Friday, May 31, 2013

Maine House overwhelmingly rejects assisted suicide bill

An article published in the Bangor Daily News in Maine reports on the overwhelming defeat of the assisted suicide bill in the Maine House. The article was written by Matthew Stone on May 31, 2013 and titled: Maine House says no to physician-assisted suicide law.

The article reported that:
House members voted 95-43 against the measure, which is sponsored by Rep. Joseph Brooks, an independent from Winterport. The bill next heads to the Senate. 
Brooks’ bill, LD 1065, would allow a patient and his or her doctor to sign companion end-of-life care agreements. Those agreements would be signed after the two have discussed the patient’s medical condition and treatment options and the patient has rejected life-extending treatments and agreed to accept “care that is ordered or delivered by the physician that may hasten or bring about the patient’s death.” 
The bill also would free doctors from criminal liability or the possibility of professional discipline for helping a consenting patient end his or her life. 
The vote followed an emotional debate on the House floor in which lawmakers described their experiences caring for parents and friends as their lives ended.Brooks said ill patients should be able to decide to end their lives when they can die in dignity. 
“Dignity was important to this mill laborer,” he said of his father. “Had he been aware that he was lying in a hospital bed in the living room of his home not in control of anything, he would have probably said, ‘Please help me with this.’” 
“How many of us have lost or seen others lose loved ones who linger painfully and unnecessarily for long periods?” asked Rep. Roberta Beavers, D-South Berwick. “We treat ill pets more humanely than we treat ill parents.” 
But in letting doctors administer lethal doses of medication, the assisted-suicide bill would go too far, said Rep. Ann Dorney, D-Norridgewock. End-of-life care has changed for the better in recent years, said Dorney, a physician. 
“We have very good end-of-life care. We have very good hospice care. We have very good palliative care,” she said. “I guess I’m not sure we need this bill.” 
Dorney also worried about the prospect of a guardian who makes medical decisions for a patient making the decision to end that patient’s life. 
Rep. Deborah Sanderson, R-Chelsea, said she wouldn’t want to rob a patient of a natural end to life. 
“I sat with my mom the last five days of her life. I slept in a wheelchair by her bed,” Sanderson said. “The night before my mother passed, my mother said, ‘It’s not like what I thought it would be.’ She said, ‘It’s peaceful.’ And I was very glad to hear that.” 
The Maine House’s rejection of the physician-assisted suicide legislation came more than a week after Vermont Gov. Peter Shumlin signed a similar measure into law in that state. Vermont’s law was the first in the nation to be approved through the legislative process. 
Physician-assisted suicide measures on the books in Oregon and Washington passed through public votes. 
In Maine, voters rejected a physician-assisted suicide ballot measure in 1990.
People in Maine with disabilities and those living with chronic conditions should be comforted by the fact that legislators in their state have decided to reject assisted suicide, an act threatens the lives of vulnerable citizens.

Book Review: Alzheimer’s disease, the soft target of the euthanasia debate.

Deakin University Australia - May 24, 2012

http://www.deakin.edu.au/news/2013/240413alzheimersandeuthanasia.php?

Megan-Jane Johnstone
The way Alzheimer’s disease is portrayed by advocacy groups and the media is having undue influence on the euthanasia debate, according to a Deakin University nursing ethics professor.

Deakin’s Professor Megan-Jane Johnstone has examined the ‘Alzheimerisation’ of the euthanasia debate in a new book - ‘Alzheimer’s disease, media representations and the politics of euthanasia: constructing risk and selling death in an aging society’ - based on her extensive research into the media representations of Alzheimer’s and the shift in public attitudes towards euthanasia.
“Alzheimer’s has been portrayed as the ‘disease of the century’ that is poised to have a near catastrophic impact on the world’s healthcare system as the population ages,” Professor Johnstone said. 
“This representation of the disease—along with other often used terms such as ‘living dead’, a ‘funeral that never ends’ and a ‘fate worse than death’—places Alzheimer’s as a soft target in the euthanasia debate because it plays to people’s fears of developing the disease and what it symbolises. It positions Alzheimer’s as something that requires a remedy; that remedy increasingly being pre-emptive and beneficent euthanasia.”
Professor Johnstone acknowledges that euthanasia is a polarising and emotive issue, however she warns that the public could be unduly swayed by the way the media, and pro-euthanasia groups, frame the issue as ‘simply a matter of choice’ and through the use of highly personalised, individual experiences.
“Euthanasia is far from a simple matter of choice, as choice itself is no simple matter; it is an extremely complex phenomenon. And Alzheimer’s disease cannot be adequately portrayed through highly publicised individual cases,” Professor Johnstone explained. 
“But this is the messaging coming through the media and influencing the public’s perception of Alzheimer’s disease and euthanasia, and calls into question the credibility of public opinion and opinion polls on which future public policy could be considered.”
Professor Johnstone’s book is not a treatise on the arguments for or against euthanasia and does not take a position either way.
“My hope is that the book will open people’s eyes to the ‘Alzheimerisation’ of the euthanasia debate and encourage them to critically evaluate the messages they are receiving from all sides of the debate,” Professor Johnstone said. 
“The proposal to allow euthanasia as a morally warranted option in the treatment of Alzheimer’s disease and other dementia’s is neither simple nor straightforward. 
“Anything less than an honest, transparent and accountable debate, which has been lacking to date, would be an assault on the integrity of all—both those for and against the euthanasia proposal—who are trying in their own ways to care for those who are confronting the hard-nosed reality of their inevitable mortality.”
Alzheimer’s disease, media representations and the politics of euthanasia: constructing risk and selling death in an aging society’ is published by Ashgate Publishing in Australia.

Professor Johnstone is Academic Chair in Nursing and Associate Head of School (Research) in the School of Nursing. She teaches at undergraduate and postgraduate levels and also supervises higher degree students. Professor Johnstone is an active researcher and scholar in the field of nursing and health care ethics. Her work has focused on a range of issues including: clinical risk management and patient safety ethics, health and human rights, cross-cultural health care ethics, health care disaster ethics, public health emergency ethics, moral policy development and end-of-life decision-making, dementia care ethics, and professional conduct in health care domains. She has published numerous journal articles and commentaries, and is the author of several books, including the internationally acclaimed Bioethics: a nursing perspective (now in its 5th revised edition) and the ICN commissioned work Ethics in nursing practice: a guide to ethical decision making (co-authored with Sara T. Fry USA, 2008). 

Thursday, May 30, 2013

Gallup: Support for assisted suicide fluctuates based on the wording of the question.

Support for assisted suicide in America is at a low when the question includes the word "suicide"

By Alex Schadenberg, 
International Chair, Euthanasia Prevention Coalition.

A Gallup survey conducted (May 2 - 7, 2013) found that support for assisted suicide fluctuates by almost 20% based on the wording of the question.

