation
between the wishes of terminally ill parents and decisions by their
offspring. Journal of the American Geriatrics Society, 41(6), 599-604.
Sovner, R., & Hurley, A. D. (1982). Suicidal behavior in mentally retarded
persons. Psychiatric Aspects of Mental Retardation Newsletter, 1(10), 37-40.
Spector, S. (1990). Gas chambers. In I. Gutman (Ed.), Encyclopedia of the
holocaust (Vol. 2, E-K, pp. 539-544). New York: Macmillan.
Swann, S. W. (1987). Euthanasia on the battlefield. 2nd Annual Conference:
Military medicine (1986, Bethesda, Maryland). Military Medicine, 152(11),
545-549.
ten Have, H. A. M. J., & Welie, J. V. M. (1992). Euthanasia: Normal medical
practice. Hastings Centre Report, 22(2), 34-38.
Thrush, J. C., Stewart, C. S., & Paulus, G. S. (1985). Effect of parental
socialization on student nurses' attitudes toward euthanasia. Death Studies,
9(5-6), 395-415.
Travis, R. (1991). Two arguments against euthanasia. Gerontologist, 31(4),
561-562.
Tuteur, M. (1993). Neo-Nazis & disability in Germany: Never again...once
again! Abilities, 16, 64-65.
U. S. experiments on people compared to Nazi atrocities. (1993, December 29).
The Edmonton Journal, p. B8.
CHECK AUTHORS Van, d. S., & Isaac (1988). How voluntary is voluntary
euthanasia? [Special Issue: Controversies in palliative care: A thematic
issue]. Journal of Palliative Care, 4(1-2), 107-109.
Vice, J. (1989). The morality of mental illness: Thomas Szasz's critique of
psychiatry. Journal of Humanistic Psychology, 29(3), 385-393.
Voeckler, C., Bilwes, M., Oswald, A., & Schneider, G. (1989). Schizophrenie
et euthanasie [Schizophrenia and euthanasia]. Symposium: The psychiatric
evolution (1988, Saint-Maurice, France). Evolution Psychiatrique, 54(2),
387-395.
Voeckler, C.,Bilwes, M.,Oswald, A.,Schneider, G. et al. (1989). Vous avez
dit: Euthanasie? [Did you not say: Euthanasia?]. Symposium: The psychiatric
evolution (1988, Saint-Maurice, France). Evolution Psychiatrique, 54(2),
397-411.
Volicer, L. (1986). Need for hospice approach to treatment of patients with
advanced progressive dementia. Journal of the American Geriatrics Society,
34(9), 655-658.
von Ronn, P. (1991). Zum indirekten Nachweis von Totungsaktivitaten wahrend
der zweiten Phase der NS-"Euthanasie" [Indirect proof of murderous activities
during the second stage of the Nazi-"Euthanasia"]. Recht and Psychiatrie,
9(1), 8-13.
Wade, C. H., & Anglin, M. D. (1987). Factors influencing decisions to
terminate life. Social Biology, 34(1-2), 37-46.
Walsh, B. W., & Rosen, P. M. (1988). Self-mutilation: Theory, research, and
treatment. New York: Guildford Press.
Wanzer, S. H., Federman, D. D., Adelstein, S. J., Cassel, C. K. et al.
(1989). The physician's responsibility toward hopelessly ill patients: A
second look. New England Journal of Medicine, 320(13), 844-849.
Wasserman, D. (1989). Passive euthanasia in response to attempted suicide:
One form of aggressiveness by relatives. Acta Psychiatrica Scandinavica,
79(5), 460-467.
Watts, D. T., Howell, T., & Priefer, B. A. (1992). Geriatricians' attitudes
toward assisting suicide of dementia patients. Journal of the American
Geriatrics Society, 40(9), 878-885.
Waxman, H. M., Astrom, S., Norberg, A., & Winblad, B. (1988). Conflicting
attitudes toward euthanasia for severely demented patients of health care
professionals in Sweden. Journal of the American Geriatrics Society, 36(5),
397-401.
Weeks, D., & Johnson, C. (1992). A second decade of high school death
education. Death Studies, 16(3), 269-279.
Weir, R. F. (1992). The morality of physician-assisted suicide. Law, Medicine
and Health Care, 20(1-2), 116-126.
Wickett, A. (1986). The mercy killer: Cold blooded or compassionate?
Euthanasia Review, 1(1), 20-32.
Williams, J. R. (1991). When suffering is unbearable: Physicians, assisted
suicide, and euthanasia. Journal of Palliative Care, 7(2), 47-49.
Winkler, E. (1985). Decisions about life and death: Assessing the Law Reform
Commission and the Presidential Commission Reports. Journal of Medical
Humanities and Bioethics, 6(2), 74-89.
Wolfensberger, W. (1981). The extermination of handicapped people in World
War II Germany. Mental Retardation, 19(1), 1-7.
Yarnell, S. K., & Battin, M. P. (1988). AIDS, psychiatry, and euthanasia
[Special Issue: Ethical treatment of patients with AIDS]. Psychiatric Annals,
18(10), 598-603.
Zucker, A. (1986). To the marriage of true minds: Some synergisms of ethics,
law, and medicine. Death Studies, 10(2), 119-133.
Zucker, A., & Annarino, L. (1986). Department of law and ethics. Death
Studies, 10(3), 301-304.