Dying with Dignity Laws Allow Patients to Regain Autonomy Lost to Illness

36 min readJan 28, 2021

Since the late 1990’s, the United States has implemented “Right to Die” laws in nine states throughout the country. Right to Die laws stipulate that competent individuals can seek out a physician for the purpose of performing physician-assisted death (“PAD” or “assisted death”) within the last six months of a terminal illness.[i] PAD differs from withholding/withdrawing life-sustaining treatment in that some physicians view PAD as a killing, while others view the latter process as simply letting a patient die. Death with Dignity is one of many nonprofit organizations that advocates for the normalization and legalization of physician-assisted dying throughout the country and has assisted in the passage of many state’s Right to Die laws.[ii] Death with Dignity discourages the use of the phrase “assisted suicide” because the group and its patients view the term as “inaccurate, inappropriate, and biased” and stigmatizes assisted death.[iii] Though PAD is a completely voluntary process, opponents openly criticize the laws and processes and have actively tried intervening to end the practice. Groups typically cite morality, religion, and concerns of euthanizing disabled individuals as reasons to overturn or inhibit PAD laws. Evidence shows that these are baseless claims, and support for PAD laws has grown since Oregon’s initial PAD legislation in the 1990’s. Critics have continued to interfere in legislation, but because grappling with a terminal illness is almost unknowable to those who do not experience it, deciding its morality should not be a decision left to the courts. Physician-assisted dying laws should be legal throughout the county in order to inform patients of all their options when it comes to considering end-of-life care. However, current laws do not sufficiently address concerns raised by its opponents. State legislators ought to work to synthesize the requirements of PAD to ensure that proponents and opponents of PAD alike understand the process.

I. What is Physician-Assisted Death/Dying?

Suicide is defined as “the action or an act of taking one’s own life.”[iv] People generally commit suicide to escape the difficulties in their lives, often citing chronic depression, substance abuse, mental health issues, financial struggles, and racial/sexual discrimination as contributing causes.[v] It can come as a complete shock to the victim’s friends and family, even causing some of the factors that led to the loved one’s suicide, like severe depression, to manifest in those it affects.[vi] Terminal illness has also been identified as a contributing cause to suicides, especially in cancer patients who become depressed after their diagnosis.[vii] They might feel that they are out of options and wish to die on their own terms, rather than suffering through their illness. Many people with terminal illness feel this way but do not want to commit suicide and instead turn to their state’s assisted dying laws, if they have them. Assisted dying is defined as “the taking of lethal drugs, provided by a doctor for the purpose, by a patient considered to be incurable.”[viii] Physician-assisted dying is a process in which a patient obtains legally prescribed medication that ends her life after consumption. The process of PAD generally takes a month to complete, and doctors recommend that patients consult friends and family before making the decision to pursue assisted death. In doing so, friends and family have time to come to terms with the circumstances and can prepare for their loved one’s death.[ix]

II. Why Do People Seek Physician-Assisted Death?

Physicians must ascertain what is influencing the patient’s desire to die and determining whether she needs a psychological evaluation before continuing the process.[x] Several studies have been conducted on patients seeking PAD to determine what the most influential factors are when making their decisions. The vast majority of patients who sought PAD cited loss of autonomy as their main concern regarding their illness’s progression, while other reasons included the loss of the ability to do enjoyable and meaningful activities, fear of future suffering, and wanting to control the time and manner of death to die at home.[xi] Some feared the prospect of worsening pain or quality of life, the inability to care for themselves, previous negative experience around death and dying, uncontrollable pain or concerns of future pain, financial implications of continuing treatment, as well as not wanting to burden family, friends, or caregivers.[xii],[xiii] Most participants did not view physical symptoms such as pain, shortness of breath, fatigue, confusion, and loss of bowel control as deciding factors when seeking PAD.[xiv] Neither did feeling ready to die, believing that life tasks were complete, or thinking that life was pointless play a part in their decision.[xv] Though these are small samples, patients’ biggest concern appears to be wanting to have control over their life, rather than admitting defeat and succumbing to their illnesses.

Patients are not the only people involved in this decision; physicians often recommend that they consult family members before deciding to move forward with assisted dying. One study in Oregon reached out to the family members of those who have elected PAD to see how they were coping after their loved one had passed. Overwhelmingly, family members said they supported legalization of physician-assisted death, were in agreement with and wanted the option for their loved one, and would even consider it for themselves.[xvi] The study also found that families who had a loved one who chose PAD felt more prepared and accepting of their death.[xvii] Conversely, the study found that family members of patients whose requests for PAD were denied felt distressed about how their loved one ultimately died.[xviii] Again, though this is a small sample, it demonstrates that many families believe the benefits of assisted death outweigh the cons of a dragged-out illness.

Because there is a stigma surrounding suicide, Death with Dignity recommends avoiding that language. One patient, Jack Newbold, described his disdain at the way the media covered his choice to die, lamenting: “I’m not committing suicide, and I don’t want to die. I was upset by media reports that I intend to ‘kill’ myself. I’m not killing myself; bone cancer is taking care of that. I may take the option of shortening the agony of my final hours.”[xix] Were it not for the cancer, Newbold would not consider dying; the cancer is the driving force behind him seeking PAD, but he does not consider it as suicide. Many people choose PAD because they want to maintain control and prevent suffering. Physicians swear to do no harm, but many are opposed to this idea of helping their patients avoid future harm and suffering.[xx]

III. Differences between Physician-Assisted Dying and Euthanasia

There are a few different forms of “assisted dying” recognized in the field of medicine, and physician-assisted dying and euthanasia are often confused.[xxi] Physician-assisted dying is a method by which a patient self-administers a lethal dose of medication that a doctor prescribed, while euthanasia occurs when a physician directly causes the patient’s death.[xxii] Though euthanasia will not be the focus of this paper, its three variations are still worth mentioning. On one end of the spectrum are non-voluntary euthanasia and involuntary euthanasia, both of which are generally considered homicide.[xxiii] The former is a scenario in which a physician administers life-ending medication to a patient who either too young to consent or incapacitated and cannot consent, while the latter involves a patient who is able to consent, but does not, and is essentially killed.[xxiv] Involuntary euthanasia is not legal in the United States and is widely viewed as a form of eugenics, in that Hitler used it to kill the physically and mentally disabled, the elderly, and terminally ill in Nazi Germany.[xxv],[xxvi] Some groups opposed to PAD believe that in normalizing the process, involuntary euthanasia will become commonplace and abused in our country.

