Physician-Assisted Dying

The prohibition on health professionals assisting their patients to die stands as

a central tenet of most professional medical associations worldwide and under-

pins many codes of practice and ethics. The ethical and legal underpinnings for

such a prohibition rest primarily on the principles of non-maleficence and

beneficence. Prima facie, to hasten the death of one’s patient irrevocably harms

the interest a person has in continued life and offends against the sanctity of

life. Yet one’s interest in continued life may be trumped by the greater interest

one has in not suffering – something that may only be relieved by death.

In certain qualified circumstances a physician assisting a patient to die is, in

principle and practice, accepted in many countries and jurisdictions around the

world as ethically and legally permissible. The term physician-assisted suicide

(Materstvedt et al., 2003) refers to the practice of a doctor assisting a patient

to die by giving them the means to end their own life at the patient’s explicit

request, and is legally and ethically permitted in five states of the United States:

Oregon (1997), Washington (2008), Montana (2009), Vermont (2013) and

New Mexico (2014). However, the term (physician assisted suicide) is

contentious1: (Quill, 2012) it may be seen to imply that an individual has lost

Correspondence: E-mail: p.malpas@auckland.ac.nz

© 2016 Informa UK Limited, trading as Taylor & Francis Group

Mortality, 2016

Vol. 21, No. 4, 295–304, http://dx.doi.org/10.1080/13576275.2015.1137279

the ability to make rational decisions, and it has associations with mental

ill-health.

The practice of assisting a patient to die by actively and intentionally ending

their life at their explicit request is permitted in some European countries: The

Netherlands (2002), Belgium (2002) and Luxembourg (2008). It is generally

referred to as euthanasia (Materstvedt et al., 2003). All three countries also

permit physician-assisted suicide. The Canadian province of Quebec recently

allowed a law to permit doctors – in qualified circumstances – to administer

and prescribe a lethal dose of drugs to competent patients who requested such

an action (Hivon & Barrette, 2014), and in February 2015, the Supreme Court

of Canada ruled that prohibiting assisted suicide is unconstitutional (Woolf,

2015). Federal and provincial governments have one year to enable legislation

that will respect the Supreme Court ruling. Switzerland (1942) permits assisted

suicide which may or may not be physician-assisted, but prohibits euthanasia

(Griffiths, Weyers, & Adams, 2008). It is illegal in every jurisdiction in the

USA for a doctor directly to assist a patient to die by administering a lethal

dose of medication to them.

Doyal rejects the commonly made moral distinction between active (euthana-

sia) and passive (physician-assisted suicide) acts that hasten death arguing that

there is no relevant difference between them (Doyal & Doyal, 2001). Dworkin

and Frey (Dworkin, Frey, & Bok, 1998) claim that in cases of physician-

assisted suicide and euthanasia, the doctor and patient act together; the two

acts only differ in who acts last. Quill concurs that in the case of physician-

assisted suicide, whilst the patient must be able to take the lethal medication by

their own hand, ‘the prescribing physician is morally and legally responsible as

an accomplice’ (Quill, 2012). For the purposes of this discussion, the practices

of physician-assisted suicide and euthanasia will be referred to as physician-

assisted dying (PAD) as the intention of the patient and the doctor is the

patient’s death.

Intense political and social debate about PAD is currently being played out

in a number of countries around the world, including New Zealand, the UK,

France, Canada, the USA and Australia; however most professional medical

organisations in these countries decline to engage with the topic (Bosshard

et al., 2008) and some are clearly opposed to such practices. The American

Medical Association states that PAD is ‘fundamentally incompatible with the

physician’s role as healer and would pose serious societal risks’.2 The New

Zealand Medical Association3 states that PAD is unethical in both concept and

practice, explicitly stating that even if the law would recognise the legal permis-

sibility of PAD, the association would ‘continue to regard them as unethical’.

In a recent British Medical Journal editorial, three editors supported Lord

Falconer’s Assisted Dying Bill that would allow adults who are expected to live less

than six months, to be provided with medication to end their lives (Delamothe,

Snow, & Godlee, 2014). The British Medical Association remains firmly opposed

to legalising PAD.

