A Dignified Departure1

Laura Chan 07731390

A Dignified Departure:

An Argument for the Legalization of Physician Assisted Death

Field Focus: Criminal Justice and Corrections

Dennis Bracken & Phil Simon

Friday December 5, 2014

A Dignified Departure2

Introduction“Probably not many people would use such an option, but making it legal would certainly

prompt a much-needed discussion about what it means to prolong life without prolonging the capacity to enjoy it.” – (Appleby, 2014)

End-of-Life options are not new concepts in Canadian medicine, but are part of an

ongoing debate that has ebbed and flowed through the last thirty years. To define terms

commonly heard from both sides; physician assisted death, (PAD), is where the patient actively

ends their own life, for example, ingesting life-ending medication prescribed to them by a doctor.

Euthanasia can be described as passive or active. This refers to the doctor’s role; either hastening

death by withholding treatment or administering life-ending drugs. For the purposes of this

paper, the term physician assisted death will include the variations mentioned above, they will be

distinguished between when needed. Under current legislation both acts hold equal chance of

persecution, if not so much socially as in the past, legally. The onus is therefore on the courts to

reconsider the impact of current law on the population as well as that of changes to what actions

will be allowed.

I have always been aware of the issue, but my interest peaked when I came upon a

documentary, “How to Die in Oregon”, which chronicled the path taken by the state to legalize

PAD in its least intrusive form, allowing a prescription to be written and filled for use by the

individual. As a private citizen and after viewing the film, I am concerned with the limitations of

traditional medical care, particularly what is allowed in palliative settings. As a social work

student, I see this type of legislation as needing expansion to include PAD, in all its forms, to

allow us as individuals control over our own lives, convey respect for our dignity as human

beings and preserve the integrity of the relationships formed with others, specifically caregivers.

A Dignified Departure3

Restriction to End-of-Life options results in the oppression and denial of rights of

everyone and is a primary concern in regards to those affected by chronic, degenerative or

critical illness. My interest in pursuing a law degree brought me to cover the issue for this brief

as the current penalty for assisting in a suicide is quite severe. Though the term “suicide” is

rejected by proponents and replaced with the less stigmatizing ‘death’, the act of assisting in a

suicide carries with it a loss of license as well as a lengthy prison sentence.

Background “If I cannot give consent to my own death, whose body is this? Who owns my life?” – Sue Rodriguez, (in Einstat-Weinrib, 1994, emphasis added).

Sue Rodriguez, Gloria Taylor and many others have brought the issue of physician

assisted death to the fore on many occasions, yet with these opportunities we had done nothing.

The Supreme Court of Canada has recently heard arguments for the decriminalization of

Physician Assisted Death, (PAD). This issue has had a long history in our country and across the

world. Once a very contentious issue, recent polls indicate support for the move to amend the

criminal code has grown. Even so, it remains to be seen if changing social attitudes will be a

strong enough factor to influence the final decision. In a poll taken just after the start of the

Gloria Taylor case began, The National Post reported that 67% of Canadians supported

legalizing assisted suicide, whereas only 3% of physicians consulted agreed (Blackwell, 2011).

That support has grown to 85% for the general population. Surprisingly, medical professionals in

favour of decriminalizing PAD now match that number (Dying with Dignity Canada, 2014).

The issue has been successfully in several jurisdictions, in varying ways. In all examples,

enough time has passed that the changes have proven successful, especially the definitions

guiding their implementation. There have been social conditions shown to be conducive to this

A Dignified Departure4

type of legislation being passed such as careful phrasing when codifying the laws, public

education of the new acts and , cultural, religious/spiritual heterogeneity, nothing that could not

be accomplished in Canada, and certainly, environmentally speaking, anything that is not found

here. So in taking the lessons from these earlier models, we would not be reinventing the wheel,

but repositioning the individual to be the driver of their life’s path.

The Problem “I think our society is very confused about liberty. It makes no sense to prevent people who wish to die from doing so.” – Andrew Solomon (in Reynolds, 2014)

In Canada, 100,000 people are living with various forms of Multiple Sclerosis, a chronic,

progressive and degenerative disease that in some cases begins in children as young as two years

old, (MS Society of Canada, n.d.). For individuals dealing with such degenerative diseases, the

restriction of access to end-of-life options for them and their caretakers is an abuse of authority

and a form of oppression. When dealing with matters of life and death, the oppression resulting

from the limitations on choice of action can create undue stress, anxiety, and hardship for the

patients and their families.