Voluntary euthanasia is on the other end of the spectrum; legal in some countries, like Australia and the Netherlands, but illegal in others, like the United States.[xxvii] There are two forms of voluntary euthanasia: passive and active. Active euthanasia occurs when patient gives informed consent and obtains physician-approval for the process, but her physician administers the lethal dose.[xxviii] The United States does not currently support active euthanasia, but passive euthanasia, the withdrawing/withholding of life-sustaining treatments (“WWLST”) and instead providing pain management, occurs frequently and is commonly advertised as hospice treatments.[xxix]

Withdrawing life-sustaining treatments is an act protected by the Due Process Clause of the Fourteenth Amendment. In the 1990 case Cruzan v. Director, Missouri Department of Health, the Supreme Court held that competent individuals had the ability to refuse unwanted life-sustaining medical treatment, but that nobody has a right to die.[xxx] The Court also held, however, that in order for an incompetent person’s life-sustaining treatment to be withdrawn, there must be “clear and convincing” evidence that those were her wishes.[xxxi] Therefore, when making an end-of-life decision, the patient or her healthcare agent must do so with informed consent, knowing that she will no longer receive supplements like food, water, medication, and oxygen.[xxxii] Overarchingly, patients pick options that they consider to be “in accordance with their values, goals, and priorities for their future”, though patients might sometimes be pressured by family members to make a different decision.[xxxiii] Many patients routinely refuse to continue life-sustaining treatment, choosing instead to die during the natural course of their illness in family homes, nursing homes, and hospitals across the country.[xxxiv] Although removing life-sustaining treatments ultimately leads to death, some physicians view it as a more moral process than assisting in a patient’s suicide.[xxxv]

IV. Some Physicians’ Moral and Religious Objections to Assisting Patients in Dying Lead to More Suffering

Some physicians who do not support PAD but agree to the cessation of life-sustaining treatment might subscribe to the acts and omissions doctrine (“AOD”) in an attempt to rationalize their morality. The AOD essentially philosophizes omissions as moral and actions as immoral.[xxxvi] For instance, withdrawing life-sustaining treatment is more passive than actually prescribing medication that hasten the death of a patient, and therefore, WWLST is ethically sound.[xxxvii] Some physicians believe that PAD is immoral because they substantially act to expedite death, rather than letting their patient die naturally, even if that “natural” death involves suffocation, dehydration, and/or starvation, albeit painlessly.[xxxviii] So even if a state has PAD legislation, it is not a mandatory program with which every physician and hospital system must comply; it is voluntary, and abstaining physicians can choose to refer patients to another physician who participates.

In some cases, it might even be difficult to find a physician willing to participate in assisted dying. In one instance, a patient with a terminal cancer diagnosis could not find a physician willing to participate, so she shot herself in her bathtub.[xxxix] The Washington State Health Department’s complaint said the incident could have been “prevented peacefully”, but that the hospital that refused the option threatened to fire its employees if they discussed the option with her.[xl] Brittany Maynard, a terminally ill woman whose journey through PAD was publicized several years ago, moved from California to Oregon in order to qualify for and receive PAD.[xli] In Washington State, there are some areas that do not have a doctor willing to participate in PAD within a 100-mile radius, which might be an unmanageable distance for terminally ill patients to overcome to visit a physician multiple times in the span of one month.[xlii] Though assisted death should remain voluntary for physicians, entire hospital systems should not be able to opt out, as this decision possibly deprives patients of their chosen form of healthcare and forces them to experience unnecessary suffering.

Oregon legalized PAD in 1994 with the Death with Dignity Act, and in 1995, several doctors conducted a study that revealed over 2700 Oregonian physicians’ opinions regarding the new legislation.[xliii] The survey determined that almost three-quarters of the responding physicians agreed that terminally-ill patients had a right to commit suicide (not necessarily assisted), 66 percent believed PAD would be ethical in some cases, while 60 percent believed it should be legal in some cases.[xliv] Over a third of physicians felt that PAD is immoral, citing a violation of professional ethics or their own moral/religious beliefs, and more than half of the respondents said they would not be willing to prescribe a lethal prescription to patients due to concerns regarding legal liability and moral reasons.[xlv] Just four percent of respondents said they would not even refer the patient to another physician who did participate in the program.[xlvi] Morality is a major contributing factor in a physician’s decision to partake in assisted death, but many physicians take religious beliefs into account, too.

A group of oncologists in 2017 published a paper that admonishes the option of physician-assisted death. Dr. Mark O’Rourke advises other physicians that if they “prescribe PAS/PAD because a patient asks for it … they set themselves up to become mere providers of services on demand,” even acting unprofessionally.[xlvii] This statement seems to reject the notion of bodily autonomy, saying patients cannot request specific treatments and that doctors should not entertain their requests. The idea that physicians who participate in PAD programs act unprofessionally might stem from a moral standpoint, in that physicians swear to “do no harm” in the practice of medicine; furthermore, the Code of Medical Ethics says PAD is “fundamentally incompatible with the physician’s role as healer.”[xlviii] One could argue, however, that by refusing the patient her right to die, the physician is doing harm by making her suffer through the symptoms that are causing her to seek PAD. O’Rourke even invalidates the majority of patients’ reasoning for seeking PAD. He writes that their desire to control the circumstances surrounding their deaths is not a “sufficient reason” to pass PAD legislation.[xlix] Moral and religious views often cloud the judgment of those who are supposed to make objective decisions that benefit people from many walks of life.

a. Religious Opposition

Some, including those with religious backgrounds, worry that physicians might influence patients’ decisions to pursue PAD. David Stevens, the CEO of The Christian Medical & Dental Associations believes PAD is a sacrilegious act that violates Christian morality. Stevens attempts to explain that physicians have no idea how to gauge the patient’s level of suffering, saying it is immeasurable and subjective. [l] But this is the whole reason that patients seek PAD: to alleviate suffering that is only knowable to those who have experienced it. It is illogical to argue that a physician cannot act in accordance with his patient’s wishes simply because he cannot measure her suffering. When a patient’s prognosis is terminal, there is typically very little that can be done to slow her death, and allowing patients control the circumstances surrounding their own death might be the only sense of control they have in their lives.

Stevens goes on to say that patients can commit suicide without doctor intervention whenever they want to. However, by seeking PAD, patients make it clear that they want a painless death, rather than committing suicide on their own in a potentially painful manner.[li] When legislators and people in power let their prejudices and personal beliefs get in the way of their ability to make objective decisions, they put people at risk for unnecessary suffering.