296 P. J. Malpas and R. Glynn Owens

In the following discussion we briefly defend the position that the ethical

acceptability of PAD as a last resort option at the end of life is, in principle,

settled. We then critically consider the objection that whilst this may be estab-

lished in principle, PAD is not part of the role of the doctor (Kass, 1989;

Gaylin, Kass, Pellegrino, & Siegler, 1988; Breitbart, 2012) nor the business of

medicine (Randall & Downie, 2010). Whilst we acknowledge the role of other

health professionals within the arena of PAD (Kuhse & Singer, 1993), for the

purposes of this discussion, we focus our attention on the role of doctors.

Ethical Permissibility of PAD

In many countries it is recognised that an adult of sound mind has a legal and

moral right to refuse any medical treatment and to withdraw from existing

medical treatment, even if their decision goes against medical recommenda-

tions, and will hasten their death. Thus for instance, a person may request to

be removed from the dialysis schedule when they determine that the benefits

from dialysis are outweighed by the burdens which such treatments impose on

their quality of life. Philosophically, the principle of respect for individual

autonomy is paramount – a competent adult should not have to endure medical

treatment that he or she believes can no longer benefit him or her (Warnock &

Macdonald, 2009). Individuals have a right to be left alone and ‘to make deci-

sions about his or her own body on any level’ (Morgan & Sutherland, 1998).

The recent death of Brittany Maynard in Oregon highlights an individual’s

right to decide when their quality of life is no longer acceptable to them

(Anonymous, 2014; Angell, 2014). Brittany exercised that right under Oregon’s

Death with Dignity Act which allows physician aid-in-dying.

The creation of an advance care plan with one’s physician or the enactment

of instructions in an advance directive provides individuals with some certainty

about their medical preferences around medical treatment and care at the end

of life and gives further evidence of autonomy’s reach. At times a person’s med-

ical decision-making per their instructions, may hasten their dying (for instance,

the decision not to be resuscitated or to decline certain medications). Such

instructions are generally held to be consistent with both law and ethics and

reflect growing recognition that a humane death is not as simple as managing

pain relief adequately. It entails looking to what the patient says makes their life

meaningful and worth living (Boisvert, 2010).

The significance and centrality of respecting the autonomous decisions of

individuals near the end of life, underpins the argument for the ethical permis-

sibility of PAD as a last resort option at the end of life. The argument has been

strongly advanced that there is no valid ethical distinction between the actions

of a doctor who complies with a competent patient’s request to be removed

from ventilator support (and the patient dies), and the same doctor who admin-

isters a competent terminally ill patient an assisted death (on request) via a

lethal injection (Rachels, 1974; Brock, 2001).

Physician-assisted dying is ethical 297

Assuming for the sake of argument that this view is reasonably settled, it still

leaves unresolved whether such actions are part of a doctor’s role, or an

extension of it. It is in this direction that we now turn.

The role of the doctor

Although it might be argued that involvement in assisted dying runs contrary to

the fundamental role of the doctor, (that of healing and preserving life), such

an argument becomes difficult to sustain when closely examined. A simple

approach to arguing this would be to assert that the deliberate ending of a

patient’s life is in breach of the medical practitioner’s ‘Hippocratic Oath’. In

answering such an objection one might most obviously call into question the

relevance to the present day of a policy thought to date back some twenty-five

centuries. What was appropriate in the times of the Ancient Greeks cannot sim-

ply be assumed to be similarly appropriate in the twenty-first Century. Indeed,

a moment’s reflection will illustrate that in any case the injunctions of the oath

have already been overridden with respect to practices such as surgery and

abortion – and it is unlikely that many medical practitioners regard, as the Oath

directs, the children of their teachers as brothers, nor is it common practice to

provide instruction in medicine free of charge to these ‘brothers’. Appealing as

it may be to cede the profession’s autonomy to one of its early practitioners, to

do so would be no more logical than to expect modern chemists to have their

practice guided by that of the alchemists.