The issue of PAD affects several professions: Social Work, Health Care and Law. The

focus of the argument is there is a need for the practice in order to carry out the mandates of all

three professions, and more importantly to assure the individual that they will have choice and

control at the end of their life.

Collaboration is needed between the professions to ensure the individual is put first. This

would include the legalization of assisted dying, all forms in a medical context; the extension of

palliative care protocols to include such practices; thorough education to all health care providers

A Dignified Departure5

of them, as well as education and activism aimed at the public to inform them of their options

and remove the stigma that makes death an often uncomfortable topic of conversation.

A Social Work Stance “For all but our most recent history, dying was typically a brief process. These days, swift catastrophic illness is the exception; for most people, death comes only after long medical struggle with an incurable condition….or the multiple debilities of very old age.” (Gawande, 2010)

As social workers, we strive to meet the person where they are. In building rapport we

aim to find ways for them to navigate through their difficulties, often imposed by society. For all

our clients, especially someone suffering from a terminal, degenerative or critical illness, we

champion a holistic view of health; we are a profession focused on the bio-psycho-social and

spiritual aspects of one’s life as critical to their overall health. What we do with our lives brings

meaning to them, one should have the choice as to what this meaning is and the same control

when facing death. In a study of the individuals involved in palliative care, both professionally

and personally many trends were shown. One was that the personality of those who opted for

Physician Assisted Death were consistent with such choice, not out of character due to their

circumstances. These traits included wilful, fiercely independent, as well as reflective (Miller,

Hedlund & Soule, 2006). Their self-image, and sense of autonomy can be hampered by the

restrictions they face at such a critical time. Even if they were to go through with an assisted

death, the burden of the consequences for the parties involved can weigh heavily on them and

their family. With this barrier, we carry much responsibility in helping what is, for now, an

irreconcilable situation. We have to work to make end-of-life options the decision of those

affected by acute or prolonged illness or injury.

A Dignified Departure6

Our ethics and values seem to be in line with the health care professionals who are involved in

palliative care and other critical care areas of medicine. In Gloria Taylor’s case, the right to die

follows only after we tend to the subjective aspects of the individual’s life such as their self-

image, self-esteem, sense of worth and autonomy, all which affect their quality of life. The

belief that patients have a right to self-determination is entrenched Social Work values, as well as

in law and medical ethics. Unfortunately, the existing laws do not communicate the same.

Subsequently, the patient is denied options to a decision that should ultimately be in their hands.

Pursuing the (social) justice aspect of our code, we offer an alternate view of the physician’s

actions as compassionate not criminal. Gawande’s statement expresses the issues faced when

death remains imminent, but the timing not so. As Social Workers we are granted fluidity to

work in and impact all areas of our society. Legally speaking, we must see those who assist

others with their final wishes as benevolent players in an act which recognizes the empowerment

of others at a crucial time. In this sense, social justice includes seeking justice for these allies by

pushing for amendments to the criminal code which currently put these people at risk of legal

sanctions.

The Impact on Health Care

“I worry that we have put medicine out there as a potential saviour, almost a new religion over the last 100 years….and every death is a preventable death- and that death is, in some way, a failure” – Dr. Robert Fowler (in Priest, 2011).

In debates, PAD has been compared to abortion, which before legalized, went

underground (How to die in Oregon, 2011). The same restrictions that hamper efforts by social

workers to help the individual apply to many in the health care field who wish to offer their

patients choice at the end of life. In both cases, their hands are tied. Though many have carried

A Dignified Departure7

through with the request, they did so at great personal risk. These are consequences that send a

strong message to other would-be helpers as well as those who would seek their service.

Health care and medicine are areas where the basic values that guide and support

decisions on patient care are the self-determination and autonomy of the individual. Courts have

long recognized that the physician-patient relationship is built on trust; and from this relationship

stems the idea of fiduciary duty. That is the understanding that the physician must act with good

faith and loyalty toward the people they support, never placing their own personal interests ahead

of the patient's (Canadian Medical Protective Association, 2010). There are already measures in

place for end-of-life care that grant some choice to the patient. An example of this would be the

Do Not Resuscitate orders that one can request to have placed in an advanced directive. This

allows for the withholding of life saving intervention in case of medical emergency for those

terminally or critically ill.