Religious and moral beliefs have affected lawmakers for decades. Take abortion, for example: In Roe v. Wade, the Supreme Court held that a woman has a right to choose whether to have an abortion without excessive government restriction, but that the states can still interfere.[lii] Since that decision, states have been regulating a woman’s right to choose, often citing religious beliefs as an underlying factor. When signing Alabama’s restrictive abortion ban in May 2019, Governor Kay Ivey said the law was a “powerful testament” to Alabama’s belief that “every life is a sacred gift from God.”[liii] Given that statement, it seems highly unlikely that a republican-controlled Alabama, or any conservative-controlled state with deeply held religious values, would ever support PAD legislation if lawmakers keep bringing religion into regulating medical practice.

b. “Killing” vs. “Letting Die” is an Important Distinction that Could be Applied Either Way

This is not to say that only conservative-leaning states with religious ideals oppose PAD legislation. In 1997, the Supreme Court in Vacco v. Quill held that New York’s ban on assisted dying did not violate the Equal Protection Clause and dismissed Petitioner’s idea that WWLST is “nothing more nor less than assisted suicide.”[liv] The Court elaborated upon the difference between the two acts: in facilitating WWLST, death is not necessarily the physician’s intent, while in PAD, it is. [lv] When withdrawing a patient’s life-sustaining treatments, the Court says the physician intends to “honor” and “respect” her wishes, while a physician who takes part in PAD intends for his patient to die.[lvi] However, one could make the argument that a physician assisting his patient in dying is simply respecting her wishes, too.

Because the patient initiates the process of PAD, it is her intent to hasten death. The physician, in prescribing the lethal dose of medicine, simply intends to respect her wishes and assist her in that endeavor. The Court in Vacco stated that by prohibiting PAD but codifying a right to WWLST, New York “reaffirmed the line between ‘killing’ and ‘letting die’”: assisting in death and withdrawing life-sustaining treatments.[lvii] Like all other states’ Right to Die laws, Oregon law prohibits a physician from actually taking part in a patient’s death. The Death with Dignity law stipulates: “Nothing in [this act] shall be construed to authorize a physician … to end a patient’s life by lethal injection, mercy killing or active euthanasia.”[lviii] Oregon’s law allows one to infer that a physician who actively intervene in the patient’s suicide, like giving her a shot or feeding her the medication, “kills” her.

Physicians prescribe medication to PAD patients but cannot force them to take it. Therefore, it makes sense that simply providing a patient with access to a lethal dose of prescribed medication could be construed as “letting die”, rather than “killing”. Because physicians cannot physically cause a patient’s death, they instead let their patients decide whether to ingest the lethal dose. Furthermore, physicians such as Jane Petro, an Assistant Director at Westchester County Medical Center, observed that physicians are free to prescribe pain medication to patients without guaranteeing the patients will not misuse the medication to induce death on their own.[lix]

Although the results of both processes are generally the same, the Court has illustrated WWLST as a process that doctors and patients can morally consent to, but prohibited them from participating in PAD and emphasized its immorality. In doing so, the Court seemingly applied the acts and omissions doctrine, which is also demonstrated in When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context, a publication by The New York State Task Force on Life and the Law (“Task Force”). The Task Force states that New York “embraces individual autonomy” when it comes to the state’s medical policies, but that is not the case.[lx] By permitting a physician to withdraw a patient’s life-sustaining treatments, but prohibiting him from prescribing the patient’s requested medication to hasten her death, the state clearly limits patient’s autonomy, and also implicitly regards WWLST as moral and PAD as immoral.

c. The Notion That Physician-Assisted Death Facilitates Abuse of Vulnerable and Disabled Individuals Is Wrong

The Task Force, like O’Rourke and Stevens, believes that legalizing PAD will lead to abuse and pose immense risks to the ill and vulnerable.[lxi] The Task Force, however, takes the position that the “ill and vulnerable” will not be disproportionally targeted by physicians on the basis of their ailments, but because their autonomy is “already compromised” by their living situations.[lxii] Living in poverty, having a lack of access to good medical care, and being part of a stigmatized social group are some factors that the Task Force feels might be exploited by physicians and result in euthanasia.[lxiii]

O’Rourke’s article even suggests that physicians pressure patients into choosing assisted dying because the doctor-patient relationship is “is asymmetric, with safety, information, and power on the side of the physician.”[lxiv] However, studies show that many physicians who participate in PAD are not willing to aid every patient who consults them about the process.[lxv] Physicians routinely reject patients after screening for mental health issues.[lxvi] Physicians must determine the root of the desire for PAD, and if they conclude that the patient would be better off with mental health counseling than hastened death, they can turn them down.[lxvii] One study concluded that generally, if a physician deems a patient to be depressed when they request PAD, he will not honor the request unless he can establish that depression did not provoke the request.[lxviii] The idea that physicians will coerce patients into seeking PAD when it is unnecessary is shared by disability rights groups, though their stance on the matter of PAD as a whole is slightly confusing.

V. Some Disability Rights Groups Believe Physician-Assisted Dying is Discriminatory, and Could Lead to Euthanasia

a. Groups Claim that Physician-Assisted Dying is Discriminatory and Violates the American with Disabilities Act

Disability rights groups list many concerns with PAD and how the future of the process might affect disabled people, but their views seem to be at opposition with one another. There are beliefs that PAD excludes disabled patients on a discriminatory basis, but also fears that physicians will target disabled people and eventually begin euthanizing them. First and foremost, the Disability Rights Education & Defense Fund (“DREDF”) argues that PAD legislation violates the Americans with Disabilities Act.[lxix] The group states that because physicians are subject to the nondiscrimination requirements of the ADA, any “standard for suicide intervention that is based on whether a person does or does not have a disability violates the ADA.”[lxx] They state that not permitting disabled people to seek PAD is blatantly discriminatory when considering the factors that accepted PAD patients exhibit.

Not Dead Yet, another organization fighting to end PAD treatments, joins DREDF in the belief that PAD creates a double standard on the basis of patient’s health statuses. The groups say that promoting suicide prevention for disabled people while facilitating terminally ill people who exhibit signs of disability to seek assisted death is a violation of the ADA.[lxxi] Many state PAD laws stipulate that disability on its own will not make anyone eligible for the process; a terminal illness with less than six months to live must be the driving factor in the request.[lxxii] Pro-rights groups view this as exclusionary and discriminatory, but at the same time, these same groups believe that physicians aim to normalize PAD in the disabled population in order to coerce patients into pursing it.[lxxiii]

b. Expanding Access to Physician-Assisted Suicide Will Not Lead to Physicians Abusing Disabled Individuals

Disability rights groups seem to believe that over time, physicians will write lethal prescriptions to anyone who expresses concern over a trait associated with deterioration of quality of life. First and foremost, when nearing the end of life, people’s motor skills deteriorate and they typically lose the ability to do things for themselves. Many disabled individuals often live with the symptoms that cause people to seek an assisted death, like the inability to walk, incontinence, and blindness, and find the notion of assisted dying offensive.[lxxiv] Therefore, Not Dead Yet believes that PAD legislation is extremely discriminative towards people with disabilities. Not Dead Yet laments the “prevalent but insulting” belief that “losses in bodily function are lacking dignity”, and believes that society will soon normalize the difficulties faced by disabled people as the basis for PAD.[lxxv]

