Amicus Curiae Brief — Vacco v. Quill
Supreme Court brief1997
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Nos. 96-110 and 95-1858
IN THE
Supreme Court of the
OCTOBER TERM, 1996
STATE OF WASHINGTON, et al. ,
Petitioners,
vs.
HAROLD D. GLUCKSBERG, M.D., et al.,
Respondents.
DENNIS C. VACCO, ATTORNEY GENERAL OF THE STATE
OF NEW YORK, et al.,
Petitioners,
vs.
TIMOTHY E. QUILL, M.D., et al.,
Respondents.
ON WRITS OF CERTIORARI
TO THE UNITED STATES COURT OF APPEALS
FOR THE SECOND AND NINTH CIRCUITS
BRIEF OF THE WASHINGTON STATE
PSYCHOLOGICAL ASSOCIATION, THE AMERICAN
COUNSELING ASSOCIATION, THE ASSOCIATION
FOR GAY, LESBIAN AND BISEXUAL ISSUES IN
COUNSELING, AND A COALITION OF MENTAL
HEALTH PROFESSIONALS AS AMICI CURIAE
IN SUPPORT OF RESPONDENT
EDWARD C. DUMONT
Of Counsel Counsel of Record
TAMAR FEDER 125 Broad Street
New York, New York 10004
LEE A. THORSON (212) 558-3411
BIRMINGHAM, THORSON
& BARNETT, P.C.
Counsel for the Washington State
Psychological Association
December 10, 1996
QUESTION PRESENTED
Whether a State may prohibit physicians, completely
and under any set of circumstances, from providing mentally
competent, terminally ill adults with the means medically
necessary to choose the manner and timing of their death.
TABLE OF CONTENTS
Page
QUESTION PRESENTED .........-.5eee08. i
TABLE OF AUTHORITIES ..............45. iv
INTEREST OF THE AMICI ............... l
SUMMARY OF ARGUMENT ............... 3
DT Seabees s<abecteececcces 6
Ill. It Is Possible To Assess Whether Or Not A
Terminally Ill Patient Who Has Requested
Assistance In Hastening Death Is Mentally
Competent And Has Made A _ Reasoned,
Informed, And Voluntary Decision To Seek
SD ED 6 6:0 6 6b wee eep ares 10
A. Assessing Capacity to Make Reasoned
ED cccdi ses caus tustaes 10
B. Assessing the Rationality of a Decision . 14
1. “Inherent irrationality” ........ 15
2. Correlation with mental illness ... 19
C. Assessing the Voluntariness of a Decision 25
CUES ccc ccceccecboeseweeuses 30
TABLE OF AUTHORITIES
CASES Page(s)
Addington v. Texas,
Se ED ced eececceseeuen 10, 11, 13
Cooper v. Oklahoma,
See Ge GUE 4 cedecbesetés 10, 11, 13
Cruzan v. Director, Missouri Department of Health et al.