Also, the practice of palliative sedation is used in the administration of pain relieving

medicine. At a certain degree, this can hasten death, as one’s body may be too weak and the dose

proves too strong. The argument that physician assisted death goes against the Hippocratic Oath

of do no harm, neglects the practices already in place. The difference being that palliative

sedations first objective is to manage and lessen pain, whereas active euthanasia, often carried

out by the same means is meant to terminate life. It seems arbitrary that the fashion of assistance

is what is under scrutiny, as the palliative sedation so often practiced could be likened to a Type

1 error, and following a DNR could be seen as a type 2 error, if we were to be fair. Following a

DNR is, in practice, is passive euthanasia administered with consent. Consent should be key in

any legislation allowing for PAD and a strong factor in its regulation and enactment. Indeed, the

A Dignified Departure8

risks to the vulnerable are increased as long as these practices are banned and remain

underground.

Those opposed to legalizing PAD have been very vocal about the dreaded slippery slope.

The abuses of such legislation that will no doubt impact the poor, elderly, disabled. The fear that

the option will be pushed by doctors everywhere and unwilling patients subject to treatment

without consent is a great scare tactic but ignores the ethics, values and legal guidelines already

in place when it comes to patient care, namely, the concepts of beneficence, non-maleficence,

fiduciary duty and included in that, informed consent (Cohen-Almagor, 2013). Also, In many

countries where this legislation has been debated a similar sentiment of cost savings of

terminating a life versus accessing long term institutionalization has been used to oppose the

implementation. This falls short when the countries which have successfully implemented PAD

are reviewed. All are highly ranked in their economic health care commitments as well as other

social service provisions (Titterington, Rivolta & Schraufnagel, 2013). Allowing for an

expansion of health care options to include PAD does not mean that it will be a consideration for

everyone, but the option being available will make a difficult situation easier for those faced with

the choice.

In Terms of Law“Peace order and good government are the legitimate objects of legislative powers conferred by

statute” – The Canadian Constitution, preamble

Social work is not mentioned in law, but is a mandated resource in palliative care. As

such we all cross paths when the discussion of physician assisted death is re-ignited. There

remain severe repercussions for the physician who aids in the death of a patient. Currently under

section 241(b) of the Canadian Criminal Code, helping an individual commit suicide carries a

A Dignified Departure9

maximum penalty of fourteen years’ incarceration, (CBC News, 2014). The professional penalty

added to that for physicians involved is loss of their license. As citizens of a developed nation

where we live longer but endure more diseases of senescence, we must change these

consequences on those who sincerely are trying to follow their ethics of do no harm. Otherwise,

the abuse of the vulnerable, which is often used as a defense against assisted suicide, has already

been imposed.

In the cases of Gloria Taylor, as well as that of Sue Rodriguez, specific concerns were

included. As one suffering from a degenerative disease, Taylor, as did Rodriguez, was seeking

exemption from the governing legislation to have a physician assist her in ending her life when it

had reached a point she felt to be no longer tolerable. Two issues raised by this situation is the

dignity of the human being, and the seemingly arbitrary nature of the existing laws. As Taylor

put it, simply taking a shower, which she could no longer do for herself, “(was) experienced as

an assault on her privacy, dignity and self-esteem”, (Dyer, 2012). The larger issue raised earlier

and unsuccessfully by Rodriguez, is the unintentional restriction put on her due simply because

of her disability. Under Canadian law, advising or assisting one towards suicide is illegal; the act

when executed by the individual herself is not. Rodriguez argued that the assisted suicide ban

created an inequality because persons capable of ending their lives could do so without

contravening Canadian law while those whose disabilities prevented them from committing

suicide would be putting themselves and any person at their aid in opposition to the law, (Avila,

1994).

American Examples

“When your conscience says law is immoral, don’t follow it” - Dr. Jack Kevorkian

A Dignified Departure10

It has been almost 25years since Dr. Kevorkian’s first publicized assisted suicide. In the

time between, several states have enacted legislation allowing physician assisted dying. Oregon’s

victory in passing the Death with Dignity Act came after similar legislation failed in California

and the first attempt at the same in Washington State. One of the biggest challenges was the

position stated by opponents that prescribing the required medication violated the Controlled

Substances Act, and therefore both physician and pharmacist would be in breach of the law. This

point was dismissed, the Rx given special status within the DWDA and the legislation enacted.