Many disability rights groups share the fears expressed above, that vulnerable populations will be unfairly targeted by physicians participating in PAD. One of Not Dead Yet’s talking points includes the idea that many assisted suicide organizations aim to expand eligibility to reach more people.[lxxvi] By being able to facilitate more assisted deaths, the group believes that physicians will coerce disabled patients into pursuing the process. Not Dead Yet, however, illogically assumes that physicians will neglect to examine or treat “vulnerable” patients before recommending they pursue assisted death.[lxxvii] The group even makes a baseless claim, saying the continued use of PAD leaves the “door open for involuntary euthanasia”; this adverse prediction is reminiscent of Nazi Germany’s use of euthanasia to kill the terminally ill and disabled.[lxxviii],[lxxix]

Furthermore, Stevens of the Christian Medical & Dental Associations, expressed his concerns regarding whether PAD would eventually encourage medical professionals to “more regularly put an end to burdensome patients.”[lxxx] Critics believe that if the process is normalized, physicians might suggest PAD before exploring all other end-of-life options, but that does not seem to be the case. The vast majority of scholarly articles, often written by physicians, grapple with the issue of whether PAD can ever be ethical and if physicians can morally carry out patient’s requests. The worry that physicians will abuse their power seems to come from the potential normalization of assisted dying as an accepted practice.

c. Patients are More Likely to Pressure Physicians into Facilitating Assisted Death

Another viewpoint describes how patients, rather than physicians, might abuse the wider and more relaxed criteria if PAD is normalized. The majority of patients who seek PAD come from white, middle class, and well-educated backgrounds, who historically receive better access to healthcare than disadvantaged and vulnerable groups.[lxxxi] Doctor Carol Gill from the University of Illinois at Chicago believes that rather than seeking physician-assisted death as a means to regain control over their lives, “people from disadvantaged groups might consider hastened death because their health-care needs are not being met.”[lxxxii] Gill suggests that if PAD becomes more normalized and the criteria widens, disabled and other vulnerable groups might seek PAD on their own volition. Additionally, that means that people who would not necessarily have qualified in the past might be able to persuade a physician into participating in PAD for them in the future.

This is a vast departure from the stances that disabled rights groups take, in that Gill believes the patients will seek out PAD at an increasing rate, while groups believe physicians will target disabled people and abuse them. If anything, family members can be more coercive than physicians because it is family who surrounds the patient as they ingest the medication.[lxxxiii] For example, DREDF believes that patients who are continuously denied might go “physician shopping” until they find one willing to provide them with an assisted death. The group claims that “doctor shopping gets around any ‘safeguards,’” but then cites an example in which an elderly woman was clearly being controlled and coerced into the process by her daughter.[lxxxiv] The belief that physicians would choose to coerce their patients into PAD rather than help them is unsubstantiated, but often supported by disability rights groups.

Disability rights groups take many stances that are at fault with one another. On one hand, the groups believe it is unfair that disabled people are excluded for exhibiting the same characteristics that invite terminally ill people into the process, furthering the stigma that one might be better off dead than disabled.[lxxxv] On the other hand, groups declare that physicians aim to expand eligibility so they can pressure and coerce people with disabilities into pursuing PAD.[lxxxvi] There is no evidence for either claim. In fact, a study conducted in Oregon and the Netherlands concluded that PAD rates showed “no evidence of heightened risk for … the physically disabled or chronically ill…people with psychiatric illnesses…[and other vulnerable groups].”[lxxxvii] The medical profession takes its duty as healers so seriously that one of the only times a physician was convicted of a charge occurred in the late 1990’s when courts convicted Dr. Jack Kevorkian for second-degree murder after he physically assisted in the suicide of a patient.[lxxxviii]

VI. Jack Kevorkian Made Physician-Assisted Death More Accessible by Forcing People to Acknowledge End-Of-Life Treatments

In 1999, after eight years of assisting over 130 patients in dying, a jury convicted Dr. Jack Kevorkian for second-degree murder.[lxxxix] The earlier assertion that a physical attempt by a physician to aid his patient in her suicide could be considered “killing” rather than “letting die” becomes relevant when considering that despite being tried for four murders, Kevorkian’s only conviction came after he aired evidence of himself injecting a lethal dose of medication into a patient on TV.[xc]

Jack Kevorkian, sometimes known as “Dr. Death”, was a massive and radical proponent of physician-assisted dying, even seeking to utilize executed prisoners in medical research as early as 1959.[xci] Dr. Kevorkian, though viewed as a murderer by many, created a legacy of “challenging social taboos” and being influential in the growth of hospice care in the United States.[xcii] After studying PAD methods in the Netherlands, Kevorkian returned to the U.S. and advertised himself as a “death counseling” consultant by the 1980’s, and performed his first assisted death in 1990.[xciii]

Kevorkian lost his medical license a year after his first PAD procedure, but continued to assist patients for seven more years.[xciv] Many criticized his methods as unprofessional and unethical because he often operated out of the back of a van and used machines that he invented himself. Kevorkian developed these machines after visiting a quadriplegic on life support, who, as Kevorkian describes, was being kept alive by “religious nuts” and decided that he needed to provide a way to release people from their suffering.[xcv] Once attached to the patient, the machines delivered narcotics intravenously or by releasing carbon monoxide through a gas mask.[xcvi] Thanks to his studies in the Netherlands, Kevorkian learned how to get around the law.

By insisting the patients pressed the button to initiate death themselves, Kevorkian often circumvented criminal prosecution because he was not the principal actor in bringing about the patient’s death. However, he did not take many of the safety precautions that are mandatory before going ahead with the process today. Kevorkian claims that not only did he consult primary care physicians and mental health professionals before continuing the process, he also gave the patients a month to change their minds.[xcvii] However, there is evidence that patients did not always receive psychological screenings, some procedures happened within 24 hours of an initial meeting, and many patients might not have even had terminal illnesses with fewer than six months to live at the time of death.[xcviii] Furthermore, many state laws today require the patient seeing PAD have the ability to self-administer the medication, but Kevorkian clearly did not enforce this in his practice.[xcix]

Kevorkian’s murder conviction came after a 60 Minutes interview aired footage of Kevorkian himself injecting the narcotics into a patient, crossing the fine line between assisted death and euthanasia.[c] The patient seemed unable to do it himself, which today would likely invalidate his eligibility.[ci] It is important to note that juries convicted Kevorkian because he was the one who administered the lethal dose and effectively killing the patient, instead of letting him act and die by his own doing.

Kevorkian’s efforts, though rudimentary and unregulated, were quintessential in changing the attitude around assisted dying in the United States. Kevorkian stated that his ultimate goal was to turn euthanasia into a “positive experience” and to force physicians to face the uncomfortable truth that their “responsibilities include assisting their patients with death.”[cii] Although critics were vocal regarding their disdain of his methods and unchecked practice of PAD, they “generally agreed” that his methods helped initiate a conversation around the taboo subject of end-of-life-care.[ciii] Hospice care grew, and physicians became more “sympathetic to those in severe pain and more willing to prescribe medication to relieve it” as a result of Kevorkian’s actions.[civ] Today, though many PAD advocates denounce the actions taken by Kevorkian, it is hard to imagine that he did not have some impact on the PAD movement and its success in states like Oregon in the late 1990’s.