Pe ere ee 11, 14
Medina v. California,
ee 11, 13
Compassion in Dying et al. v. State of Washington et al.,
Oe renee Ce Gee, TED cect ccccecese 6, 21
Quill et al. v. Vacco et al.,
ek yy f . |) Cee 7, 21, 27
STATUTES
Cal. Prob. Code § 812 (West Supp. 1996) ........ 10
Cal. Prob. Code § 813 (West Supp. 1996) ........ 13
Cal. Prob. Code § 1881 (West Supp. 1996) ....... 13
ee ae BOG SE OD cs cc cccecveces 24
BOOKS
American Psychiatric Association, Diagnostic and Statistica
Manual of the Mental Disorders, (4th ed. 1994) . 17, 18
P. Appelbaum and T. Gutheil, Clinical Handbook of
Psychiatry and the Law (2d ed. 1991) ........... 16
M. Battin, The Death Debate: Ethical Issues in Suicide
SPPrerrrrrrrerererrrverererc yy 29
S. Blumenthal and D. Kupfer, eds., Suicide Over The Life
Cycle: Risk Factors, Assessment, And Treatment Of Suicidal
| Freres Te 19, 20
GD wesdéeutvecdcdsebedetsentbeobsueuees 20
S. Jamison, Final Acts of Love: Families, Friends, and
Mamas Gen GGGEe cc ccc co eccesscscns 22, 28
R. Maris, Pathways to Suicide: A Survey of Self-Destructive
Pe Ge c 6 oh ees naeckeseceeeeenes 20
R. Maris et al., Assessment and Prediction of Suicide
SG cho ebaesus bes Caee nbd boue ee eeeen 20
J. Meerloo ed., Suicide and Mass Suicide (1962) . . . . 20
National Association of Social Workers, Social Work Speaks:
NASW Policy Statements (3d ed. 1994) ....... 10, 19
R. Neils, Dying Well Network, Death with Dignity
FAQs (Frequently Asked Questions) (1996) (on file with
Se. 36a kd Ca teeesek eauutesaeee kes 17
ee ae ee 22, 28
N. Peruzzi et al., Ethics and Behavior
Cn iG wt ie aes 5 owe 6 Gb b eee 19
J. Werth, Rational Suicide? Implications for Mental Heath
Prafessiomalis (IS9Q) www es 12, 14, 15, 23, 28
ARTICLES
Annas and Densberger, Competence to Refuse Medical
Treatment: Autonomy vs. Paternalism, 15 U. Tol. L.
Sf PPT TTP Tere TT Teer 12, 13
Appelbaum and Grisso, Assessing Patient’s Capacities to
Consent to Treatment, 319 New Eng. J. Med. 1635
PPT TT TT TEC CTT ETT TTT Tee 12
Appelbaum and Roth, Competency to Consent to Research,
39 Archives of Gen. Psychiatry 951 (1982) ....... 12
Back et al., Physician-Assisted Suicide and Euthanasia in
Washington State: Patient Requests and Physician Responses,
i. vce eke eesaeeebe 29
Baron et al., A Model State Act to Authorize and Regulate
Physician-Assisted Suicide ,
33 Harv. J. on Legis. 1 (1996) ............ 24, 25
Block and Billings, Patient Requests to Hasten Death:
Evaluation and Management in Terminal Care, 154 Archives
of Internal Med. 2039 (1994) ............ 24, 29
Cohen et al., Astitudes Toward Assisted Suicide and
Euthanasia Among Physicians in Washington State, 331 New
Ming. 3. Mad. GD CIDE) 2 ww cece cer cccccces 23
Drane, The Many Faces of Competency, 15 Hastings Center
Report, No. 2, 17 (1985) 2... eee ee es 12
Freedman, Competence, Marginal and Otherwise; Concepts
and Ethics, 4 Int’ J.L. and Psychiatry 53 (1981)... . 12
Ganzini et al., Attitudes of Oregon Psychiatrists Toward
Physician-Assisted Suicide, 153 Am. J. Psychiatry 1469
GED ccc vbeseebese 666s 66 6seebueeewet 23
Holtby, Social Work, Suicide, and Self-Deliverance, |
National Social Work AIDS Network Readings & Writings
*S | |. Brrr rerrrirl oe 15, 28
Jones and Dilley, Rational Suicide and HIV Disease, 8
Focus: A Guide to AIDS Research and Counseling 5 (July
. SPPePrerrT rey ce ee 22
Lester, Easing the Legacy of Suicide: Counselor Assisted
Suicide, in Changes (forthcoming 1997) ........ 28
Patel, Pathology of Suicide, 13 Medicine, Science, and the
Th sf .L: SPREE EEELELEPETree 20
Pope et al., Ethics of Practice: The Beliefs and Behaviors of