The survey found that: 
51% of Americans support assisted suicide when the process is described as doctors helping a patient "commit suicide" while 70% of Americans supported assisted suicide when it was described as allowing doctors to "end the patient's life by some painless means."
The report from Gallup stated:
Gallup has asked both questions of U.S. adults aged 18 and older annually since 2001, as part of its Values and Beliefs survey. This year's update was based on interviews with 1,535 adults, and each question was asked of a separate half-sample.
Gallup reported that support for assisted suicide is down in recent years. The recent Gallup poll indicated that 45% of Americans were opposed to assisted suicide, which is the highest level since the poll question began in 1996. Gallup reported that:
... current support -- with 51% of Americans in favor and 45% opposed -- is similar to that of the previous three years, and is nearly identical to attitudes in 1996. In the interim, support steadily rose to 68% by 2001 and remained above 60% through 2004, after which it started to falter.
We learned from the recent defeat of the assisted suicide referendum in Massachusetts that once people learn more about assisted suicide, they become less likely to support it. 

Polling originally indicated that people in Massachusetts supported assisted suicide. After a good campaign informing Massachusetts voters of what assisted suicide is, it was defeated.

Several years ago I attended the World Federation of Right to Die Societies Conference. The euthanasia lobby knew from polling and focus groups that changing the language of the debate and message discipline would lead to more support for assisted suicide and euthanasia. 

The Gallup survey report concluded that:
A wording that refers to the patient's intention to end his or her life as "suicide," doesn't say family members are involved in the decision, and doesn't specify that the procedure will involve "painless means" produces lower support than the alternative wording. However, the resulting difference offers important insights into the complex nature of Americans' views on this question, as well as the negative connotation suicide has, generally. Underscoring this, the same poll finds just 16% of Americans saying suicide is morally acceptable. At the same time, the public is evenly split over whether "doctor-assisted suicide" is morally acceptable: 45% say it is, and 49% say it is not.
The Euthanasia Prevention Coalition has also learned that certain language is more effective. We agree with the Gallup poll that the use of the term assisted suicide or assisting a suicide is more effective than terms like: prescribed death, aid in dying or assisted dying.

Links to previous polling information.
- Do Americans want to legalize assisted suicide?
- Canadians want good end-of-life care not euthanasia or assisted suicide.
- More Americans believe that assisted suicide is morally wrong.
- Why the assisted suicide referendum was defeated in Massachusetts.

Hospital for Sick Children in Toronto dehydrating children with disabilities to death based on Quality of Life assessments

The following article represents a synthesis of the findings, with commentary by myself about the study: Parental Perceptions of Forgoing Artificial Nutrition and Hydration (FANH) During End-of-Life Care.

The first part of the article is a synthesis of the study, while the second part of the article is my commentary about the findings in the study.

By Alex Schdenberg, International Chair of the Euthanasia Prevention Coalition.

A study entitled: Parental Perceptions of Forgoing Artificial Nutrition and Hydration (FANH) During End-of-Life Care was published in the Journal Pediatrics in its May 5, 2013 edition concerning the reactions of parents to the experience of withdrawing nutrition and hydration (FANH) from a child who was dying or experiencing a low quality of life at the Hospital for Sick Children in Toronto.

The study is based on independent interviews with parents after the child died.

The study sought input from twelve families of children who died after FANH. Three families were not interested in participating in the study and three families could not be reached. A total of eleven parents from six families participated in the study. One family had two children who died after FANH. Six children died after ANH was withdrawn, while one child died after ANH was withheld.

Two of the children died before the third month of life, two of the children died after the third month but before the sixth month of life and 3 children died at age 14 or 15.

Participation in the study was based on parents who were 18 years or older, who lived within 125 miles of the hospital and were fluent in English.

The study first defined the practice of FANH. 
ANH is defined by the Hospital for Sick Children as a life-sustaining treatment that is provided by naso gastric, or gastric tubes. ANH is provided when children cannot meet their dietary requirements or when it becomes unsafe to do so.
 The study states: 
“Although ANH may support biological existence and increase weight, there is no evidence that it improves survival or quality of life in dying children or adults. ANH carries significant risks and potential complications.”
The study states: 
“Providing ANH at the end of life (EOL) is a medical intervention that may be withheld or withdrawn depending on the balance of risk and benefits. Forgoing ANH (FANH) may be considered in the presence of neurologic devastation, irreversible total intestinal failure, and proximate death from any pathological cause. Although denying oral sustenance to children who want to eat or drink (and can do so safely) is ethically and legally wrong, when the potential or actual burdens are believed to outweigh the benefits the option to FANH either completely or by providing small amounts of “comfort feedings” insufficient to sustain life, may be a legitimate method of palliation.”
While many factors for FANH were considered the study found that the primary factor for FANH was the perceived poor quality of life QoL. Pain and suffering was a contributing factor in all but one child, the daughter of the family whose son had already died of the same condition, were motivated by a concern for her future suffering.

All of the parents stated that they found it helpful when professionals shared their past experiences with FANH as well as the evidence from adult medical literature. The parents needed reassurance and continued guidance after the FANH decision was made.

All parents felt that the quality of death was good. Some parents had worried about how death might unfold, and some were disturbed by their child’s changes in appearance as death approached: 
“we just saw him starting to waste away and that was the hard part.”
Some parents felt guilty about their decision and most found it emotionally difficult to watch their child die.

The parents generally believed that their child’s death was peaceful and comfortable. Many of the parents believed that their child’s comfort increased after FANH based on previous problems with feeding.

Some parents were not confident that their child’s comfort increased after FANH, but there was no indication that the child’s suffering increased. Parental doubts about quality of death may reflect their own suffering from watching their child die.

Study recommendations:
  1. Physicians should take responsibility for introducing FANH to families who perceive their child to have a poor quality of life.
  2. The focus of feeding should be comfort and not nourishment.
  3. Physicians should assure parents that under certain EOL conditions, FANH is medically, legally and ethically acceptable and it is not a form of euthanasia.
  4. Health care providers should share their knowledge and experience with parents.
  5. Health care providers should assume that parents will worry about hunger, starvation and dehydration after FANH. Clinicians must emphasize that feelings of hunger and starvation do not usually occur and good oral hygiene will avoid problems with dehydration.
  6. Parents will continue to doubt. Clinicians should guide and reassure the parents.
  7. Parents should be offered opportunities to create a legacy.
  8. Parents indicated that the multidisciplinary team needs to speak with one voice. The opinions of dissenting team members must be respected however they should not be shared with the family to avoid feelings of being judged.
  9. Opportunities should be made for staff to voice their objection with the family being present. 
Conclusion:
FANH is considered a legitimate form of palliation at the end of life (EOL). This is the first study to use interviews to describe the perception of parents whose children died after FANH. FANH was largely determined by the perception of their child’s poor quality of life and related to negative effects of feeding. Parents must decide in FANH is right for their child and reassurance is required by a united medical team. Persistent doubts are common requiring ongoing support form the medical team after FANH.

------------------------------------------

Commentary by Alex Schadenberg:
The study Parental Perceptions of Forgoing Artificial Nutrition and Hydration (FANH) During End-of-Life Care does not help parents and health care providers decide when it is appropriate to withdraw or withhold ANH from a child or newborn. 

This study fails to make ethical distinctions between a FANH decision that allows natural death to occur because the child is actually dying and a FANH decision that causes death. 