Recent discussions of the role of the doctor have recognised both the changes

in the problems for which doctors provide treatment (baldness, sexual dysfunc-

tion, antisocial behaviours (Caddell & Newton, 1995)), and in the societal con-

text within which their services are delivered. Thus we find in the modern

literature assertions such as:

The proper role for the physician is to provide care’ that is, to preserve the human essence of their patients and assert the unique human possibility of experiencing meaning even in the last moments of life, while providing ame- lioration of suffering, and respecting the autonomy of patients to refuse or stop life prolonging measures. (Breitbart, 2012)

The medical ethos entails respecting the patient’s autonomy and well inten- tioned decision-making, accompanying him or her in situations in which heal- ing has become impossible, and taking into account his or her personal values and priorities. (Martin, Mauron, & Hurst, 2011)

Neither quote necessarily defends PAD per se; both however articulate power-

fully the contemporary role of the doctor and the significance of respecting

patient autonomy. We argue that PAD has a place in medical care at the end

of life when a patient’s personal values and priorities are taken into account.

Thus such practices are entirely consistent with the doctor’s role.

298 P. J. Malpas and R. Glynn Owens

Within the context of discussion on PAD, other commentators argue that

assisted dying has no legitimate place in a doctor’s practice (xxx, 2014;

Marcoux, 2010; Kass, 1992). Randall and Downie claim the involvement of

doctors as decision-makers in the practices of euthanasia and assisted suicide

flatly contradict what it means to be a doctor (Randall & Downie, 2010).

Others take a more neutral stance, leaving the decision to proceed (or not) with

a request for an assisted death with the doctor. Under this view, such involve-

ment becomes a conscientious decision, concerned with one’s own moral or

religious code as it is with other factors such as the depth of one’s relationship

with the patient (much like the provision of abortion and sterilisation services).

Despite this, there is clearly a significant minority within the profession who

do not see assisted dying as fundamentally incompatible with their role, given

that they are willing to perform such acts even when illegal (Mitchell & Owens,

2004; Kuhse, Singer, Baume, Clark, & Rickard, 1997; Van Der Maas, Van

Delden, Pijnenborg, & Looman, 1991; Taylor, 2015; Malpas, Mitchell, &

Koschwanez, 2015).

It appears then, that the current debate involves a range of assertions regard-

ing the ‘proper’ role of the doctor, together with observations of actual practice;

these two do not always remain entirely concordant. Before asking what is the

appropriate role of the doctor it might justifiably be asked ‘who is do decide?’

Clearly, in any individual case then, the individual has a reasonable entitlement

to refuse to take part in any act which would be contrary to their own deeply

held principles. Similarly it is reasonable to expect that practitioners would have

some rights to restrict the activities of their colleagues when they had good evi-

dence or reason to expect that these activities would impact on themselves (e.g.

by affecting their own relationship to their patients). Unlike the first example,

though, where a case could be argued simply for ‘opting-out’ without any need

for greater justification than ‘… it’s against my principles …’, it is arguably only

fair that an attempt to impose those principles on others should require a rea-

sonably rigorous standard of evidence in support of the case being made. Thus,

in a situation where some practitioners are willing to provide assistance in dying

and others are not, then it is likely that this will, to some extent, influence

patients’ choice of physician. But arguably it is better for everyone concerned if

physicians and patients hold similar views to each other; a patient who does

not believe in contraception or abortion may feel more comfortable with a doc-

tor whose views are concordant with their own, and vice versa. Certainly there

is no reason to assume that any existing good relationship between a doctor

who does not believe in assisted dying and a patient who shares those beliefs

will be affected by knowing that on the other side of town there is another doc-

tor who provides assistance in dying to patients who support such practices. At

the very best, the argument that ‘the profession providing euthanasia will

destroy the doctor–patient relationship’ can only be used to justify individuals

refusing to become involved in assisted dying where they feel it will affect their

own relationships. It cannot be used to justify preventing others from providing

such services (Buchalter, 2009).

Physician-assisted dying is ethical 299

Impact on other professional areas

Perhaps a more legitimate concern regarding the provision of assisted dying is

that the legalisation of euthanasia could lead to a diminution of other services

provided at the end of life – in particular that it might result in lack of support

for palliative care, or adversely affect the quality of palliative care services. Such

arguments might be seen to have an intuitive appeal – surely, it could be

argued, governments will opt for the cheaper alternative of assisted dying rather

than investing money in/on palliative care services? This argument, however,

involves an assumption that palliative care and assisted dying are alternatives,

and that more of one will somehow involve less of the other. Yet both logic

and experience suggest that this assumption is unwarranted. In countries where

legislation permits any form of assisted dying, there is a consistent requirement

that before assistance can be given, all other options must be considered.