Three years after its passing, loss of autonomy was given as a reason to access the DWDA; the

number of patients who received the medication still outnumbers the patients who ultimately

take it (Kondro, 2009). This is in opposition to the fear that legalizing PAD will affect the

psyches of patients and they will be more liable to give up. Though illness can impact our mental

health, each region has included an assessment piece to guard against misuse. In Oregon, the

passing of PAD legislation revealed a paradox: when allowed access to the medication to end

their life sooner, led to a surge in wellbeing and peace of mind. This in turn renewed many

patients desire to live longer. The theory behind this reaction relates back to the concept of

dignity and self-determination, the individual shifts their self-perception from “helpless victim”

to “willing survivor” (Lee, 2010). Upon a second attempt and shortly after Oregon’s victory,

Washington State passed Initiative 1000, allowing similar practice.

Both the ODWDA and WDWDA carry very strict limitations as to what practices this

term covers. Under Oregon’s individuals may acquire life ending medication by prescription

from their doctor, but must administer the medication themselves (Bollman, 2009). This poses an

obstacle to those suffering from degenerative diseases such as ALS, MS and other illnesses that

cause deterioration of mobility. Though a step in the right direction, these can be seen as half

A Dignified Departure11

measures made without the consultation of all people affected. If the quality of life is the concern

and reason for the need for PAD, with the existing terms of the act legislated, what options are

left for those who are able to follow through with the practice at a time in their lives they feel is

still optimal and worth living?

Vermont’s Patient Choice at End of Life Act has allowed for a compromise between the

needed legislation and regulation of Physician Assisted Death and the autonomy and freedom of

the patient by still requiring a terminal diagnosis, but not enforcing the same 6month prognosis

as the first two states (Tucker, 2014). However, they still have to self-administer, a problem

when seeking equality under the law for those afflicted with physically limiting illnesses.

Montana challenged Right-To-Die legislation in 2007. The idea that the individual

protection of one’s personal freedoms as stated in the Constitution includes their end of life

decisions, and therefore also offer protection to those whose help is requested and assist in PAD.

This decision was brought up again in 2009, where the question of constitutional protection was

not addressed. Instead, the state has allowed for a “consent defence” in which the physician will

not be prosecuted if the process of due care was followed and informed, free and enduring

consent was given by a competent, chronically ill patient. In its ruling, the court stated that

“nothing in the Supreme Court or state statutes indicate that allowing PAD would go against

public policy” (Mason, 2010). According to Bollman (2014), bioethicists agree with the right to

the idea of individual autonomy in the end of life. The decision in Montana stated the same

sentiments: one has the right to determine one’s own fate as long as it does not impede on the

rights of another.

A Dignified Departure12

International SuccessesEstablishing access to aid in dying via statute or court decision is possible. But is it necessary? Most medical care is not governed by statute or court decision, but is instead governed by professional practice standards, also referred to as best practices, or "standard of care." –Tucker, 2014

Colombia has successfully defended PAD, in all forms, from legal prosecution permitting

that certain conditions are met. The patient must be terminally ill yet competent to give consent

(Butler, Tiedmann, Nicol & Valiquet, 2010). The issue is still largely divisive in a country that is

moving forward but whose population is still largely, devoutly catholic. This has also been a

barrier to legislating similar acts in Spain for the same reasons. This religious homogeneity has

been linked to some failures to implement PAD around the world. With the passing of PAD in

several European countries, many are now in support of the change (CBC News, 2014). In the

shrinking global community we live in, many people of various spiritual and religious

backgrounds still see the importance of self-determinism as a reason to support such law.

Belgium legalized Euthanasia in 2002, there remain no regulations on Physician Assisted

Death as described in the US models (Butler, Tiedmann, Nicol & Valiquet, 2010). In these cases,

grounds for prosecution are considered on a case by case basis, and have to prove that due care

was not shown to the individual. This has led to an underreporting depending on the methods of

PAD used and reflects the difference between European countries and the importance of careful

codification as this specifies what is legal, and what is recorded due to the practice’s status

(Cohen, Wesemael, Smets, Bilsen & Deliens, 2012). In Belgium, within the eligibility criteria

there is a distinction between those patients whose death is expected in the near future or not. If

not expected soon, there are additional criteria to be met such as two additional medical doctors’

professional consult and opinion and at least one month between the request and its fulfillment

(Lewis & Black, 2013).