The study acknowledges the difference between allowing natural death to occur and causing death when it states in the beginning:
"Providing ANH at the end of life (EOL) is a medical intervention that may be withheld or withdrawn depending on the balance of risks and benefits. Forgoing ANH (FANH) may be considered in the presence of neurologic devastation, irreversible total intestinal failure, and proximate death from any pathologic cause."
I can agree with most of the previous statement, but the findings in the study indicate that the Hospital for Sick Children have gone beyond these parameters and the recommendations from the study expands the parameters for FANH.

My concerns:
1. FANH is ethically the same as euthanasia when ANH is withheld or withdrawn from a person who is not otherwise dying, with the intention of causing death. Legally, FANH is not considered euthanasia, even when the decision intentionally denies the basic necessaries of life from a person who is not otherwise dying. 
2. People with disabilities experience significant discrimination and perceptions of cultural bias on a regular basis. Allowing physicians to introduce FANH to families will only perpetuate further discrimination to their existence.
3. FANH decisions should not be primarily based on Quality of Life (QoL). People with disabilities, who at times require ANH, have experienced a long history of discrimination. Perceptions of Cultural bias are often held by care-givers and families. A person with a disability may need to be protected rather than dying by FANH. 
4. The focus of feeding should be both comfort and nourishment. To deny a person with disabilities feeding for nourishment is the sign of systemic discrimination and cultural bias. 
5. It is normal for parents to doubt a FANH decision and re-assuring the parents, when it may be the wrong decision, creates social pressure rather than moral clarity. 
6. The multi-disciplinary team should not be encouraged to speak as one voice, if the FANH decision is wrong. It is not possible to protect vulnerable people when the system pressures dissenting voices to be silent.
Conclusion:
The study lacks objectivity:
1. It assumes that the FANH decisions that were made were ethically acceptable. The study ends up promoting FANH rather than providing guidelines for FANH. 
2. The study does not ask the question, why have three families refused to take part in the study? Was it because their experience with FANH was negative?
This study creates significant concerns related to the care of children with disabilities at the Hospital for Sick Children in Toronto. Negative perceptions of disability are highlighted by a willingness to dehydrate to death children with disabilities who may or may not be dying primarily based on Quality of Life.

Children with disabilities need to be provided a peer advocate (a person with a positive attitude towards disability) to protect their lives from medical care decisions that are not in the best interest of a person with a disability or that will result in their intentional death.

Links to previous articles:

Wednesday, May 29, 2013

Euthanasia Prevention Coalition challenges Global News on its one-sided reporting.

Today, Global News has published another one-sided article concerning assisted suicide. The article is connected to a one-sided poll that asks: Should doctor-assisted suicide be legal? 

The options are: YES, dying adults should be able to get help to end their life, or NO, it is wrong on moral grounds.

The poll is skewed by its wording. People may want help to die, that doesn't mean they want assisted suicide and many people oppose assisted suicide for reasons other than morality.

Yesterday I sent the this email to Global news concerning their promotion of assisted suicide. I wrote:
I am very disappointed with the one-sided article produced by Emily Mertz concerning assisted suicide in Canada. Link to the article. 
It appears that Global News wants to promote assisted suicide rather than report on the issue in an honest and straight forward manner.  
As the executive director of the Euthanasia Prevention Coalition we will be sending a strong complaint to the CRTC unless you decide to change your policy and produce TV news programs that are balanced.  
In your program there is no information about the abuse of assisted suicide in Switzerland or the abuse of euthanasia in the Netherlands and Belgium. There is almost no information about the possible negative consequences associated with euthanasia and assisted suicide. There is no information on why disability groups, such as the Council of Canadians with Disabilities and Community Living oppose euthanasia and assisted suicide.  
Global News re-published the original article and added an online poll. Link to the article.

The online poll asked the question: Should doctor assisted suicide be legal in Canada?  YES or NO.

On the Global news website under the title of Principles and Practices, Global News claims:
"Our primary directive is to report accurate, balanced, timely and comprehensive news and information in the public interest ...  
News events and public issues may be analyzed and put into context, as long as comment or opinion is clearly identified and kept distinct from regular news coverage."
Jeffrey & Janet Corriveau
Global News is contravening its own principles and practices and they are presenting a one-sided view on an issue of social importance with Life and Death in the balance.

Last year the Global News 16 x 9 program aired a eugenic euthanasia program titled Taking Mercy featuring a woman who wanted her adult children with significant disabilities to be euthanized.

The Taking Mercy show was then featured on the Dr. Phil show. Link.

The Council of Canadians with Disabilities responded to the Taking Mercy segment. Link.

EPC wants you to send a complaint to the CRTC at: http://www.crtc.gc.ca/RapidsCCM/Register.asp?lang=E

EPC is tired of the one-sided reporting and we demand balanced programming on the issues of euthanasia and assisted suicide.

Alex Schadenberg
Executive Director
Euthanasia Prevention Coalition
email: info@epcc.ca or call: 1-877-439-3348.

Monday, May 27, 2013

'Death with Dignity' claims another victim

This article was written by Paul McHugh, a former psychiatrist in chief at Johns Hopkins Hospital. This article was printed on page A13 of the US edition of the Wall Street Journal on May 25, 2013

Now Vermont has joined the misguided movement toward assisted suicide.

Paul McHugh
By Paul McHugh, Wall Street Journal, May 25, 2013

Nearly 30 years ago, Arnold Schwarzenegger's "Terminator" character made famous the phrase "I'll be back," the implacable cyborg assassin's response to a setback. Today, similarly relentless terminators are among us, also with a deadly mission: to move America toward acceptance of physician-assisted suicide.

On Monday, the terminators gained a victory when Vermont Gov. Peter Shumlin signed into law the "Patient Choice and Control at End of Life Act." The bill had been passed by the state legislature the week before without consulting the electorate, possibly because the lawmakers had seen what happened last fall next door in Massachusetts, where voters rejected a similar initiative. Now Vermont doctors will be able to prescribe lethal medication to patients as the state joins Oregon, Washington and Montana in supporting the practice. (Assisted suicide is technically prohibited in Montana)

Hippocratic Oath
So the terminators are back. The reasons for opposing them and opposing physician-assisted suicide never went away. The reasons have been with us since ancient Greek doctors wrote in the Hippocratic oath that "I will neither give a deadly drug to anybody if asked for it nor will I make a suggestion to that effect." The oath is a central tenet in the profession of medicine, and it has remained so for centuries.

Dr. Leon Kass, in a brilliant essay on the Hippocratic oath in his 1985 book "Toward a More Natural Science," explains why this has been true. Medicine and surgery, he says, are not simply biological procedures but expressions, in action, of a profession given to helping nature in perpetuating and enhancing human life. "The doctor is the cooperative ally of nature," Dr. Kass writes, "not its master." It shouldn't need saying, but the exercises of healing people and killing people are opposed to one another.

Traditionally the public rests its trust in doctors on this understanding of medicine. Doctors occasionally remind the public of it when they explain why they do not participate in capital punishment or bear arms in military service.