Clearly if palliative care is a reasonable and effective alternative to assisted

dying in a particular case, this can only be considered if resources are available.

Logically, if it is considered that palliative care might be an alternative course

of action, assistance in dying could not legally be provided until this had been

offered.

In practice, the evidence is clear that the palliative care/assisted dying pairing

is not in any sense a dichotomy, and there is evidence that both can coexist

effectively (Bernheim et al., 2008; Bernheim, Distelmans, Mullie, & Ashby,

2014b), both in countries where assisted dying is legal and those where it is not

(Saunders, 2008). In New Zealand, for example, the overwhelming majority of

physicians who admitted (illegally) helping their patients to die had access to

palliative care services (Mitchell & Owens, 2004; Malpas et al., 2015); clearly

the availability of such services is not seen as meeting the needs of every termi-

nally ill patient. Nor does the provision of legally accepted assistance in dying

impair the development of palliative care; in the Netherlands and Belgium, for

example, there has been a substantial increase in the availability of palliative

care services in the years during which euthanasia has been available (Bernheim

et al., 2014b; Bernheim, Chambaere, Theuns, & Deliens, 2014a). Evidence

from both Oregon and Washington states show that the majority of individuals

who used the Death With Dignity Act to end their lives were enrolled in hos-

pice or palliative care (Washington State Department of Health, 2013; Oregon

Government, 2014). Moreover, professional ‘high care’ hospices in the Nether-

lands, whilst not providing euthanasia themselves, will refer patients who insist

to an institution which does. Thus, it is possible to provide specialist palliative

care whilst at the same time accepting a patient’s right to assistance in dying.

Clearly, the assumption that palliative care and assisted dying are opposed is

questionable in terms of practical experience.

A further concern that society’s trust in the medical profession and the doc-

tor–patient relationship would be undermined were PAD to be legally permit-

ted (Saunders, 2008) needs further elucidation. The doctor’s obligations of

trust and seeking the patient’s good are a central component of the role and

300 P. J. Malpas and R. Glynn Owens

underpin a defining aspect of the medical profession (Australian Medical

Association, 2011; New Zealand Medical Association, 2011). This is especially

so at the end of life where individuals and their families may be particularly

vulnerable.

Sobel (Sobel, 1996) claims that the role of the doctor is to advocate for the

patient, ‘fighting against disease regardless of transitory pain, depression or

fear’. According to Sobel, that sacred trust is predicated on the conviction that

the doctor is a ‘stalwart ally’ of the patient. To permit PAD, it is argued, is to

thwart the advocacy role and abandon the fight, resulting in a loss of trust or

confidence. Others concur, agreeing that patients will struggle to believe that

doctors have their best interests at heart when they (doctors) are permitted to

end the lives of their patients (Gaylin et al., 1988; Pellegrino, 1992). However

this vision of medicine is inherently paternalistic, lying within a tradition of

medicine that posits that the doctor knows best and will do everything to sus-

tain life. Yet far from undermining trust, the doctor who ‘listens carefully to

the expressed desires of a patient and then honestly responds in conformity to

those desires would most likely be a physician that gains, rather than loses

patient trust’ (Momeyer, 1995; Sumner, 2011).

Furthermore studies conclude that the public (Lindblad, Lofmark, & Lynoe,

2009; Hall, Trachtenberg, & Dugan, 2005; Graber, Barceyi, Robertf, &

Roberta, 1996), and patients (Graber et al., 1996), do not believe PAD will

erode trust in medical services; for instance one study found that trust in medi-

cal services would increase if PAD were legally available at the end of life

(Lindblad et al., 2009).

Conclusion

In principle and in practice, physician-assisted dying is legally available and

ethically sanctioned in a number of jurisdictions around the world. Here, the

doctor is pivotal in both the practice of euthanasia and assisted suicide, and

such practices are viewed as part of the role in much the same way that prac-

tices such as abortion and sterilisation are regarded. Furthermore in countries

where such practices are illegal, evidence shows that some physicians assist

their patients to die, confirming the view that physicians themselves consider

such assistance as part of their role in caring for patients at the very end of life.