~ Psychologists as Therapists, 42 Am. Psychologists 993
STD ccc chet cesar eens een ebds sue bes 23
Quill, Physician-Assisted Death: Progress or Peril?,
24 Suicide and Life-Threatening Behavior 315 (1994) . 21
-Vii-
Quill et al., Proposed Clinical Criteria for Physician-Assisted
Suicide, 327 New Eng. J. Med. 1380 (1992) ...... 15
Roth et al., Tests of Competency to Consent to Treatment,
134 Am. J. Psychiatry 279 (1984) ............. 12
Siegel, Rational Suicide: Considerations for the Clinician, 54
Psychiatric Quarterly 77 (1982)............... 21
Temoche et al., Suicide Rates Among Current and Former
Mental Institution Patients, 138 J. Nervous and Mental
CC os - cco bade 6 & 606868 be & 21
Tepper and Elwork, Competence to Consent to Treatment as
a Psycholegal Construct, 8 Law and Human Behav or 205
Et 5 46 WA 6 6.40 Ue he Oeree’ C6 Ge kOe rae e's 12
Tuckman et al., Emotional Content of Suicide Notes, 116
Am. J. Psychiatry 59 (1959) ............. 20, 21
Werth and Liddle, Psychotherapists’ Attitudes Toward
Suicide, 31 Psychotherapy: Theory, Research and Practice
DE «6 heb weebses £5464 6500860688 23
Brief for the American Suicide Foundation, Amicus Curiae,
Supporting Reversal, State of Washington et al. v.
Glucksberg et al. (Case No. 96-110) ...... 15, 16, 25
-Viii-
IN THE SUPREME COURT OF THE UNITED STATES
OCTOBER TERM, 1996
No. 96-110
STATE OF WASHINGTON, et al., Petitioners,
v.
HAROLD GLUCKSBERG, M.D., et al., Respondents.
No. 95-1858
DENNIS C. VACCO, ATTORNEY GENERAL OF THE
STATE OF NEW YORK, et al., Petitioners,
Vv.
TIMOTHY E. QUILL, et al., Respondents.
ON WRITS OF CERTIORARI TO
THE UNITED STATES COURTS OF APPEALS
FOR THE SECOND AND NINTH CIRCUITS
BRIEF FOR THE WASHINGTON STATE
PSYCHOLOGICAL ASSOCIATION, THE
AMERICAN COUNSELING ASSOCIATION, THE
ASSOCIATION FOR GAY, LESBIAN AND
BISEXUAL ISSUES IN COUNSELING AND A
COALITION OF MENTAL HEALTH
PROFESSIONALS AS AMICI CURIAE SUPPORTING
RESPONDENT
INTEREST OF THE AMICI’
Any consideration of the question before the Court in
this case must involve the related issues of (i) whether a
mentally competent adult patient would ever freely choose to
hasten death, and (ii) whether it is possible to ascertain that
a particular patient is mentally competent, adequately
advised, and has freely made such an irrevocable choice.
The amici are mental health professionals whose training and
experience qualify them to provide the Court with insight on
these important questions.’
The Washington State Psychological Association
(“WSPA”) is a non-profit professional association of
approximately 900 doctoral level psychologists, and other
related mental health practitioners. The WSPA’s mission is
to support, promote and advance the science and practice of
psychology in the public interest. Many WSPA members
work in areas directly affected by the issues raised by
physician-assisted suicide, and confront the problems faced
by terminally ill patients and their families on a regular
basis. WSPA members routinely assess the mental capacity
of patients, including those who are terminally ill and those
contemplating suicide. By reason of the skills, training and
experience of its members, WSPA believes it can provide
meaningful insight into the mental capacity of terminally ill
patients and into the diagnostic and evaluative resources
available to verify such capacity. While the existence of a
constitutional right to die is a legal question beyond the
' This Brief is being filed with the written consent of all parties in
accordance with Sup. Ct. R. 37(2)(a).