But the terminators who champion physician-assisted suicide propose that, as seen in intensive-care units, contemporary medicine prolongs unnecessary suffering.

As a psychiatrist, I work with doctors on such units, and I can testify that all of them realize that human life itself is limited in duration and scope. These doctors regularly consider just how far they should go in sustaining a hope for recovery—cooperating with nature's resilience in treating advancing disease. They also consider when prolonging a futile effort should be replaced by comforting the person as his life naturally comes to an end. The judgment is delicate, though, and most families are justified in leaving it to skilled physicians.

Another argument for physician-assisted suicide is that many patients with cancer live too long in pain. The suffering could be reduced if their legitimate wish for death were fulfilled. These are the arguments pressed by Dr. Timothy Quill and many in the Oregon "death with dignity" group.

Dr. Kathleen Foley
But scientific publications from oncologists such as Kathleen Foley, who studies patients with painful cancers, reveal that, quite to the contrary, most cancer patients want help with the pain so they can continue to live. Suicide is mentioned only by those patients with serious but treatable depressive illness, or by those who are overwhelmed by confusion about matters such as their burden on loved ones and their therapeutic options. These patients are relieved when their doctors attend to the sources of their psychological distress and correct them.

In the nearly two decades that Oregon has permitted physician-assisted suicide, I became suspicious that just such depressed and confused patients number large among those who ask for and take life-ending poisons. Why suspicious? Because the law does not demand a psychiatric assessment before they take the fatal step.
Yet all efforts by psychiatrists anxious to read the medical charts of these patients after their deaths have been thwarted by the champions of their suicides, who have shrouded the patients' mental states in secrecy by raising the "privacy privilege." I believe that these doctors are killing patients of the sort that I help every day.

And then there is this talk about "death with dignity," as the Oregon and Washington laws are titled. Surely what we want is "life with dignity." Seeking life, we're ready to endure much in order to keep it going. Think of the life-saving and life-preserving colonoscopy—all dignity drops with your trousers.

The advance of the hospice movement has made a shambles of the terminators' insistence that medicine prolongs suffering and denies dignity. The doctors, nurses and social workers committed to hospice care demonstrate how an alliance with nature at life's end plays out in just the way that the medical profession intends. As hospice ways become more familiar, the public can overcome the fears that the terminators used to win over the Vermont legislature.

For you see, the terminators ultimately are not merely interested in killing people who are suffering the throes of a final illness. They have even others in mind, as history tells us. The drive to allow doctors to "assist" in suicide is not recent. Its roots are in the Progressive era of the early 20th century, when many Americans placed utter confidence in reform and in technocratic elites. Then the enthusiasts for euthanasia lined up with those clamoring for government intervention in the name of eugenics and population control.

Across the decades, Americans have fought off such dire temptations with reasoned arguments about the nature of medicine. Despite Vermont's unfortunate decision, Americans elsewhere likely will continue to defeat physician-assisted suicide at the ballot box and in the statehouse. But the enemies of life are terminators—they'll be back.


Dr. McHugh, former psychiatrist in chief at Johns Hopkins Hospital, is the author of "Try to Remember: Psychiatry's Clash Over Meaning, Memory, and Mind" (Dana Press, 2008).

Friday, May 24, 2013

Emotional and Psychological Effects of Physician-Assisted Suicide and Euthanasia on Participating Physicians

Kenneth R. Stevens, Jr., M.D., FACR*

Abstract: This is a review and evaluation of medical and public literature regarding the reported emotional and psychological effects of participation in physician-assisted suicide (PAS) and euthanasia on the involved physicians.

Materials and Methods: Articles in medical journals, legislative investigations and the public press were obtained and reviewed to determine what has been reported regarding the effects on physicians who have been personally involved in PAS and euthanasia.

Results and Discussion: The physician is centrally involved in PAS and euthanasia, and the emotional and psychological effects on the participating physician can be substantial. The shift away from the fundamental values of medicine to heal and promote human wholeness can have significant effects on many participating physicians. Doctors describe being profoundly adversely affected, being shocked by the suddenness of the death, being caught up in the patient's drive for assisted suicide, having a sense of powerlessness, and feeling isolated. There is evidence of pressure on and intimidation of doctors by some patients to assist in suicide. The effect of countertransference in the doctor-patient relationship may influence physician involvement in PAS and euthanasia.

Conclusion: Many doctors who have participated in euthanasia and/or PAS are adversely affected emotionally and psychologically by their experiences.

The report by The New York State Task Force on Life and the Law stated: 
"Many physicians and others who oppose assisted suicide and euthanasia believe that the practices undermine the integrity of medicine and the patient-physician relation-ship. Medicine is devoted to healing and the promotion of human wholeness; to use medical techniques in order to achieve death violates its fundamental values. Even in the absence of widespread abuse, some argue that allowing physicians to act as 'beneficent executioners' would undermine patients' trust, and change the way that both the public and physicians view medicine." 1
The counter-argument has been expressed by Margaret Battin and Timothy Quill, editors of a book favoring legalization of PAS. These PAS advocates have stated that there is no evidence that PAS "legalization would corrupt physicians and thus undermine the integrity of the medical profession," and that "there is substantial evidence to the contrary." 2

Purpose

When new treatments or procedures in medicine are developed, they are scrutinized to determine if there are adverse or harmful effects associated with them. In the same way, physician-assisted suicide and euthanasia deserve to be evaluated to determine if they have adverse or harmful effects. Instead of focusing on the involved patients, this investigation focuses on the reported effects on the doctors who are involved in assisted suicide and euthanasia.

This investigation's focus is to determine what has been reported regarding the following questions:
  • What have been the emotional and psychological effects of participation in PAS and euthanasia on the involved doctors?
  • What have they expressed to others regarding their experiences?
  • Are physicians being pressured, intimidated or psychologically influenced to assist in suicide or perform euthanasia?
  • What has happened to doctors who have written prescriptions? Have they continued to be involved with assisted suicide with other patients after the experience with the first patient or have they stopped their involvement?
Materials and Methods

Since the passage of Oregon's assisted suicide law in 1994, the author has gathered and archived articles from medical journals, legislative investigations, and the public press regarding assisted suicide and euthanasia. This collection of articles numbers into the thousands, including dozens of books on the subject. Other articles were identified and obtained using PubMed and the following search words: "euthanasia, assisted suicide, physicians, responses, psychological, emotional." These publications were reviewed and analyzed to obtain information regarding the above questions.