Over the past decade many jurisdictions have allowed PAD in qualified cir-

cumstances, recognising that for a small number of patients, a medically

assisted death aligns with the role and responsibilities doctors have towards

their patients at the end of life.

Of course, a case can be made that certain actions may be inappropriate as

part of a doctor’s role even if legally authorised and actually practised by some

practitioners in different countries or times. Perhaps the most obvious of these

is the involvement of doctors in the death penalty – an action which may be

legal and indulged in by some, but which nonetheless could be (and by many

medical organisations is) seen as an entirely inappropriate role. There is here,

Physician-assisted dying is ethical 301

however, a critical difference, in that the person being executed is not in any

meaningful sense a patient of the physician concerned. Etymologically the term

‘patient’ itself indicates a person who is suffering, and the practice of medicine

is arguably one directed towards the relief of such suffering. In the case of capi-

tal punishment, a patient is not being treated, and whilst medical skills are

being used, what is being practised is not medicine. In the case of assisted

dying, the person is indeed a patient, is indeed suffering, and the application of

medical skills in the relief of such suffering can be seen as entirely consistent

with the doctor’s role qua doctor. Seen together with societal changes that prioritise the autonomy and interest

of individuals, and recognising that many of the concerns predicted in the wake

of PAD being legalised have not, in those countries which have legalised it,

been realised, we conclude there is no strong argument, in principle, which

precludes assistance in dying from being part of a doctor’s role.

Disclosure statement

Phillipa J. Malpas declares that she is a member of the End-of- Life Choice Voluntary Euthanasia Society of NZ. Both authors declare no financial conflicts of interest.

Funding

Phillipa J. Malpas’s research has been generously supported by a grant from the Health Research Council of New Zealand (Grant number 12/657). The funding source had no involvement in the study design, research, and in the writing of the article or in the decision to submit it for publication

Notes

[1] Those who object to its use claim that the focus should not be on the physician who pro- vides the lethal means, rather it should remain on the patient who makes an informed deci- sion both to request a lethal dose of medication and take it at a time of his/her choosing. Moreover in the jurisdictions noted above, the doctor is not legally required to be with the patient when they self-administer the lethal medication, further distancing the doctor from the patient’s death. Finally, the term is not used in Oregon, Washington or Vermont Death with Dignity laws.

[2] http://www.ama-assn.org//ama/pub/physician-resources/medical-ethics/code-medical-ethics/ opinion2211.page.

[3] http://www.nzma.org.nz/policies/advocacy/position-statements/euthanasia.

REFERENCES

ANGELL, M. (2014). The Brittany Maynard effect: How she is changing the debate on assisted dying. The Washington Post, from http://www.washingtonpost.com/opinions/the-brittany-maynard- effect-how-she-is-changing-the-debate-on-assisted-dying/2014/10/31/efc75078-5df0-11e4-8b9e- 2ccdac31a031_story.html.

ANONYMOUS. (2014). A terminally ill US cancer sufferer says goodbye and ends her life legally. The New Zealand Herald.

AUSTRALIAN MEDICAL ASSOCIATION. (2011). Role of the Doctor – 2011. Retrieved November, 2014, from https://ama.com.au/position-statement/role-doctor-2011

302 P. J. Malpas and R. Glynn Owens

BERNHEIM, J. L., DESCHEPPER, R., DISTELMANS, W., MULLIE, A., BILSEN, J., & DELIENS, J. (2008). Development of palliative care and legalisation of euthanasia: Antagonism or synergy? BMJ, 336, 864–867.

BERNHEIM, J. L., CHAMBAERE, K., THEUNS, P., & DELIENS, L. (2014a). State of palliative care development in European countries with and without legally regulated physician-assisted dying. Health Care, 2, 10–14.

BERNHEIM, J. L., DISTELMANS, W., MULLIE, A., & ASHBY, M. A. (2014b). Questions and answers on the Belgian model of integral end-of-life care: experiment? prototype? Journal of Bioethical Inquiry , 11, 1–23.