A Dignified Departure13

Voluntary, active euthanasia has been practiced in the Netherlands, and in all practicality

legal, since 1980. It was officially legalized in 2002 and carries with it many conditions to be

met (Rurup, Smets, Cohen, Bilsen, Onwuteaka-Philipsen & Deliens, 2011). The Netherlands

model is the most comprehensive. The term PAD includes the practice used on Oregon, as well

as active euthanasia. These practices are available, after due care guidelines are met, to both the

terminally, critically ill and those who are otherwise facing unbearable, hopeless suffering. As

such, the procedures can be carried out as stated by the patients verbal request, or, in case of

advanced disease leading to inability to speak or comatose condition, an advanced directive may

be followed.

The at-risk groups named by opponents of legalizing such practices, namely, women, elderly,

uninsured, poor, racial/ethnic minorities, physically, chronically disabled, and minors were

shown to be at no increased risk once the law was passed (Battin, Van der Heide, Ganzini, Van

der Wal, & Onwuteaka-Philipsen, 2007). This is in part due to the social acceptance of the

practice before legislation came into place, but also due to the carefully considered means by

which it could be used and the intent behind its enactment. The common knowledge of the PAD

procedures available to the people of the Netherlands proves that the access to information and

options is key in successfully implementing these practices to expand the ability of palliative and

heath care in general.

Policy Recommendations Many clinicians have trouble on a moral level distinguishing between medication that might hasten death – an act that is required if the dying are to receive appropriate care - and giving drugs in order to hasten death, which is euthanasia. – LaDuke, 2004

In the debate over legalizing PAD, both sides are ultimately conveying the same values,

those for human life and autonomy (Boudreau & Somerville, 2013). The difference is in what

A Dignified Departure14

they see the outcome to be. Those who advocate for the expansion of health care to include these

end of life options see them as bringing greater control to the individual, whereas, opponents fear

the choice being taken away and instead motivated by greed and social factors. In light of the

catastrophizing that has been done around the topic, there has been proof that although there may

be deontological arguments against PAD, there are also ways to view the same points in a more

moderate way. For example, the idea of the physician’s intent to be towards healing or curing

the patient, never to kill, takes away the idea that for many there is no cure. In relieving suffering

they can fulfill their duty and still respect the autonomy of the individual (Dieterle, 2007). In

putting forward the inherent wrongness of killing, again we have to ask in whose eyes? Death is

not a harm to those who seek PAD, as there comes a time when the weight and struggle to

continue on with the quantity of life exhausts the individual and detracts from the quality of their

life. Even Arch Bishop Tutu has reversed his stand on PAD. He stands by the belief in “the

sanctity of life – but not at any cost” (Crowley, 2014). Also, killing is a term that assumes

malevolent intention against another. If one wishes to die, and can acquire a physician’s aid in

doing so, no such act has been committed.

In fearing the end of advances in palliative care, there is an assumption that all patients

who are eligible for PAD will opt-in. In fact, the availability of the services has not meant an

increase in accessing them, (Bollman, 2014). The continuation of research will not be stopped by

including them into the choices one has in that situation. Indeed, Dieterle (2007) states the care

of the terminally ill has improved in both European and American jurisdictions where PAD is

practiced; the enhancement of life is another focus of palliative practice. The availability of PAD

would only help to create a fully integrated health care model. Every social policy has the

A Dignified Departure15

potential for abuse. It is up to us to draft legislation that allows for PAD, with the safeguards in

place to defend against such misuse.

Luckily we are not the first at the drawing board and can use many of the lessons learned

from the other jurisdictions to formulate a complete Act that covers both concerns. In the interest

of space, I have combed through the Netherlands’ model for some items to consider when

passing PAD into law. They are as follows:

1. First, there would need to be clear definitions of the terms Physician Assisted Death,

Passive Euthanasia, and Active Euthanasia. There would then have to be the acts

considered under each of those terms. For passive euthanasia we have already used

many of these practices for decades. It is for the areas in which PAD will be

expanded into active euthanasia that we will need to be clear on what we will allow,

(prescribing and aiding in the administration of the medication.)

2. There would need to be, as always, full disclosure to the patient of their condition,

prognosis, and all of their options so as to ensure informed consent. The idea of a

living will to state the individual’s wishes for decision related to PAD upon

incapacitation would have to be written into legislation as well. With this piece, a

time period during which such a document is valid so as to be purposeful but not

indefinite, would have to be decided on.