? Mental health professionals include psychiatrists, psychologists,
social workers, professional counselors and marriage and family
therapists.
special expertise of WSPA, WSPA hopes to demonstrate that
evaluative processes do exist for reliably assessing mental
capacity, even for patients who are terminally ill, and even
for patients who may contemplate suicide.
The American Counseling Association (“ACA”) is the
largest non-profit organization of professional counselors in
the United States, with approximately fifty-five thousand
members. ACA is an educational, scientific, and professional
organization whose members are dedicated to the
enhancement of human development throughout the life span,
and who work to support and enhance the worth, dignity,
potential and uniqueness of each individual. Indeed, the
ACA’s Code of Ethics and Standards of Practice states that
“The primary responsibility of counselors is to respect the
dignity and to promote the welfare of clients.” Many of
ACA’s members provide mental health services, including
psychotherapy and psychological assessments. Professional
counselors serve in private practice, community mental
health centers, mental health agencies, schools, universities,
hospitals, rehabilitation facilities, business, industry,
correctional institutions and religious organizations. ACA’s
members are trained in the diagnosis, etiology, and treatment
of mental and emotional disorders, including depression.
Given the counseling profession’s largely unique focus on
human development, and on individual self-determination
and self-actualization, ACA feels it imperative to express its
position regarding the ability of terminally ill adults to
choose the manner and hasten the timing of their death.
The Association for Gay, Lesbian & Bisexual Issues in
Counseling ("AGLBIC") is an association of gay and non-
gay professional counselors seeking to promote greater
understanding and insight toward counseling gay, lesbian and
bisexual clients. AGLBIC offers professional training for all
counselors interested in developing clinical skills that will
enable them to be more effective. AGLBIC’s interest in
these cases stems from its members’ experience with gay,
lesbian, and bisexual persons with HIV disease.
The Coalition of Mental Health Professionals Supporting
Individual Self-Determination in Decisions to Hasten Death
is an ad hoc group of academics, private practitioners,
administrators and consultants. These individuals have
training and experience in the mental health professions
which makes it appropriate for them to offer their views on
the possibility of free and rational choice in the context
relevant to this case. All Coalition members have extensive
experience providing psychotherapy, often to persons who
are terminally ill, and/or strong records of research and
writing on depression, grief, suicide, psychotherapy
personality disorders, and substance abuse. A list of
Coalition members is attached to this brief as Appendix A.
SUMMARY OF ARGUMENT
The decisions of the courts of appeals in these
. . . . Cases
limit their holdings to a narrow set of circumstances: cases
involving mentally competent, terminally ill adults who have
made, or wish to have the option to make, the choice to
select the manner and hasten the time of an otherwise
quickly and inevitably approaching death. Implementation of
either decision therefore depends on the ability to assess
whether a terminally ill patient is mentally competeni, and
whether a particular decision to seek assistance in dying is
rational and voluntary. These central issues of the
competence, rationality, and voluntariness of end-of-life
decisions are ones with respect to which many mental health
professionals have special training and experience.
Two central values for mental health i
ue professionals are
the intertwined principles of client autonomy and self-
determination. Mental health professionals do not promote
any particular resolution of the terminal-care issues that may
arise near the end of a client’s life. Rather, in the context of
end-of-life decisions, clients are helped by providing them
with the means to make informed choices.
In determining legal competence, courts have inevitably
relied on the training, experience, and judgment of qualified
mental health professionals to assess an individual’s capacity
to make reasoned decisions. In the context relevant to these
cases, there is no dispute that States may appropriately set
high standards for making such assessments. Under existing
or suggested standards, an evaluator would focus, for
example, on a patient's ability to make a coherent assessment
of costs and benefits and to draw conclusions that are
logically consistent with his or her own values, rather than
on the particular outcome of the patient’s deliberation. Once
appropriate standards have been set, mental health
professionals who have the requisite training, experience,
and direct contact with an individual patient will be in a
position to assess whether the patient has the capacity to
make a reasoned end-of-life decision.