BOISVERT, M. (2010). Should physicians be open to euthanasia?: YES. Canadian Family Physi- cian, 56, 320–322.

BOSSHARD, G., BROECKAERT, B., CLARK, D., MATERSTVEDT, L. J., GORDIJN, B., & MULLER-BUSCH, H. C. (2008). A role for doctors in assisted dying? An analysis of legal regulations and medi- cal professional positions in six European countries. Journal of Medical Ethics, 34, 28–32.

BREITBART, W. (2012). The physician’s role in physician-assisted suicide. Palliative & Supportive Care, 10, 237–239.

BROCK, D. (2001). Medical decisions at the end of life. In H. KUHSE & P. SINGER (Eds.), A companion to bioethics (pp. 261–273). Malden: Blackwell Publishing Ltd.

BUCHALTER, M. (2009). Committee for ethical issues in medicine. Clinical Medicine, 9, 195. CADDELL, D. P., & NEWTON, R. R. (1995). Euthanasia: American attitudes toward the

physician’s role. Social Science & Medicine, 40, 1671–1681. DELAMOTHE, T., SNOW, R., & GODLEE, F. 2014. Why the Assisted Dying Bill should become law

in England and Wales. BMJ, 349, g4349. DOYAL, L., & DOYAL, L. (2001). Why active euthanasia and physician assisted suicide should be

legalised. BMJ, 323, 1079–1080. DWORKIN, G., FREY, R., & BOK, S. (1998). Euthanasia and physician-assisted suicide. New York,

NY: Cambridge University Press. GAYLIN, W., KASS, L. R., PELLEGRINO, E., & SIEGLER, M. (1988). Doctors must not kill’. JAMA,

259, 2139–2140. GEORGE, R. (2014). We must not deprive dying people of the most important protection. BMJ,

349, g4311. GRABER, M., BARCEYI, L., ROBERTF, W., & ROBERTA, O. (1996). Patients’ views about physician par-

ticipation in assisted suicide and euthanasia. Journal of General Internal Medicine, 11, 71–76. GRIFFITHS, J., WEYERS, H., & ADAMS, M. (Eds.). (2008). Euthanasia and the law in Europe.

Oxford: Hart Publishing. HALL, M., TRACHTENBERG, F., & DUGAN, E. (2005). The impact on patient trust of legalising

physician aid in dying. Journal of Medical Ethics, 31, 693–697. HIVON, V., & BARRETTE, G. (2014). Bill 52 An Act respecting end-of-life care. Quebec, Canada:

Quebec Official Publisher. KASS, L. R. (1989). Neither for love nor money: why doctors must not kill. Public Interest,

94, 25–46. KASS, L. R. 1992. “I will give no deadly drug.” Why doctors must not kill. Bulletin of the American

College of Surgeons, 77, 6–17. KUHSE, H., & SINGER, P. (1993). Voluntary euthanasia and the nurse: An Australian survey.

International Journal of Nursing Studies, 30, 311–322. KUHSE, H., SINGER, P., BAUME, P., CLARK, M., & RICKARD, M. (1997). End-of-life decisions in

Australian medical practice. Medical Journal of Australia, 166, 191–296. LINDBLAD, A., LOFMARK, R., & LYNOE, N. (2009). Would physician-assisted suicide jeopardize

trust in the medical services? An empirical study of attitudes among the general public in Sweden. Scandinavian Journal of Public Health, 37, 260–264.

MALPAS, P. J., MITCHELL, K., & KOSCHWANEZ, H. (2015). End-of-life medical practices in general practice in New Zealand – 13 years on. NZMJ, 128, 29–36.

MARCOUX, H. (2010). Should physicians be open to euthanasia?: NO. Canadian Family Physician, 56, 321–323.

MARTIN, A. K., MAURON, A., & HURST, S. A. (2011). Assisted suicide is compatible with medical ethos. The American Journal of Bioethics, 11, 55–57.

Physician-assisted dying is ethical 303

MATERSTVEDT, L. J., CLARK, D., ELLERSHAW, J., FORDE, R., BOECK GRAVGAARD, A. M., MULLER-BUSCH, H. C., … RAPIN, C. H. (2003). Euthanasia and physician-assisted suicide: A view from an EAPC Ethics Task Force. Palliative Medicine, 17, 97–101.