3. There would need to be competency requirements in place, both for the physician and

patient. For the health care professionals involved, there would be a need for some

length of relationship, or consultation with the individual’s primary care provider.

This would ensure a fuller understanding of the patient’s background and current

A Dignified Departure16

situation. Also, as the provision of such services would be an option to the patient, so

too would there be the choice for the doctor to provide it, or not.

The use of a required number of requests and the timing in between the requests

and the administration of PAD would also have to be taken into consideration.

Competency requirements would include the forms of PAD available to the

individual based on their prognosis. We want to legalize this to honour the autonomy

of the person, in doing so we would want to intervene only as is needed. A second

medical opinion, as well as psychiatric assessment where major depression is a

suspected factor in PAD requests would be necessary to ensure due care is followed.

4. Pending the passing of this new legislation, education must be a part of

implementation. Both for professionals in all the disciplines discussed earlier as well

as for the general public. We would need to educate people about what it means,

(their medical choices), who would have access to it and how that would look. Part of

the public education piece would be to assuage the fears of the opponents by

explaining the benefits, and more importantly the voluntary nature of these medical

procedures.

Conclusion The evidence shows that risks exist, she added, “but they can be identified and very substantially

minimised through a carefully designed system imposing stringent limits that are scrupulously

monitored and enforced.” – Judge Lynn Smith (in Dyer, 2012)

The latest polls seem favorable, and the knowledge and results shown by other

jurisdictions can be used to push for and support legislative change here in Canada. In medical

situations, including palliative care, one can request a Do Not Resuscitate, (DNR) Order, as well

A Dignified Departure17

an end to life saving treatment, even if lack of that intervention results in death, (Death With

Dignity Canada, 2014). Many Canadians feel that the request and act of Physician Assisted

Death in serving the same purpose should be granted similar status. If we truly see it as such, we

need to start treating death as a part of life and start acknowledging the impact of choice in our

lives, throughout our life. We need to legalize Physician Assisted Death in all its forms to help

the individuals who work in the health care profession the freedom to follow their oath and serve

their patients’ wishes. We need comprehensive, varied options for people facing the end of life

so they can leave with a sense of control, peace and dignity. We need to act carefully, taking into

consideration the protocols used in other jurisdictions. We need to act now and reflect the will of

the Canadian population.

A Dignified Departure18

References

Appleby, J., Johns, F., & Davis, D. (2014, November 15). "Prophylactic Suicide" New York Times. Retrieved November 16, 2014, from: http://www.nytimes.com/2014/11/16/opinion/sunday/prophylactic-suicide.html?_r=0

Avila, D. (1994). Rodriguez v. attorney general of Canada. Issues in Law & Medicine, 9(4), 389-394. Retrieved from: http://go.galegroup.com.proxy2.lib.umanitoba.ca/ps/retrieve.do?sgHitCountType=None&sort=RELEVANCE&inPS=true&prodId=HRCA&userGroupName=univmanitoba&tabID=T002&searchId=R1&resultListType=RESULT_LIST&contentSegment=&searchType=AdvancedSearchForm¤tPosition=2&contentSet=GALE|A15169191&&docId=GALE|A15169191&docType=GALE&role=

Battin, M., Van der Heide, A., Ganzini, L., Van der Wal, G., & Onwuteaka-Philipsen, B. (2007). Legal Physician-assisted Dying in Oregon and the Netherlands: Evidence Concerning The impact On Patients In "vulnerable" Groups. Journal of Medical Ethics, 33(10), 591-597. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2652799/

Blackwell, T. (2011, December 29). 67% of Canadians support legalizing assisted suicide: poll. National Post. Retrieved from: http://news.nationalpost.com/2011/12/29/67-of-canadians-support-legalizing-assisted-suicide-poll/

Bollman, C. (2009). A dignified death? Don't forget about the physically disabled and those not terminally ill: An analysis of physician-assisted suicide laws. Southern Illinois University Law Journal, 34(2), 395-415. Retrieved from: http://heinonline.org.proxy2.lib.umanitoba.ca/HOL/Page?page=395&handle=hein.journals/siulj34&collection=journals

Boudreau, J., & Somerville, M. (2013). Euthanasia is not medical treatment. British Medical Bulletin, 106(1), 45-66. Retrieved from: http://bmb.oxfordjournals.org.proxy2.lib.umanitoba.ca/content/106/1/45