There should be no dispute that, before allowing a
physician to assist a terminally ill patient to hasten death, a
State may also constitutionally require some particularized
assessment of the patient’s end-of-life decision. Although
some have argued that any decision to hasten the end of
one’s life must be either irrational or the product of mental
illness, that argument is merely conclusory. Evaluation of
particular decisions must instead focus first and primarily on
the deliberative process involved, not on the decision
ultimately made. Similarly, neither research nor experience
supports the assertion that decisions to hasten death are so
highly correlated with mental illness as to justify a
prophylactic rule banning all physician assistance in dying.
Rather, research indicating that terminal illness, particularly
if accompanied by intractable pain or other special
circumstances, presents a special case for rational suicide is
reinforced by studies showing that a significant proportion of
mental health professionals believe that hastening death can
be a reasonable choice. Under proper circumstances, a
choice to control the manner and hasten the time of one’s
own death is neither inherently irrational nor indicative of
mental illness.
Mental health professionals who work with terminally il!
patients are as concerned as others that decisions to hasten
death not be impulsive or ambivalent, and that they be made
free from any coercion or undue influence. Such dangers
may largely be avoided through appropriate state regulation,
including mandatory waiting periods and the involvement of
mental health professionals in evaluation and counseling.
With a strong commitment to patient autonomy as a guiding
principle, mental health professionals are uniquely suited to
serve as counselors and advocates for terminally ill patients
in the face of any improper pressure. Moreover, appropriate
—— po os ay meh ma denying patients who
ina to , informed, and intelligent end-
of-life decisions the opportunity to do so.
; Frank discussion of end-of-life issues among terminally
ill patients, their treating physicians, and appropriate mental
health professionals would necessarily raise the issues of
capacity, rationality, and voluntariness discussed in this
brief. The process of evaluation and counseling that should
accompany any end-of-life decision will often lead patients
to choose some option other than assisted suicide — even if
the patient actively considers that course as one possibility.
The cases before the Court involve what is presently, and is
likely to remain, a minority of patients who reach a carefully
considered decision to hasten the end of life, even after a
thorough exploration of the alternatives. Nonetheless, various
considerations suggest that protection of the public would be
enhanced, not diminished, by bringing physician assistance
in dying into the open and allowing for comprehensive legal
regulation.
ARGUMENT
I. RECOGNITION AND IMPLEMENTATION OF
THE CONSTITUTIONAL RIGHT AT ISSUE IN
THESE CASES DEPENDS ON THE ABILITY TO
ASSESS WHETHER A TERMINALLY ILL
PATIENT IS MENTALLY COMPETENT, AND
WHETHER SUCH A PATIENT IS ACTING
RATIONALLY AND VOLUNTARILY WHEN HE
OR SEEKS ASSISTANCE IN CHOOSING
THE TIME AND MANNER OF DEATH.
This case presents the narrow but important question
whether a State may constitutionally prohibit physicians,
under any set of circumstances, from providing mentally
competent, terminally ill adults with the means medically
necessary to choose the manner and hasten the timing of
their death. In the opinion below in No. 96-106, the Ninth
Circuit recognized “a constitutionally protected liberty
interest in determining the time and manner of one’s own
death.” Compassion in Dying et al. v. State of Washington
et al. 79 F.3d 790, 793 (9th Cir. 1996). The court then held
that, in the particular context of a competent, terminally ill
patient whose physician is willing to prescribe appropriate
medication, that interest outweighs even the State's
substantial general interest in preventing suicide. In that
context, the court held, “the state has wide power to
regulate, but it may not ban” willing physicians from
providing medical assistance to a competent patient who
chooses to hasten the already fast-approaching end of life.
artificial nutrition and hydration. Quill et al. v. Vacco et al.