Results and Discussion

The Netherlands Doctors in the Netherlands who have had experience with assisted suicide and euthanasia, have expressed concerns regarding the effects on doctors. A report from the Netherlands stated: "Many physicians who had practiced euthanasia mentioned that they would be most reluctant to do so again." 3

Emanuel stated that "in a television program reporting a euthanasia case, the Dutch physician who performed euthanasia noted that: 'To kill someone is something far reaching and that is something that nags at your conscience. . . . I wonder what it would be like not to have these cases in my practice. Perhaps I would be a much more cheerful person.'"4

The American Medical News reported the following comments from Pieter Admiraal, a leader of Holland's euthanasia movement: "'You will never get accustomed to killing somebody. We are not trained to kill. With euthanasia, your nightmare comes true.'" 5

In 1995-96, 405 Dutch doctors were interviewed regarding their feelings after their most recent case of euthanasia, assisted suicide, life ending without an explicit request, and alleviation of pain and other symptoms with high doses of opioids. The percentage of doctors expressing feelings of discomfort were: 75% following euthanasia, 58% following assisted suicide, 34% following life ending without an explicit request, and 18% for alleviation of pain with high doses of opioids. Fifty percent of the euthanasias and 40% of the assisted suicides were followed by "burdensome" feelings; and 48% of the euthanasia and 49% of the assisted suicide cases were followed by emotional discomfort. The willingness to perform physician-assisted death again was 95% after euthanasia and 82% for life ending without an explicit request.6 The doctors sought support afterwards following 43% of the euthanasia cases and following 16% of cases involving ending life without an explicit request.

Evidence reported by the British House of Lords Select Committee on the Assisted Dying for the Terminally Bill in 2005 includes the following candid responses by Dutch physicians and ethicists to questions from the committee:
    Q1250 Response by Dr. Legemaate: "No physician ever likes performing euthanasia."

    Q1350 Question by Baroness Finlay: "The first time that you performed euthanasia, how did you feel about it as a clinician?"
    Response by Dr. Van Coevorden: "Awful."

    Q 1351 Response by Dr. Mensingh van Charente: "It is not a normal medical treatment. You are never used to it."

    Q1535 Question by Baroness Finlay: "Looking after complex patients can be exhausting. It can be physically and emotionally exhausting. I certainly know of a case where a patient was almost pressured by the doctor, by being offered euthanasia. I wondered if that reflected the doctor's personal distress and whether you have come across cases where the doctor is thinking of euthanasia as the only solution?"
    Response by Dr. Zylicz: "I was giving consultations in several situations like this, when the GP was calling me about a patient with gastrointestinal obstruction. He said, 'The problem is that the patient is refusing euthanasia.' I said, 'What happened?' He said, 'In the past, all these kinds of situations, when people were intractably vomiting, I solved by offering euthanasia. Now this patient does not want it, and I do not know what to do.' That was really striking. Providing euthanasia as a solution to every difficult problem in palliative care would completely change our knowledge and practice, and also the possibilities that we have . . . . This is my biggest concern in providing euthanasia and setting a norm of euthanasia in medicine: that it will inhibit the development of our learning from patients, because we will solve everything with euthanasia."

    Q1539 Response by Professor Jochemsen: "I know from physicians who are opposed to performing euthanasia that they are afraid of saying so when applying for jobs and trying to find a post as a physician. In certain circumstances, that will make it much more difficult for them to get a job."

    Q1580 Response by Dr. Jonquiere: "When I received a request for euthanasia and I hear this also from my colleagues - when a patient said, 'Doctor, this is unbearable for me. Please help me die,' the first reaction as a doctor is, 'Oh my God! A request again!' and I will find whatever I can to prevent it."

    Q1585 Response by Dr. Jonquiere: "My point is that, because doctors find the request so difficult - the most difficult request you can get as a doctor - that, in itself, is the reason why they try to find whatever way they can not to do it."

    Q 1735 Question by Baroness Finlay: "The doctors who have performed euthanasia have often described it, certainly initially, as being emotionally draining, emotionally difficult, and that they have taken some time off, have perhaps not worked the next day, to have a break and then to carry on working. Has that been your experience?

    Response by Dr. de Graas: "It certainly has been, but I think that a lot is changing in that regard. The first letter of SCEN [Support Consultation Euthanasia Network] is the 's' for 'support,' and that is essential. Also as a nursing home physician confronted with euthanasia, I know that it is emotionally draining; but it is absolutely important to discuss it, not only with the SCEN doctor but with all your colleagues, to keep yourself healthy."

    Q1736 Question by Baroness Finlay: "Do you think that it has become less stressful, as the process has become more developed over the time that you have had it?"

    Response by Dr. de Grass: "For the individual physician it never becomes less stressful. That is absolutely impossible. What we are learning as a group, however, is that, before we become emotionally worn-out, there are a lot of possibilities to keep yourself in a good emotional state."7
These responses indicate the significant adverse emotional and psychological stress experienced and reported by Dutch physicians who are involved with euthanasia and PAS.

The United States 
Two surveys of physicians in the United States have examined and reported on the effects on physicians of performing PAS or euthanasia.8

In a structured in-depth telephone interview survey of randomly selected United States oncologists who reported participating in euthanasia or PAS, Emanuel reported 53% of physicians received comfort from having helped a patient with euthanasia or PAS, 24% regretted performing euthanasia or PAS, and 16% of the physicians reported that the emotional burden of performing euthanasia or PAS adversely affected their medical practice.9

In a mail survey of physicians who had acknowledged performing PAS or euthanasia, Meier reported the following responses pertaining to the most recent patient who had received a prescription for a lethal dose of medication or a lethal injection among the 81 physician respondents (47% were prescriptions, 53% were injections): 18% of the physicians reported being somewhat uncomfortable with their role in writing a prescription, and 6% were somewhat uncomfortable with the lethal injection. 10

The State of Oregon 
The first cases of legal PAS in Oregon occurred in 1998. In 2000, thirty-five Oregon physicians who had received requests for assisted suicide from patients were interviewed regarding their responses to such requests. Mixed feelings were expressed by the physicians. The authors noted: "Participation in assisted suicide required a large investment of time and had a strong emotional impact. . . . Even when they felt they had made appropriate choices, many physicians expressed uncertainty about how they would respond to requests in the future [as indicated by the responses from two physicians]:
    'But my thoughts are about the fact that I know that it is a very difficult thing as a physician . . . . I wonder if I have the necessary emotional peace to continue to participate.' (Physician D)

    'I find I can't turn off my feelings at work as easily . . . because it does go against what I wanted to do as a physician.' (Physician I)"11
Timothy Quill M.D., a published advocate for legalization of assisted suicide, wrote an invited editorial about this study. He noted the apparent lack of preparation for the personal emotional toll that such interactions had on the physicians.12

In 1998, the first year of Oregon's Death with Dignity Act, fourteen physicians wrote prescriptions for lethal medications for the fifteen patients who died from physician-assisted suicide. The annual report observed that: "For some of these physicians, the process of participating in physician-assisted suicide exacted a large emotional toll, as reflected by such comments as, 'It was an excruciating thing to do . . . it made me rethink life's priorities,' 'This was really hard on me, especially being there when he took the pills,' and 'This had a tremendous emotional impact.' Physicians also reported that their participation led to feelings of isolation. Several physicians expressed frustration that they were unable to share their experiences with others because they feared ostracism by patients and colleagues if they were known to have participated in physician-assisted suicide."13 This type of information regarding the emotional impact on the involved physicians has not been presented in subsequent Oregon annual reports.