Butler, M., Tiedmann, M., Nicol, J., & Valiquet, D. Parliamentary Information and Research Service, (2010). Background paper: Euthanasia and assisted suicide in Canada. Retrieved from: http://publications.gc.ca.proxy2.lib.umanitoba.ca/collections/collection_2010/bdp-lop/bp/2010-68-eng.pdf

Canadian Medical Protective Association. (2010). Fiduciary Duty. In Medico-legal handbook for physicians in Canada (7th ed., p. 10). Ottawa: The Canadian Medical Protective Association. Retrieved from: https://oplfrpd5.cmpa-acpm.ca/-/a-medico-legal-handbook-for-physicians-in-canada#4g

A Dignified Departure19

CBC News, (2014). Assisted suicide: Where do Canada and other Countries stand? Retrieved from: http://www.cbc.ca/news/canada/assisted-suicide-where-do-canada-and-other-countries-stand-1.2795041

Cohen, J., Wesemael, Y., Smets, T., Bilsen, J., & Deliens, L. (2012). Cultural differences affecting euthanasia practice in Belgium: One law but different attitudes and practices in Flanders and Wallonia. Social Science & Medicine, 75(5), 845-853. Retrieved from: http://www.sciencedirect.com.proxy2.lib.umanitoba.ca/science/article/pii/S0277953612003772

Cohen-Almagor, R. (2013). First do no harm: Pressing concerns regarding euthanasia in Belgium. International Journal of Law and Psychiatry, 36(5,6), 515-521. Retrieved January 1, 2014, from http://www.sciencedirect.com.proxy2.lib.umanitoba.ca/science/article/pii/S016025271300068X

Crowley, S. (2014, July 14). Tutu's support for death with dignity will advance issue worldwide, says Compassion and Choices: Oregon Death-With-Dignity Law co-author welcomes archbishop's change of heart. Retrieved from: http://www.prnewswire.com/news-releases/tutus-support-for-death-with-dignity-will-advance-issue-worldwide-says-compassion--choices-267063421.html

Dieterle, J. (2007). Physician assisted suicide: A new look at the arguments. Bioethics, 21(3), 127-139. Retrieved from: http://web.a.ebscohost.com.proxy2.lib.umanitoba.ca/ehost/detail/detail?sid=42cfd225-4ffe-460e-b9ea-bfab12e3a2d4@sessionmgr4002&vid=0&hid=4212&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ==#db=a9h&AN=23894474

Dyer, C. (2012). British Columbian judge says Canada’s ban on physician assisted dying is unconstitutional. BMJ, 344, 4251. Retrieved from: http://www.bmj.com.proxy2.lib.umanitoba.ca/content/344/bmj.e4251

Dying With Dignity Canada, (2014). Executive summary - 2014 Dying with Dignity Ipsos-Reid Survey. Retrieved from: http://www.dyingwithdignity.ca/resources/first-release-poll-results

Eisenstat-Weinrib, L. (1994). The body and the body politic: Assisted suicide under the Canadian charter of rights and freedoms. McGill Law Journal, 39(3), 618-43. Retrieved from: http://heinonline.org.proxy2.lib.umanitoba.ca/HOL/Page?page=618&handle=hein.journals/mcgil39&collection=journals

A Dignified Departure20

How to die in Oregon [Motion picture]. (2011). USA: Clear Cut Productions. Retrieved from: http://www.netflix.com/WiPlayer?movieid=70167107&trkid=1464504&locale=en-CA

Gawande, A. (2010, August 2). Letting Go. New Yorker. Retrieved from: http://www.newyorker.com/magazine/2010/08/02/letting-go-2

Kondro, W. (2009). Death with dignity. CMAJ: Canadian Medical Association Journal, 180(2), 163-163. Retrieved from: http://go.galegroup.com.proxy2.lib.umanitoba.ca/ps/retrieve.do?sgHitCountType=None&sort=RELEVANCE&inPS=true&prodId=HRCA&userGroupName=univmanitoba&tabID=T002&searchId=R1&resultListType=RESULT_LIST&contentSegment=&searchType=AdvancedSearchForm&currentPosition=2&contentSet=GALE|A192437867&&docId=GALE|A192437867&docType=GALE&role=

LaDuke, S. (2004). Attending Death with Dignity. Health Affairs, 23(2), 222-227. Retrieved January 1, 2014, from: http://web.b.ebscohost.com.proxy2.lib.umanitoba.ca/ehost/detail/detail?sid=217d8571-1aca-47c8-aed0-fdb8cbed1503@sessionmgr114&vid=0&hid=127&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ==#db=a9h&AN=13679769