VII. Further Opposition to State’s Physician-Assisted Dying Laws

When the Supreme Court in Vacco held that dying is not a constitutionally protected right, it delegated the responsibility of regulating assisted dying legislation to the states.[cv]

Oregon’s Death with Dignity law passed in 1994 and went into effect in 1997, and since then, California, Colorado, Hawaii, Maine, New Jersey, Oregon, Vermont, Washington State, and Washington D.C. have all passed similar laws.[cvi] Criticisms from religious groups, however, like the Christian Medical & Dental Society (“CMDS”) continue to interfere in state PAD legislation.

In Ahn v. Hestrin, the CMDS attempted to overturn California’s Right to Die law. Defendants argued that PAD legislation is constitutional in California because it “relates to improving (and indeed has improved) (1) end-of-life health for many Californians and (2) the efficacy of California’s end-of-life health care system.”[cvii] The court supported Defendant’s argument and affirmed California’s right to offer PAD to its eligible citizens in 2016. In 2017, religious groups in Vermont brought suit in an attempt to challenge Vermont’s PAD laws. The judge dismissed the case, holding that Vermont’s laws concerning end-of-life treatment require that “physicians must inform patients about all choices and options relevant to their medical treatment,” which includes assisted dying.[cviii]

Some states still uphold the belief that citizens do not have a right to die, independent of religious beliefs. Like the Supreme Court in Vacco, New Mexico’s District Court held in Morris v. Bradenburg that although patients have a right to refuse life-sustaining treatments, there is not a constitutional right to assisted [suicide].[cix] The state struck down PAD laws and does not currently have legislation in place. Conversely, while Montana does not currently have any PAD legislation, its Supreme Court held that assisted death is not unconstitutional, and a physician cannot be stopped or prosecuted from honoring a patient’s wishes to pursue PAD.[cx] Montana departed from past decisions and instead held that on their face, Montana statutes do not “indicat[e] that physician aid in dying is against public policy. In physician aid in dying, the patient — not the physician — commits the final death-causing act by self-administering a lethal dose of medicine.”[cxi] This is the differentiation that juries made when considering the Kevorkian cases; that by injecting the medication into the patient himself, Kevorkian crossed a boundary into euthanasia and commits the “final death act.” Thanks to Dr. Kevorkian’s publicized trials and life, more people began talking openly about assisted dying and inquiring about its procedures.

VIII. Procedures & Processes

Today, physician-assisted death is legal in California, Colorado, Hawaii, Maine, New Jersey, Oregon, Vermont, Washington State, and Washington D.C., and though the state laws differ, the processes and procedures are largely the same. Because PAD is currently reserved for terminally ill patients with approximately six months left to live, Death with Dignity advocates recommend that a potential patient discuss her interest in the procedure with her primary care physician as early as possible.[cxii] As previously discussed, there are many areas in which there are no providers willing to participate in PAD, so if a physician is not willing to go through with the process, the patient will still have “energy and time” to find one who is.[cxiii]

The entire PAD process typically takes three to four weeks to complete, beginning with the first oral request and ending with the prescription writing.[cxiv] Generally, states with PAD legislation require two physicians to certify that the following criteria are met. Most importantly, the patient must be diagnosed with a terminal illness that the physician reasonably believes will lead to death within six months, but she must also be 18 or older, a legal resident of the state, and mentally competent and able to administer the medication herself.[cxv] Remaining in compliance with the state statutes that are monitored by that state’s Department of Health protects participants — patients, their families, and physicians — from criminal prosecution.[cxvi] In addition to meeting the above requirements, the physician is required to inform the patient of her other options, including withdrawing/withholding life-sustaining treatments.[cxvii] He must also remind his patient that she is free to withdraw her request at any time, nor is she bound to her decision and that she can simply not take the prescription.[cxviii]

Furthermore, the prescribing physician must ensure that the patient’s decision is informed and voluntary, both when making the request, and immediately prior to writing the prescription. If either physician consulted in the case deems the patient’s ability to make an informed decision to be impaired, or that there is a strong underlying mental illness affecting the decision, she must undergo a psychiatric or psychological evaluation. In Hawaii the evaluation is mandatory for all patients seeking PAD.[cxix] This tenet is objective, in that there is not one standard to determine whether depression is a driving force in a terminally ill patient’s reason for seeking PAD. As a result, many critics believe PAD can lead to abuse and cite that as a reason to oppose PAD legislation. This is the basis from which opponents claim that patients will “physician shop” if they are repeatedly turned down from the procedure.

Once the patient is aware of the potential risks associated with her decision, states further require patients to make an initial oral request for PAD participation. To legally meet the requirements of the first oral request, the patient should ask the physician to record the request for PAD in her medical record.[cxx] Once the first oral request is made and recorded, a patient must wait at least fifteen to twenty days to lodge a second request. [cxxi] She must also submit a written request, signed by two witnesses, which can be done at any point in the process. [cxxii]

After a physician receives the written request, Hawaii, Maine, New Jersey, Oregon, Vermont, Washington State, and Washington D.C. mandate the physician waits at least 48 hours before writing the prescription, while California and Colorado do not require a waiting period. [cxxiii] The patient may fill the prescription whenever she wants; there is no waiting period once the physician writes it. California and Hawaii law, however, require the patient to fill out two Final Attestation Forms once again affirming that the patient has made an informed and voluntary decision. One form should be filled out 48 hours before taking the medication, and another 48 hours after taking the medication.[cxxiv]
Once the patient has obtained her prescription; she is free to take it or discard it. Over a third of patients in Oregon who do acquire an aid-in-dying prescription do not end up taking it, but rather die naturally from the disease (for various reasons).[cxxv] If a patient elects not to ingest the medication, one study in Oregon concluded that even patients who obtained a prescription but did not consume it “realize[d] an improvement in their quality of life from the sense of control that comes with mere receipt … of the prescription.”[cxxvi] If the patient does elect to ingest the medication, a physician must warn her of the potential side effects, including nausea and the possibility that it will fail.[cxxvii]

Taking the medication is a two-step process. First of all, in order to qualify for current PAD treatments, the patient must be able to self-administer the medication.[cxxviii] Because Kevorkian’s patient was seemingly unable to self-administer, Kevorkian himself stepped in and that is when he performed euthanasia, rather than an assisted death. Today, taking a prescribed lethal dose of medication involves mixing the prescribed barbiturate with water and drinking it within it thirty seconds to two minutes to ensure she does not fall asleep before ingesting the full lethal dose.[cxxix] Typically, the patient will fall asleep within ten minutes and dies within three hours.[cxxx]

The process is entirely voluntary, and physicians must remind patients at every stage that they are free to change their mind at any point. Many people who seek PAD are comforted in knowing that it is an opportunity to regain control over a disease that has taken away their autonomy. Despite what some opponents believe, people are not forced or coerced into assisted dying programs by physicians — in fact, family members are more likely to act maliciously towards the end of life and more precautions need to be taken to prevent instances of abuse.