A 1999 mail-survey of physicians' experiences with the Oregon Death with Dignity Act reported: "Some physicians who provided assistance with suicide under the Oregon Death with Dignity Act reported problems, including unwanted publicity, difficulty obtaining the lethal medication or a second opinion, difficulty understanding the requirements of the law, difficulties with hospice providers, not knowing the patient, or the absence of someone to discuss the situation with." "Four physicians expressed ambivalence about having provided assistance with the suicide, though two of the four noted that they had become less ambivalent over time. One of these physicians decided not to provide such assistance again."14

The emotional trauma experienced by some Oregon doctors is noted in the following responses obtained in Oregon in December 2004 by the British House of Lords committee:
    Q766 Question by Baroness Finlay: "In a conversation after we had taken evidence this morning from David Hopkins, he said that, at the beginning, he had the feeling that doctors needed to tell the whole story because they were very traumatized by having been involved, but that, in the last year, that is not happening as they have become used to it. I wondered whether you felt that was echoed within your research."

    Response by Dr. Goy: "Again, anecdotally, yes. This was a monumentally difficult experience for a doctor early on, even considering changing the direction of care from preserving life and extending life to helping someone end it. For many, they have done it maybe for one patient and cannot reconcile that they have done it and they are very uncomfortable with it."

    Q767 Question by Baroness Finlay: "The Dutch experience is that often doctors take the next day off because they cannot cope with taking any clinical decisions at all."

    Response by Ms. Glidewell: "Sometimes they are overwhelmed by the impact of this which is contrary to what they normally do."15
Dr. Peter Reagan's description of his experience with "Helen" was the first individual account in the medical literature of assisted suicide in Oregon.16 His account reveals his emotional and psychological concerns. As Helen was dying from his prescribed lethal medication "[t]he three of us [Dr. Reagan and Helen's son and daughter] sat around her bed talking quietly about the emotional struggle we'd each been through."17Regarding his thoughts and emotions leading up to writing the lethal prescription, Dr. Reagan wrote:
I had to accept that this really was going to happen. Of course I could choose not to participate. The thought of Helen dying so soon was almost too much to bear, and only slightly less difficult was the knowledge that many very reasonable people would consider aiding in her death a crime. On the other hand, I found even worse the thought of disappointing this family. If I backed out, they'd feel about me the way they had about their previous doctor, that I had strung them along, and in a way, insulted them.18
This is an example of a doctor feeling intimidated and coerced by the family and patient to participate in assisted suicide.

In writing about Helen's expressed appreciation for his role in the assisted suicide, Dr. Reagan wrote, "I thanked her and then turned away with my tangle of emotions." "That afternoon. . . I wrote the prescription for the 90 secobarbital. I hesitated at the signature and stared out the window. . . . I tried to imagine deciding to die. . . . Whenever I tried, I experienced a sadness much more profound than what I saw in her." "I slept badly."19

The extent of Dr. Reagan's personal concerns is exemplified by his editorial inclusion of the following: "Experience in the Netherlands suggests that doctors are profoundly affected by an act of physician-assisted suicide. Gerrit Kimsma, a Dutch family physician and medical ethicist, writes with colleagues that some professionals become dysfunctional and may require a lot of time to recover."20

Further insight into Dr. Reagan's experience is found in an earlier newspaper reporter's interview in 1998 of a then anonymous doctor whose story, matches that of "Helen" and Dr. Reagan:
    Q: What did you learn from the experience?

    A: I think the most important thing is for doctors to understand how huge of an experience it's going to be for them and that they must have ways of dealing with it for themselves.

    Q: How did you feel the day that your patient planned to use the medication?

    A: I would look out the window that day and try to imagine what it would feel like to take leave of the Earth that day - and it was a pretty nice day - and the sadness that that thought induced in me and I couldn't find it in my patient. And that was a profound experience.

    Q: What about the death was a struggle for you?

    A: A big piece is grief. A big piece is a funny sort of ambivalence where a person says, 'Really nice to have met you. Really nice to have gotten to know you a little better. Where's the medicine?' I have a feeling of responsibility that I can't say I'm entirely proud of. I did what I felt was right, given bad choices. But frankly, maybe I'm kidding myself a little bit, but it's better to not feel good about this. . . . I have to admit, I am blown away by how different this felt than a natural death. And I am still not clear on what to make of that. . . . Just the suddenness of it. It's shocking to have somebody go from telling a family story to being dead. It's a strange, strange, strange transition.21
Later in 1998, the same reporter noted, "Reagan still grapples with his experience. He has declined other requests from patients who weren't qualified. But if he meets another patient who is qualified, he will help. To him, it would feel like abandonment if he didn't."22 Dr. Reagan is expressing that he would have "no choice" and is an example of a doctor feeling intimidated by the patient and family to participate in assisted suicide.

In a newspaper interview in 2001, the same reporter wrote, "Dr. Peter Reagan, the primary physician in the first publicly described case in 1998, said the experience changed his feelings about assisted suicide. If he were dying, 'I made a commitment that I wouldn't ask my own doctor to help in this way,' Reagan said, 'because it's a lot to ask.'" 23Dr. Reagan described his troubled feelings in the reversal of his role as a healer, to his role in assisting Helen in her suicide. There is a sense of isolation. In Dr. Reagan's first comments to the public and press, he was concealed by anonymity. It was difficult for him to find others with whom to discuss his troubling experience.

Leon Cass stated that "the psychological burden of the license to kill (not to speak of the brutalization of the physician-killers) could very well be an intolerably high price to pay for physician-assisted euthanasia."24

The author of an investigation of "the euthanasia underground" reported:
The personal cost of involvement in illegal euthanasia was a central theme in interviews, and one emphasized throughout this book. 'I hate it', says one doctor, 'my partner hates it, because [she] feels that I'm going to be really horrible to be around . . . afterwards.' Another emphasized the 'emotionally demanding and draining' nature of involvement, adding 'there's only a finite amount of times you can do it' and 'I think I've almost reached the expiry date.' These are typical comments.25
Intimidation of and anger towards doctors who block access to PAS 
Hamilton and Hamilton reviewed the first case of legal assisted suicide in Oregon that was reported in the press.26 The physician who helped the ill woman end her life described the woman's tenacity and determination in her decision. "It was like talking to a locomotive. It was like talking to Superman when he's going after a train."27 The Hamiltons' psychiatric analysis of this case was that the doctor felt helpless when faced with the challenge of containing a patient who elicited images of locomotives, or of attempting to make a therapeutic intervention when talking with the patient seemed, as he put it, like "talking to Superman when he's going after a train."28 The doctor was expressing powerlessness on his part.