MORGAN, R. C., & SUTHERLAND, D. D. (1998). Society’s search for a legal and ethical basis of physician-assisted suicide. Journal of Aging & Social Policy, 9, 51–70.

NEW ZEALAND MEDICAL ASSOCIATION. (2011). Concensus statement on the role of the doctor in New Zealand. Retrieved November, 2014, from https://www.nzma.org.nz/__data/assets/pdf_ file/0006/16980/Consensus-statement-on-the-role-of-the-doctor-in-New-Zealand-November- 2011.pdf

OREGON GOVERNMENT. (2014). Division 9 – Reporting Requirements of the Oregon Death with Dignity Act. Retrieved November, 2014, from http://public.health.oregon.gov/ProviderPart nerResources/EvaluationResearch/DeathwithDignityAct/Pages/oars.aspx

PELLEGRINO, E. D. (1992). Doctors must not kill. Journal of Clinical Ethics, 3, 95. QUILL, T. E. (2012). Physicians should ‘assist in suicide’ when it is appropriate. Journal of Law,

Medicine & Ethics, 40, 57–65. RACHELS, J. (1974). Active and passive euthanasia. The New England Journal of Medicine,

292, 78–80. RANDALL, F., & DOWNIE, R. (2010). Assisted suicide and voluntary euthanasia: role contradic-

tions for physicians. Clinical Medicine, Journal of the Royal College of Physicians, 10, 323–325. SAUNDERS, J. (2008). What do physicians think about physician assisted suicide and voluntary

euthanasia? Clinical Medicine, 8, 243–245. SOBEL, B. E. (1996). Doctor-assisted suicide – an insidious malapropism undermining trust.

Coronary Artery Disease, 7, 265–266. SUMNER, L. W. (2011). Assisted death. A study in ethics and law. New York: Oxford University

Press. TAYLOR, C. (2015, July 8). GPs admit to helping patients die, amid calls for law change. New

Zealand Doctor 20. VAN DER MAAS, P. J., VAN DELDEN, J. J. M., PIJNENBORG, L., & LOOMAN, C. (1991). Euthanasia

and other medical decisions concerning the end of life. The Lancet, 338, 669–674. WARNOCK, M., & MACDONALD, E. (2009). Easeful death. Is there a case for assisted dying? Oxford:

Oxford University Press. WASHINGTON STATE DEPARTMENT OF HEALTH. (2013). Washington State Department of Health

2013 Death with Dignity Act Report, Executive Summary. Retrieved November, 2014, from http://www.doh.wa.gov/portals/1/Documents/Pubs/422-109-DeathWithDignityAct2013.pdf

WOOLF, N. (2015, February 6). Canada’s highest court strikes down ban on doctor-assisted dying. The Guardian. Retrieved from http://www.theguardian.com/world/2015/feb/06/cana das-strikes-down-ban-doctor-assisted-dying: Guardian News and Media Limited

MITCHELL, K., & OWENS, G. (2004). End of life decision-making by New Zealand general practi- tioners: A national survey. New Zealand Medical Journal, 117, U934.

MOMEYER, R. (1995). Does physician assisted suicide violate the integrity of medicine? Journal of Medicine and Philosophy, 20, 13–24.

Biographical Notes

Phillipa Malpas works as a clinical medical ethicist at the Auckland School of Medicine, Univer- sity of Auckland. She is interested in the ethical dimension of death and dying, particularly around individuals’ attitudes towards medical assistance to hasten death, and the way in which these may influence patient’s expectations of medical treatment and care at the end of life.

Glynn Owens is Professor of Psychology at the University of Auckland. A graduate of Brunel University and the University of Oxford, he has previously been Professor of Health Studies at the University of Wales, Professor of Forensic Clinical Psychology at Bangor University and Director of the clinical psychology training programme at the University of Liverpool. His research interests include aspects of end-of-life care, ethics, forensic psychology and the relation- ship between perfectionism and eating problems.

304 P. J. Malpas and R. Glynn Owens