Lee, L. (2010). The Oregon Paradox. The Journal of Socio-Economics, 39(2), 204-208. Retrieved from: http://www.sciencedirect.com.proxy2.lib.umanitoba.ca/science/article/pii/S105353570900136X

Lewis, P., & Black, I. (2013). Adherence to the request criterion in jurisdictions where assisted dying is lawful? A review of the criteria and evidence in the Netherlands, Belgium, Oregon and Switzerland. The Journal of Law, Medicine and Ethics, 41(4), 885-898. Retrieved from: http://web.a.ebscohost.com.proxy2.lib.umanitoba.ca/ehost/detail/detail?sid=62d49a38-95c9-4490-b450-8ad2a110f8dc@sessionmgr4003&vid=0&hid=4212&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ==#db=i3h&AN=93877397

Lewy, G. (2011). Assisted death in Europe and America: Four regimes and their lessons. Oxford: Oxford University Press.

Mason, E. (2010). Ignoring it will not make it go away: Guidelines for statutory regulation of physician-assisted death. New England Law Review, 45(1), 139-166. Retrieved from: http://heinonline.org.proxy2.lib.umanitoba.ca/HOL/Page?handle=hein.journals/newlr45&id=141&collection=journals&index=journals/newlr

Miller, P., Hedlund, S., & Soule, A. (2006). Conversations at the end of life: The challenge to support patients who consider death with dignity in Oregon. Journal of Social Work in

A Dignified Departure21

End-of-Life & Palliative Care, 2(2), 25-43. Retrieved from: http://www.tandfonline.com.proxy2.lib.umanitoba.ca/doi/abs/10.1300/J457v02n02_03

Onwuteaka-Philipsen, B., Brinkman-Stoppelenburg, A., Penning, C., Jong-Krul, G., Delden, J., & Heide, A. (2012). Trends in end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010: A repeated cross-sectional survey. The Lancet, 380(9845), 908-915. Retrieved from: http://www.sciencedirect.com.proxy2.lib.umanitoba.ca/science/article/pii/S0140673612610344

Priest, L. (2011, November 26). Critical care: Spending 10 weeks with patients facing death. The Globe and Mail. Retrieved from: http://www.theglobeandmail.com/life/health-and-fitness/critical-care-spending-10-weeks-with-patients-facing-death/article534583/?page=all

Reynolds, L. (2014). Losing the quality of life: The move towards society's understanding and acceptance of physician aid-in-dying and the Death with Dignity Act. New England Law Review, 48(2), 343-370. Retrieved from: http://heinonline.org.proxy2.lib.umanitoba.ca/HOL/Page?page=343&handle=hein.journals/newlr48&collection=journals

Rurup, M., Smets, T., Cohen, J., Bilsen, J., Onwuteaka-Philipsen, B., & Deliens, L. (2011). The first five years of euthanasia legislation in Belgium and the Netherlands: Description and comparison of cases. Palliative Medicine, 26(1), 43-49. Retrieved from: http://pmj.sagepub.com.proxy2.lib.umanitoba.ca/content/26/1/43

Titterington, V. B., Rivolta, P. M., & Schraufnagel, S. (2013). Right-to-die legislation: A note on factors associated with its adoption. Sociological Spectrum: Mid-South Sociological Association, 33(4), 358-373. Retrieved from: http://www.tandfonline.com.proxy2.lib.umanitoba.ca/doi/abs/10.1080/02732173.2013.732893

Tucker, K. (2014). Vermont's Patient Choice at End of Life Act: A historic "next generation" law governing aid in dying. Vermont Law Review, 38(3), 687-699. Retrieved January 1, 2014, from: http://web.a.ebscohost.com.proxy2.lib.umanitoba.ca/ehost/detail/detail?sid=27c4920e-5834-4744-a790-9f1b8d3eb3d2@sessionmgr4003&vid=0&hid=4212&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ==#db=a9h&AN=96059655

Tucker, K. (2011). When dying takes too long: Activism for social change to protect and expand choice at the end of life. Whittier Law Review, 33(1), 109-160. Retrieved from: http://heinonline.org.proxy2.lib.umanitoba.ca/HOL/Page?page=109&handle=hein.journals/whitlr33&collection=journals

A Dignified Departure22