This intimidation of doctors by patients who request assisted suicide is also described in an analysis of in-depth personal interviews of thirty-five Oregon physicians who received a request for a lethal prescription.29 The article portrays a daunting situation for the doctors. These doctors describe very forceful patients who persevered in their requests for assisted suicide, even when the doctors were unwilling to participate. One doctor quoted a patient as saying, "I am going to come in and I am going to try to convince you."30 Another doctor said, "I learned very quickly that the patient's agenda is to get the medication. When I tried to talk them out of it, or to really assess their motivations, then they perceived me as obstructionist and became quite resentful of that."31

Emotional experiences for psychiatrists who are called upon to evaluate potential assisted suicide patients' mental competency, appear to be more profound when they disqualify patients. Dr. Linda Ganzini described the painful experience of two patients whom she [as the evaluating psychiatrist] disqualified for the option of Oregon's assisted suicide law.32She stated: "These disqualifications resulted in extraordinary pain and anger for both of the patients and their families, which interfered with much-needed opportunities to resolve other emotional issues."33 Pain and anger is directed towards and felt by the evaluating psychiatrist. Such anger was energetically expressed by Kate Cheney, an Oregon PAS patient, whose evaluating psychiatrist told her, "You can't make a decision for yourself and your life, because you are not in your right mind."34 Kate Cheney's angry response was "Get out of my house. I can't believe you can tell me something like this."35 The significant anger towards the evaluating psychiatrist who disqualified her from PAS continued in Kate Cheney's daughter, who reported this experience.36

What is known regarding the frequency of and numbers of assisted suicide cases per physician?
Meier reported in a national survey of physicians, that the median number of assisted suicide cases since entering practice was two (range 1-25) for the 3.3% of surveyed physicians who had written a prescription for a patient to use with the primary intention of ending his or her own life.37The median number of euthanasia (lethal injection) cases since entering practice was also two (range 1-150) for the 4.7% of surveyed physicians who had ever given a patient a lethal injection.38

Questions regarding physician involvement in assisted suicide in Oregon 
After seven years of legalized assisted suicide in Oregon, we should have answers to the following questions:
  • What is the total number of physicians who have written prescriptions under Oregon's PAS law?
  • What has been the pattern of prescribing? How many physicians have written only one prescription, and how many have written multiple prescriptions?
  • Most importantly, are there physicians who have written prescriptions in earlier years, who are not now writing prescriptions? Why have they changed their minds, and are not now involved in assisted suicide?
The basic Oregon PAS data for the early years has been destroyed, as noted in the following personal communication: "Unfortunately, we are unable to provide any additional information than is currently available in our Annual Reports. Prior to 2001, we did collect the names of physicians who were participating. However, because of concerns about maintaining the confidentiality of participating physicians, we began using a numeric coding system in 2001. When we implemented this coding system, we destroyed the identifying data from the earlier years."39 This was also documented in the responses to Q592-4 by members of the Oregon Department of Human Services to the British House of Lords Select Committee in December 2004.40

Because this basic Oregon data was destroyed by personnel in the state agency, the answers to the above questions will never be known.

Information regarding physicians' participation in physician-assisted suicide from Oregon Health Division reports
From 1998 through 2004, 326 prescriptions for lethal drugs have been written and 208 have died under Oregon's PAS law.41

The only report from the state that has given the number of doctors prescribing from one year to the next was reported for the 1999 year: "In 1999, 22 physicians legally prescribed the 33 lethal doses of medication. Six of them also prescribed in 1998."42 This information has not been included in subsequent annual Oregon state reports.

Of the forty physicians who wrote prescriptions during 2004, twenty-eight wrote one prescription, nine wrote two prescriptions, one wrote three prescriptions, one wrote four prescriptions, and one wrote seven prescriptions.43 This was the first year that this type of information was provided in the state's annual report.44 However, a year earlier, a reporter from The Oregonian newspaper publicly reported the following information for the 2003 year, which he had personally obtained from the Oregon Department of Human Services: "Of the 42 doctors who wrote prescriptions for assisted suicide in 2003, 27 wrote one prescription, eight wrote two, six wrote three, and one doctor wrote 6 prescriptions."45 This information was not in the Oregon state annual report for that year.

Specific deficiencies in data from the annual Oregon reports are listed in Table 1. This missing information makes it impossible to provide answers to the previously noted questions.

During the first four years of legalized PAS in Oregon the prescribing physician was present at the time the patient took the lethal medication for 52% of the assisted suicides.46 However during the 2004 year, the prescribing physician was present for only 16% of the patients.47 Why are the physicians withdrawing from being present at the time of the assisted suicide?

The effect of countertransference in physician-assisted suicide 
Countertransference is defined as a phenomenon referring "to the attitudes and feelings, only partly conscious, of the analyst towards the patient,"48 Regarding the "rational" decision of physicians to assist in the ending of a person with a terminal illness, Dr. Glen O. Gabbard, a noted psychiatrist, has written:
Those decisions made by medical professionals, including psychiatrists, can never be entirely free of what we would broadly call countertransference issues. The doctor's own anxiety in the face of death, and even the hatred of the patient who does not want treatment or will not allow the doctor to be helpful, can influence a supposedly scientific or "rational" decision.49
Table 1
Information (and missing information) about assisted suicide in Oregon
Year# of
prescriptions
written
# of doctors
writing
prescriptions
for
lethal drugs
# of these
doctors
(prior
column)
who had
written
prescriptions
for lethal
drugs in
prior year/s
# of
PAS
deaths
# of doctors
writing
prescriptions
for those
who died
from
ingesting
lethal drugs
# of these
doctors
(prior
column)
who had
written
prescriptions
for lethal
drugs in
prior
year/s
199824*No prior
year
1614 of 15
deaths in 1st
years report
no prior
year
19993322627**
200039**2722*
20014433*21**
20025833*38**
20036842*4230*
20046040*37*
26**
*
Total326**208**
* Information missing from reports.
** Personal communication, March 10, 2005.50
From the published annual reports, Oregon Department of Human Services, Office of Disease Prevention and Epidemiology. 51


The involvement of countertransference with assisted suicide has been evaluated by Varghese and Kelly.52 They report that:
[T]he subjective evaluation by a doctor of a patient's 'quality of life' and the role of such an evaluation in making end-of-life decisions of themselves raise significant countertransference issues. Inaccurately putting oneself 'in the patient's shoes' in order to make clinical decisions and evaluations of quality of life leave the patient vulnerable to the doctor's personal and unrecognized issues concerning illness, death and disability.53
They state that "[f]ortunately, the ethical code prohibits certain actions on the part of the doctor. In the absence of these prohibitions, the doctor's countertransference feelings about patients could put the public in grave danger."54 They conclude "Psychopathological factors in the doctor, including reactions to illness, death, and the failure of treatment, can influence the dying patient's end-of-life decision."55

Conclusion

Physician participation in assisted suicide or euthanasia may have a profound harmful emotional toll on the involved physicians. Doctors must take responsibility for causing the patient's death. There is a huge burden on conscience, tangled emotions and a large psychological toll on the participating physicians. Many physicians describe feelings of isolation. Published evidence indicates that some patients and others are pressuring and intimidating doctors to assist in suicides. Some doctors feel they have no choice but to be involved in assisted suicides. Oregon physicians are decreasingly present at the time of the assisted suicide. There is also great potential for physicians to be affected by countertransference issues in dealing with end-of-life care, and assisted suicide and euthanasia.

These significant adverse "side effects" on the doctors participating in assisted suicide and euthanasia need to be considered when discussing the pros and cons of legalization.