IX. What Should be Done to Improve Physician-Assisted Dying

Though assisted dying programs should be legal across the country and states with existing laws are acting in the patient’s best interest, the existing laws are not perfect. The criticisms of PAD come from places of genuine concern, and the government should address those concerns to the best of its abilities to ensure that there the public can actually consider PAD a viable end-of-life treatment.

In order to properly educate the public about assisted dying, physicians must understand the process first. First and foremost, one physician complains that the PAD is barely accessible for willing physicians. He says that current PAD laws “make no provision for medical training, there is no formal system, [he] believe that is one of the major barriers and a shortcoming of the law in every state where it is legal.”[cxxxi] If a physician is unable to completely understand the process, including the factors associated with the decision making, and even choosing what narcotics to prescribe, he cannot properly assist a patient seeking assisted death to the best of his abilities. Therefore, any newly proposed law should create a state-training program that instructs physicians on the proper protocols surrounding PAD, if they choose to partake.

Protocols for PAD should also be reinforced to ensure no cases of abuse from either party are possible. To do this, states should follow Hawaii’s lead and mandate a psychiatric screening prior to beginning the process. Not only will this prevent people driven by depression from seeking PAD, but it might remove the stigma society has on conversations surrounding mental health and death. By mandating screenings, those concerned with expansion of PAD programs can be assured that physicians will not seek out patients to put to death. At the same time, though, the program should become less restrictive and accept a wider range of patients.

Sometimes physicians refuse to participate in PAD because they cannot accurately determine how long a patient has to live. As a result, some people who are truly suffering from a terminal illness are refused the comfort of assisted death and forced to live the rest of their life with a debilitating disability. The program should also re-think its stance on disability, in that disability rights groups feel the process both excludes and coerces disabled people into participating.

Assisted dying laws should not ban disabled people solely on the basis of their disability, especially if the characteristics of that disability contribute to a terminally ill person’s eligibility.

Assisted dying programs exist to ensure that patients who are suffering near the end of their lives have all available options open to them; but the stipulation that patients must be near the end of life to be suffering is offensive to disabled people. Criteria for PAD must either become more specified, removing discriminatory language, or the process should become less stringent, allowing for non-terminally ill patients, even those who simply have life-altering disabilities to participate.

X. Conclusion: PAD is Beneficial and Should be Legal

Physician-assisted dying laws should be legal throughout the county in order to inform patients of all their options when it comes to considering end-of-life care. Offering PAD services not only comforts patients in knowing that they have the option available to them if they want, but forcing people to have conversations about death has led to “more comprehensive” communication between patients, their, physicians, and family.[cxxxii] Furthermore, the costs associated with PAD are miniscule when compared with medical debt in the United States. Patients or their insurance simply pay for the life-ending medication, rather than several months’ worth of medical bills. [cxxxiii] Additionally, when a patient participates in PAD, the cause of death of her death certificate is her terminal illness, not assisted death, therefore not affecting any life insurance policies she might have.[cxxxiv] Though financial strain is not one of the most influential factors in coming to the decision to pursue PAD, patients have cited it as a concern.[cxxxv]

Opposition to assisted dying comes in the form of religious and moral justifications. Morally, some physicians view withdrawing life-sustaining treatments as a humane form of PAD. They believe that removing a patient’s breathing and feeding tubes a simply letting the patient die is more moral than providing their patient with a medication that she can take to end her life at any time. Some opponents intertwine religion and medicine, basing their criticisms on unproven claims and enforcing the notion that ending life at any stage is a sin. While other opponents fear widespread euthanasia as an eventual consequence of legalizing assisted dying laws. Progress made in the 1990’s shows that the majority of the country has a favorable opinion of assisted suicide and agrees that it should be offered as a viable option when discussing end-of-life treatment options.

[i] Death with Dignity, Death with Dignity Legislation https://www.deathwithdignity.org/faqs/#laws

[ii] Death with Dignity, Death with Dignity Legislation https://www.deathwithdignity.org/faqs/#laws

[iii] Death with Dignity, Terminology https://www.deathwithdignity.org/terminology/

[iv] Suicide, OED Online, Oxford University Pres, https://www-oed-com.proxy.binghamton.edu/view/Entry/193692?rskey=e3VL1l&result=1&isAdvanced=false

[v] Healthline, 6 Suicide Questions You Weren’t Sure How to Ask (Dec. 16 2019) https://www.healthline.com/health/why-do-people-commit-suicide#suicide-causes

[vi] Ailbhe Spillane, et al., What are the physical and psychological health effects of suicide bereavement on family members? An observational and interview mixed-methods study in Ireland, British Medical Journal, 2018 at 4. https://bmjopen.bmj.com/content/bmjopen/8/1/e019472.full.pdf

[vii] Guy Maytal and Theodore Stern, The Desire for Death in the Setting of Terminal Illness: A Case Discussion, 299 Prim Care Companion J Clin Psychiatry (2006) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1764532/pdf/i1523-5998-8-5-299.pdf

[viii] Assisted Suicide, OED Online, Oxford University Press, https://www-oed-com.proxy.binghamton.edu/view/Entry/11957?redirectedFrom=assisted+suicide#eid36684867

[ix] [ix] Linda Garzini, et al., Mental Health Outcomes of Family Members of Oregonians Who Request Physician Aid in Dying, J. Of Pain and Sympton Management 812 (2009) https://www.sciencedirect.com/science/article/pii/S0885392409007076

[x] How Death with Dignity Laws Work: Going Through the Process of Obtaining Medications, Death with Dignity https://www.deathwithdignity.org/learn/access/

[xi] Linda Ganzini, et al., Oregonians’ Reasons for Requesting Physician Aid in Dying. Arch Intern Med. 490 (2009) https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/414824 490

[xii] Id.

[xiii] Elizabeth Trice Loggers, et al. Implementing a Death with Dignity Program at a Comprehensive Cancer Center, New Eng. J. Med. 1421 (2013) https://www.nejm.org/doi/pdf/10.1056/NEJMsa1213398?articleTools=true

[xiv] Id.

[xv] Id.

[xvi] Garzini, et al., supra, at 810.