80 F.3d 716, 727-28 (2d Cir. 1996). The court then
concluded that the State treats other competent, terminally ill
patients unequally, by prohibiting even a willing physician
from prescribing appropriate drugs if and when such a
patient wishes to hasten the moment of his or her own
impending death. /d. at 729. In the limited context of
mentally competent, terminally ill patients, the court
discerned no rational relationship between that inequality of
treatment and any legitimate state interest. Id. at 730-31. The
competent, terminally ill person in the final stages of his
terminal illness.” Jd.
Although the opinions below rest on different legal
theories, both are notable for the care they take to limit their
holdings to a narrow set of factual circumstances: cases
involving mentally competent, terminally ill adults who have
made, or wish to have the option to make, the choice to
select the manner and hasten the time of a quickly and
inevitably approaching death. Whatever the proper legal
analysis, both decisions therefore depend on two important
factual propositions: that it is generally possible for a
competent person to make a reasoned decision to hasten the
end of his or her own life, and that it is possible in any
given case to assess the decision-making capacity of an
individual patient and the soundness of his or her decision-
making process.
Moreover, whether the right in question is guaranteed
directly by the Constitution, or as a matter of parity with
rights already afforded by a State to individuals who wish to
terminate life-sustaining care, both decisions seek to protect
a sphere of personal autonomy — specifically, an
individual's right to choose the time and manner of ending
the suffering caused by a terminal illness. That protection is
only sensible or desirable, however, if the choice protected
is in fact an autonomous decision made by the individual
patient. Conversely, the State’s interest in regulating, or
even prohibiting, end-of-life decisions of this type increases
to the extent that there is any uncertainty about whether a
particular patient's choice is truly voluntary.
These central issues concerning the competence,
rationality, and voluntariness of end-of-life decisions are
ones with respect to which many mental health professionals
have special training and experience. Moreover, the mental
health professions have long grappled with the ethical issues
that arise in this context. The amici offer the following
observations to the Court in the hope that they will be
helpful in informing the Court's decision on the important
question presented by these cases.
ll. MENTAL HEALTH PROFESSIONALS ARE
GUIDED IN THEIR APPROACH TO END-OF-
LIFE ISSUES BY ETHICAL PRINCIPLES THAT
INCLUDE PATIENT AUTONOMY AND SELF-
DETERMINATION, BALANCED BY LEGAL
NORMS AND CONCERN FOR PUBLIC
WELFARE.
The analysis provided in this brief is grounded in
underlying ethical principles that guide the work of mental
appropriate respect to individuals’ fundamental interests in
privacy, self-determination, and autonomy, while remaining
mindful that those interests may conflict with lega! and other
obligations. When conflicts occur, professionals attempt to
resolve them and to perform their roles in a responsible
fashion that avoids or minimizes harm. They are aware of
their professional and scientific responsibilities to the
communities and society in which they work and live.
Professionals apply and make public their knowledge of
mental health in order to contribute to human welfare. They
work to identify and mitigate the causes of human suffering.
Two central values for menta! health professionals are
the intertwined principles of client autonomy and
self-determination. In the context of end-of-life decisions,
clients are helped by providing the means for them to make
informed choices. Mental health professionals do not
promote any particular resolution of the terminal-care or
other issues that may arise near the end of a patient's life.
Rather, mental health workers who have appropriate training
and immediate involvement with those suffering from
terminal illnesses can help patients to explore, ameliorate,
cope with, or solve problems that interfere with the patient's
own control over his or her life and death.
Professionals can, for example, help patients to address
issues such as pain, depression, dignity, tranquility, financial
concerns, and the effectiveness or futility of available
medical treatments. In addition, they can assist the patient to
communicate with other health care providers, family
members, social service providers, or others concerning the
patient's needs, concerns and preferences, to help ensure that
the patient receives necessary support and that the treatment
provided comports with the patient's wishes. Finally,
professionals can promote and monitor appropriate
involvement by significant others in a patient’s end-of-life
decisions, and they can counsel both patients and survivors
in the inevitable process of grieving. See generally, e.g.,
National Association of Social Workers, Client Self-
Determination in End-of-Life Decisions, in Social Work
Speaks: NASW Policy Statements 60 (3d ed. 1994) “NASW
Statement”, (reprinted as Appendix B hereto). In all these
roles, mental health professionals seek to advance the ideals
of client autonomy and self-determination, subject to the
requirements of the law and concern for the general public
welfare.