Kenneth Stevens

* Dr. Stevens is emeritus Professor and Emeritus Chairman, Department of Radiation Oncology, Oregon Health & Science University, Portland, Oregon; and Vice President of Physicians for Compassionate Care, www.pccef.org B.S., Utah State University, 1963; M.D., University of Utah, 1966. Comments may be addressed to Dr. Stevens at: kenneth.r.stevens@verizon.net




1 new york state task force on life and the law, when death is sought, assisted suicide and euthanasia in the medical context 104 (1994).
2 M. P. Battin & T. E. Quill, False Dichotomy Versus Genuine Choice, in physician-assisted dying : the case for palliative care and patient choice 1 (M. P. Battin & T. E. Quill, eds. 2004). 
3 P. J. van der Maas et al., Euthanasia and Other Medical Decisions Concerning the End of Life, 338 LANCET 669, 673 (1991).
4 E. J. Emanuel et al., The Practice of Euthanasia and Physician-Assisted Suicide in the United States: Adherence to Proposed Safeguards and Effects on Physicians, 280 JAMA 507, 507 (1998).
5 D. M. Gianelli, Dutch Euthanasia Expert Critical of Oregon Approach, AM. MED. NEWS, Sept. 15, 1997.
6 I. Haverkate et al., The Emotional Impact on Physicians of Hastening the Death of a Patient, 175 MED. J. AUSTL. 519, 5 19-22 (2001). 
7 select committee on the assisted dying for terminally ill bill, ii assisted dying for the terminally ill bill [hl]: evidence 405, 423, 448-50, 461, 484 (London: The Stationery Office Ltd., 2005). 
8 Emanuel, supra note 4, at 507-13; D. E. Meier et al., A National Survey of Physician-Assisted Suicide and Euthanasia in the United States, 338 NEW ENG. J. MED. 1193, 1193-1201 (1998). 
9 Emanuel, supra note 4, at 511. 
10 Meier, supra note 8, at 1197. 
11 S. K. Dobscha et al., Oregon Physicians'Responses to Requests for Assisted Suicide: A Qualitative Study, 7 J. PaLLiative Med. 451, 455, 457 (2004). 
12 T. E. Quill, Opening the Black Box: Physicians'Inner Responses to Patients'Requests for Physician-Assisted Death, 7 J. PaLLiative Med. 469, 469 (2004). 
13 A. E. Chin et al., Legalized Physician-Assisted Suicide in Oregon-The First Year's Experience, 340 NEW ENG.J. MED. 577, 583 (1999). 
14 L. Ganzini et al., Physicians'Experiences Withthe Oregon Death With Dignity Act,342 NEW ENG. J. MED. 557, 562 (2000). 
15 select committee on the assis ted dying for terminally ill bill, supra note 7, at 190-91. 
16 P. Reagan,Helen, 353 LANCET 1265, 1265-67 (1999). 
17 Id. at 1265. 
18 Id. at 1266. 
19 Id. 
20 asking to die: inside the dutch debate about euthanasia 29 1-93 (G. Kinsma & D. Thomasma, eds. 1998). 
21 Erin Hoover, Doctor Who Assisted Suicide Shocked by the Suddenness, oregonian, June 14, 1998, at C2. 
22 Erin Hoover Barnett, Suicide Law Still Draws Emotional Responses, oregonian, Dec. 28, 1998 (Erin Hoover and Erin Hoover Barnett are the same person). 
23 Erin Hoover Barnett, Oregon's Assisted-Suicide Law Inspires Better Care, Many Doctors Say, oregonian, Nov. 14, 2001, at E13. 
24 L. R. Kass, "I Will Give No Deadly Drug": Why Doctors Must Not Kill, in the case against assisted suicide: for the right to end-of-life care 17, 30 (K. Floey & H. Hendin, eds. 2002). 
25 r. s. magnusson, angels of death, exploring the euthanasia underground 242-43 (Melbourne U. Press, 2002). 
26 N. G. Hamilton & C. A. Hamilton, Therapeutic Response to Assisted Suicide Request,63 BULL. MENNIGER CLINIC 191, 191-201 (1999). 
27 Id. at 196.
28 Id. at 196-97.
29 L. Ganzini et al., Oregon Physicians'Perception of Patients Who Request Assisted Suicide and Their Families, 6 J. PALLIATIVE MED. 381-90 (2003).
30 Id. at 384.
31 Id. 
32 L. Ganzini & S. K. Dobscha, Clarifying Distinctions Between Contemplating and Completing Physician-Assisted Suicide, 15 J. CLINICAL ETHICS 119, 121 (2004). 
33 Id.
34 B. C. Lee, compassion in dying 77 (2003) (As related by Kate Cheney's daughter, Erika, in chapter entitled "Kate Cheney"). 
35Id.
36Id.
37 Meier, supra note 8, at 1193-1201.
38Id.
39 Letter from D. Niemeyer, Oregon Department of Human Services, to author (Feb. 17, 2004) (on file with author).
40 select committee on the assisted dying for terminally ill bill, supra note 7, at 262.
41 Chin, supra note 13; a. d. sullivan et al., oregon's death with dignity act: the second year's experience (oregon health div., 2000); oregon health div., oregon's death with dignity act: three years of legalized physician-assisted suicide (2001); oregon department of human services, office of disease prevention and epidemiology, fourth annual report on oregon's death with dignity act (2002); oregon department of human services, office of disease prevention and epidemiology, fifth annual report on oregon's death with dignity act (2003); oregon department of human services, office of disease prevention and epidemiology, sixth annual report on oregon's death with dignity act (2004); oregon department of human services, office of disease prevention and epidemiology, seventh annual report on oregon's death with dignity act (2005). 
42 SULLIVAN, id., at 9.
43 SEVENTH ANNUAL REPORT, supra note 41 at 14.
44 Id.
45 D. Colburn, Assisted Suicide Total Edges Higher in 2003, OREGONIAN, Mar. 10, 2004, at E1. 
46 FOURTH ANNUAL REPORT, supra note 41, at 16. 
47 SEVENTH ANNUAL REPORT, supra note 41, at 24. 
48 PSYCHOANALYTIC TERMS AND CONCEPTS 29 (B. Moore & B.Fine, eds., 1968). 
49 Foreward, 18:1 COUNTERTRANSFERENCE ISSUES IN PSYCHIATRIC TREATMENT: REVIEW OF PSYCHIATRY xiii-xvi (G. O. Gabbard, ed. 1999). 
50 Personal e-mail from D. Niemeyer to author (Mar. 10, 2005) (on file with author). 
51 Chin, supra note 13; SULLIVAN, OREGON HEALTH DIVISION SECOND ANNUAL REPORT, supra note 41; OREGON HEALTH DIV., supra note 41; FOURTH ANNUAL REPORT, supra note 41; FIFTH ANNUAL REPORT, supra note 41; SIXTH ANNUAL REPORT, supra note 41; SEVENTH ANNUAL REPORT, supra note 41. 
52 F. T. Varghese & B. Kelly, Countertranference and Assisted Suicide, in 18:1 COUNTERTRANSFERENCE ISSUES IN PSYCHIATRIC TREATMENT: REVIEW OF PSYCHIATRY 85 (G. O. Gabbard, ed. 1999). 
53 Id. at 92.
54 Id. at 106. 
55 Id. at 112.

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