[xvii] Id. At 812

[xviii] Id. At 811

[xix] Californians for Compassionate Choices: ‘’Suicide’’ is Inaccurate…, BusinessWire, https://www.businesswire.com/news/home/20050928005759/en/Californians-Compassionate-Choices-Suicide-Inaccurate-Biased-Term

[xx] American Medical Association, AMA principles of medical ethics: Assisted Suicide https://www.ama-assn.org/delivering-care/ama-principles-medical-ethics

[xxi] Compassion & Choices, Understanding Medical Aid in Dying https://compassionandchoices.org/end-of-life-planning/learn/understanding-medical-aid-dying/

[xxii] Ewan Goligher, et al., Physician-Assisted Suicide and Euthanasia in the ICU: A Dialogue on Core Ethical Issues. Critical Care Medicine. 2 (2017) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5245170/pdf/nihms768538.pdf

[xxiii] Voluntary and Involuntary Euthanasia, BBC (2014) http://www.bbc.co.uk/ethics/euthanasia/overview/volinvol.shtml

[xxiv] Goligher, supra, at 2 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5245170/pdf/nihms768538.pdf

[xxv] Michael Berenbaum, T4 Progam: Nazi policy, Britannica (Feb 16 2001) https://www.britannica.com/event/T4-Program

[xxvi] Legal Information Institute, Mercy Killing, Cornell University (June 2020) https://www.law.cornell.edu/wex/mercy_killing

[xxvii] Id.

[xxviii] Goligher, supra, at 2 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5245170/pdf/nihms768538.pdf

[xxix] Legal Information Institute, Mercy Killing.

[xxx] Cruzan by Cruzan v. Dir., Missouri Dep’t of Health, 497 U.S. 261, 110 S. Ct. 2841, 111 L. Ed. 2d 224 (1990)

[xxxi] Id. At 280

[xxxii] Withholding or Withdrawing Life-Sustaining Treatment, AMA https://www.ama-assn.org/delivering-care/ethics/withholding-or-withdrawing-life-sustaining-treatment

[xxxiii] Stephanie Cooper, Taking No for an Answer: Refusal of Life-Sustaining Treatment, 12 American Medical Association Journal of Ethics 6, 444, 446 (June 2010) https://journalofethics.ama-assn.org/sites/journalofethics.ama-assn.org/files/2018-06/ccas2-1006.pdf

[xxxiv] Mark A. O’Rourke, et al. Reasons to Reject Physician Assisted Suicide/Physician Aid in Dying. Am. Society of Clincial Oncology J. 683 (2017) https://ascopubs.org/doi/pdf/10.1200/JOP.2017.021840

[xxxv] Melinda Lee, et al., Legalizing Assisted Suicide — View of Physicians in Oregon, 311–12 The New England Journal of Medicine (Feb. 1996) https://www.nejm.org/doi/pdf/10.1056/NEJM199602013340507?articleTools=true

[xxxvi] Anne-Marie Begley, Acts, omissions, intentions and motives: A philosophical examination of the moral distinction between killing and letting die, 865, 866 Journal of Advanced Nursing 28 (1998) https://onlinelibrary-wiley-com.proxy.binghamton.edu/doi/epdf/10.1046/j.1365-2648.1998.00700.x

[xxxvii] Raanan Gillon, Acts and omissions, killing and letting die, British Medical Journal vol. 292 (Jan. 1986) https://www.bmj.com/content/bmj/292/6513/126.full.pdf

[xxxviii] Melina Lee, et al., Legalizing Assisted Suicide — View of Physicians in Oregon at 311., O’Rourke, supra, at 683.

[xxxix] Jonel Aleccia, Legalizing Aid in Dying Doesn’t Mean Patients Have Access To it, NPR (Jan. 25 2017) https://www.npr.org/sections/health-shots/2017/01/25/511456109/legalizing-aid-in-dying-doesnt-mean-patients-have-access-to-it

[xl] Washington Department of Health, 2014 Complaint https://www.documentcloud.org/documents/3382239-DOH-Complaint.html

[xli] Olga Khazan, Brittany Maynard and the Challenge of Dying with Dignity, The Atlantic (Nov. 3, 2014) https://www.theatlantic.com/health/archive/2014/11/brittany-maynard-and-the-challenge-of-dying-with-dignity/382282/

[xlii] Aleccia, Legalizing Aid in Dying Doesn’t Mean Patients Have Access To it

[xliii] This study was conducted before the law went into effect; its constitutionality was under appeal at the time.

[xliv] Melina Lee, et al., Legalizing Assisted Suicide — View of Physicians in Oregon at 311.

[xlv] Id. At 311–12.

[xlvi] Id. At 312.

[xlvii] O’Rourke, supra, at 685, 686.

[xlviii] American Medical Association, AMA principles of medical ethics: Assisted Suicide https://www.ama-assn.org/delivering-care/ama-principles-medical-ethics

[xlix] O’Rourke, supra, at 684.

[l] O’Rourke, supra, at 684.

[li] Id.

[lii] Roe v. Wade, 410 U.S. 113, 93 S. Ct. 705, 35 L. Ed. 2d 147 (1973)

[liii] Kim Chandler and Blake Paterson, Alabama governor invokes God in banning nearly all abortions, AP News (May 16, 2019) https://apnews.com/article/7a47ddc761dc4b72a017b0836da3a87b

[liv] Vacco v. Quill, 521 U.S. 793, at 800 (1997).

[lv] Id. At 801.

[lvi] Id. At 801.

[lvii] Id. At 806.

[lviii] Oregon Rev. St. §127.800–127.995

[lix] Elsa Brenner, The Profound Debate on Assisted Suicide, The New York Times (Jul. 13 1997) https://www.nytimes.com/1997/07/13/nyregion/the-profound-debate-on-assisted-suicide.html

[lx] NYS Department of Health, When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context, 49 (May 1994).

https://www.health.ny.gov/regulations/task_force/reports_publications/when_death_is_sought/chap4.htm

[lxi] NYS Department of Health, When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context, 120

[lxii] Id. at 120

[lxiii] Id. at 120

[lxiv] Id. at 685.

[lxv] Roxanne Nelson, Physician-Assisted Dying: Even When Legal, Difficult to Achieve, Medscape (Aug. 21 2019) https://www.medscape.com/viewarticle/917092

[lxvi] Olga Khazan, Brittany Maynard and the Challenge of Dying with Dignity.

[lxvii] Id.

[lxviii] Diane Meier, et al., Characteristics of Patients Requesting and Receiving Physician-Assisted Death, 1541 JAMA 163 (July 14 2003). https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/215798

[lxix] Not Dead Yet Disability Activists Oppose Assisted Suicide as a Deadly Form of Discrimination, Not Dead Yet

[lxx] Disability Rights Education & Defense Fund, Assisted Suicide and Disability https://dredf.org/public-policy/assisted-suicide/assisted-suicide-and-disability/

[lxxi] Not Dead Yet Disability Activists Oppose Assisted Suicide as a Deadly Form of Discrimination, Not Dead Yet

[lxxii]Death with Dignity and People with Disabilities, Death with Dignity https://www.deathwithdignity.org/death-dignity-people-disabilities/

[lxxiii] Id.