Il. IT IS POSSIBLE TO ASSESS WHETHER OR
NOT A TERMINALLY ILL PATIENT WHO
HAS REQUESTED ASSISTANCE IN
HASTENING DEATH IS MENTALLY
COMPETENT AND HAS MADE A
REASONED, INFORMED, AND
VOLUNTARY DECISION TO SEEK SUCH
ASSISTANCE.
A. Assessing Capacity to Make Reasoned Decisions
Both decisions below begin with the assumption that a
terminally ill patient who seeks assistance in choosing the
means and time of his or her own death must be “mentally
competent” to make that final decision. Similar situations
involving the assessment of mental competence or capacity
arise in a variety of legal contexts, from competence to stand
trial to competence to make a valid will. See, e.g., Cooper
v. Oklahoma, 116 S. Ct. 1373 (1996) (competence to stand
trial); Addington v. Texas, 441 U.S. 418 (1979) (involuntary
civil commitment); Cal. Prob. Code § 812 (West Supp.
1996) (specifying criteria to be used in determining legal
incapacity to perform various acts, including “to contract, to
make a conveyance, to marry, to make medical decisions, to
vote, or to execute wills or trusts.”). Competence is a legal
-10-
question, which, when disputed, must ultimately be resolved
by the courts. In deciding such issues, however, courts have
inevitably relied on the training, experience, and expert
judgment of qualified mental health professionals to assess a
given individual's capacity to make reasoned decisions. See,
e.g., Medina v. California, 505 U.S. 437, 450 (1992); see
also id. at 465 (Blackmun, J., dissenting).
Particular legal standards of competence vary depending
on the rights and interests at stake in a given context. See,
e.g., Cooper, 116 S. Ct. at 1383-1384 (contrasting standards
for involuntary commitment and for competence to stand
trial). In the context of patients’ end-of-life decisions, there
is no dispute that the standards for assessing decision-making
capacity and legal competence may appropriately be set high.
Cf. Cruzan v. Director, Missouri Dep't of Health, 497 U.S.
261, 282-284 (1990); Addington, 441 U.S. at 423 (“The
function of a standard of proof . . . is to ‘instruct the
factfinder concerning the degree of confidence our society
thinks he should have in the correctness of factual
conclusions for a particular type of adjudication.’”). While
each State could establish its own standards and procedures
for such cases, the mental health literature suggests that an
appropriate standard would require that a terminally ill
patient be able to:
(a) understand and remember information relevant
to an end-of-life decision;
(b) appreciate the consequences of the decision;
(c) indicate a clearly held and consistent underlying
set of values that provide some guidance in
making the decision; and
(d) communicate the decision and explain the
process used for making it.
See J. Werth, Rational Suicide? Implications for Mental
Health Professionals 94 (1996).° A strict standard might
also require that
“once understanding [of the information relevant to
an end-of-life decision] has been attained, the
patient's rational manipulation of information [must
take] place in the context of the patient's
appreciation of the nature of his situation. ”