[lxxiv] Id.

[lxxv] Not Dead Yet Disability Activists Oppose Assisted Suicide as a Deadly Form of Discrimination, Not Dead Yet https://notdeadyet.org/assisted-suicide-talking-points

[lxxvi] Not Dead Yet Disability Activists Oppose Assisted Suicide as a Deadly Form of Discrimination.

[lxxvii] Id.

[lxxviii] Michael Berenbaum, T4 Progam: Nazi policy.

[lxxix] Not Dead Yet Disability Activists Oppose Assisted Suicide as a Deadly Form of Discrimination, Not Dead Yet https://notdeadyet.org/assisted-suicide-talking-points

[lxxx] Billy Hallowell, Why so many doctors oppose euthanasia and assisted suicide, Deseret News (Aug. 4, 2016) https://www.deseret.com/2016/8/4/20593178/why-so-many-doctors-oppose-euthanasia-and-assisted-suicide

[lxxxi] Kirsten Wier, Assisted dying: The motivations, benefits and pitfalls of hastening death, APA (Dec. 2017) https://www.apa.org/monitor/2017/12/ce-corner

[lxxxii] Id.

[lxxxiii] Ronald Pies, 12 Myths Surrounding Medical Aid in Dying or Physician Assisted Suicide, HCP Live (August 2018) https://www.hcplive.com/view/twelve-myths-concerning-medical-aid-in-dying-or-physicianassisted-suicide

[lxxxiv] Disability Rights Education & Defense Fund, Some Oregon and Washington State Assisted Suicide Abuses and Complications https://dredf.org/public-policy/assisted-suicide/some-oregon-assisted-suicide-abuses-and-complications/

[lxxxv] Danny Scoccia, The Oxford Handbook of Philosophy and Disability Chapter 16 (Adam Cureton and David Wasserman, 2018).

[lxxxvi] Diane Coleman, Assisted Suicide and Disability, Disability Rights Education & Defense Fund. https://dredf.org/public-policy/assisted-suicide/assisted-suicide-and-disability/

[lxxxvii] Margaret Battin, et al., Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in “vulnerable” groups, British Medical Journal 591, 2007.

[lxxxviii] Keith Schneider, Dr. Jack Kevorkian Dies at 83; A Doctor Who Helped End Lives, New York Times (June 3, 2011). https://www.nytimes.com/2011/06/04/us/04kevorkian.html

[lxxxix] Id.

[xc] Id.

[xci] Jack Kevorkian. Capital Punishment or Capital Gain, The Journal of Criminal Law, Criminology, and Police Science 50, no. 1: 50–51 (1959).

[xcii] Id.

[xciii] Lisa Belkin, Doctor Tells of First Death Using His Suicide Device New York Times (June 6, 1990). https://www.nytimes.com/1990/06/06/us/doctor-tells-of-first-death-using-his-suicide-device.html

[xciv] Schneider, Dr. Jack Kevorkian Dies at 83; A Doctor Who Helped End Lives.

[xcv] Belkin, Doctor Tells of First Death Using His Suicide Device

[xcvi] Nicholas Jackson, Jack Kevorkian’s Death Van and the Tech of Assisted Suicide, The Atlantic (June 3 2011). https://www.theatlantic.com/technology/archive/2011/06/jack-kevorkians-death-van-and-the-tech-of-assisted-suicide/239897/

[xcvii] Schneider, Dr. Jack Kevorkian Dies at 83; A Doctor Who Helped End Lives.

[xcviii] Kirk Cheyfitz, The Suicide Machine: Part 1. Kevorkian rushes to fulfill his clients’ desire to die, Detroit Free Press (June 8 2011).

[xcix] How Death with Dignity Laws Work: Eligibility, Death with Dignity https://www.deathwithdignity.org/learn/access#eligibility

[c] Caryn James, CRITIC’S NOTEBOOK; ’60 Minutes,’ Kevorkian and a Death for the Cameras, New York Times (Nov. 23 1998) https://www.nytimes.com/1998/11/23/us/critic-s-notebook-60-minutes-kevorkian-and-a-death-for-the-cameras.html

[ci] Id.

[cii] Schneider, Dr. Jack Kevorkian Dies at 83; A Doctor Who Helped End Lives.

[ciii] Id.

[civ] Id.

[cv] Vacco v. Quill, 521 U.S. 793, at 800 (1997).

[cvi] Death with Dignity, In Your State https://www.deathwithdignity.org/in-your-state/

[cvii] Ahn v. Hestin, E070545 Cal. 4th (2018) https://www.deathwithdignity.org/wp-content/uploads/2015/10/Amicus-Curiae-Brief-Submitted-071818.pdf

[cviii] Compassion and Choices, Groups Praise Dismissal of Lawsuit to Undermine Vermont Patient End-of-Life Law (April 6, 2017) http://campaign.r20.constantcontact.com/render?m=1103606868639&ca=25d4af4f-4c06-4851-84e2-ecce3292ad10

[cix] Paola V. Jaime Saenz, Morris v. Brandenburg: Departing from Federal Precedent to Declare Physician Assisted Suicide a Fundamental Right Under New Mexico’s Constitution, 250 48 N.M. L. Rev. 233 (2018). http://digitalrepository.unm.edu/nmlr/vol48/iss2/4

[cx] Baxter v. State, 2009 MT 449, 354 Mont. 234, 224 P.3d 1211

[cxi] Id. At 251.

[cxii] How Death with Dignity Laws Work: Eligibility, Death with Dignity https://www.deathwithdignity.org/learn/access#eligibility

[cxiii] Id.

[cxiv] Id.

[cxv] Id.

[cxvi] Id.

[cxvii] Id.

[cxviii] Oregon Rev. St. §127.800–127.995

[cxix] Id., HI HB2739 https://www.deathwithdignity.org/wp-content/uploads/2015/10/2018-HI-HB2739.pdf

[cxx] How Death with Dignity Laws Work: Eligibility, Death with Dignity

[cxxi] Id.

[cxxii] Id.

[cxxiii] Id.

[cxxiv] Id. The medication usually puts the patient to sleep within 10 minutes, though. Not sure why they say 48 hours after.

[cxxv] David Orentlicher et al., Clinical Criteria for Physician Aid in Dying, J. of Palliative Medicine, 261 (2016) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4779271/pdf/jpm.2015.0092.pdf Dying before actually getting the medicine, changing their mind, etc.

[cxxvi] Id. (At )

[cxxvii] Id (At)

[cxxviii] Id. At 261

[cxxix] Id. At 261

[cxxx] How Death with Dignity Laws Work: Eligibility, Death with Dignity