Appelbaum and Roth, Competency to Consent to Research,
39 Archives Gen. Psychiatry 951, 954 (1982).
Under ‘his type of standard, a mental health professional
evaluating decision-making capacity would examine a
patient’s “chain of reasoning,” and would seek to determine
whether the patient can “indicate the major factors in his
decisions and the importance assigned to them.” Appelbaum
and Grisso, Assessing Patients’ Capacities to Consent to
Treatment, 319 New Eng. J. Med. 1635, 1636 (1988). The
evaluation would focus on the patient's ability to make a
coherent assessment of costs and benefits, and to draw
conclusions that are logically consistent with his or her own
values or other stated premises for the decision, rather than
on the outcome of the patient’s deliberation. See also Annas
and Densberger, Competence to Refuse Medical Treatment:
> See also, e.g., Drane, The Many Faces Of Competency, 15 Hastings
Center Report No. 2, 17, 19 (1985); Freedman, Competence, Marginal
and Otherwise; Concepts and Ethics, 4 nt’! J.L. and Psychiatry 53, 59-
60 (1981); Roth et al., Tests Of Competency To Consent To Treatment,
134 Am. J. Psychiatry 279, 280-282 (1984); Tepper and Elwork,
Competence To Consent To Treatment As A Pyscholegal Construct, 8
Law and Human Behavior 205.
-13-
Autonomy vs. Paternalism, 15 U. Tol. L. Rev
name . 561, 568
Once an appropriate standard has been set, mental health
professionals who have the requisite training, experience,
and direct contact with an individual patient will be in a
position to assess, in the first instance, whether a patient has
the capacity to make a reasoned end-of-life decision.* Many
* Compare Cal. Prob. Code § 813 (West Supp. 1996):
A person has the capacity to give informed consent to a
proposed medical treatment if th= person is able to do all of the
following:
(a) Respond knowingly and intelligently to queries about that
medical treatment.
. (b) Participate in that treatment decision by means of a
rational thought process.
©) Understand all of the following items of minimum basic
medical treatment information with respect to that treatment:
(1) The nature and seriousness of the illness, disorder,
or defect that the person has.
(2) The nature of the medical treatment that is being
recommended by the person's health care providers.
. (3) The probable degree and duration of any benefits and
risks of any medical intervention that is being recommended
by the person's health care providers, and the consequences of
lack of treatment.
(4) The nature, risks, and benefits of any reasonable
alternatives.
See also Calif. Prob. Code § 1881 (West Supp. 1996) (standards
informed consent for conservatees). a ¥"
. This Court has commented that “the subtleties and nuances of
Psychiatric diagnosis render certainties virtually beyond reach in most
situations.” Medina, SOS U.S. at 451, quoting Addington, 441 U.S. at
prone tein. Dorf Ct. at 1382. In this context as in other
areas © or medicine), however, the impossibility of certainty does
not obviate the need to decide. Id. at 1382-83. The nature of end-of-life
decisions would certainly justify a State in adopting a legal standard
(continued...)
-13-
mental health professionals have extensive experience in
making both formal written evaluations and ongoing,
informal assessments of decision-making capacity and
rationality during the course of psychotherapy, counseling,
or psychiatric consultation in medical settings. Indeed,
professional evaluation occurs continuously during therapy
and within the context of hospital or outpatient consultations.
Is the client sensing, perceiving and comprehending
information regarding his or her situation accurately? Is the
client realistically formulating and utilizing this information?
Are the client’s perceptions being unduly influenced by
mental disorders, prescribed medications, substance abuse,
or external social or economic pressures? Overall, is the
client fully informed and rational? General criteria exist, and
specific criteria may be adopted, for making such evaluations
in the case of terminally ill patients who seek physician
assistance in controlling the manner and timing of their
deaths. See, e.g., J. Werth, supra, at 94-95. Specification
and refinement of those criteria, and their application in
particular instances, are well within the competence of the
mental health profession.
B. Assessing the Rationality of a Decision
Even if a person generally has the capacity to make
reasoned judgments, he or she may make pasticular choices
that are unduly influenced by factors not associated with
rational decision-making, such as coercion, inadequate
treatment, prescribed medications, drugs, alcohol, or mental
disorders. There should be no dispute that, before allowing
*(...continued)
under which close cases are resolved in favor of preserving the medical
status quo. See Cruzan, 497 U.S. at 283. But the inevitability of close
cases cannot, by itself, justify imposing a flat prohibition that will apply
even in cases where the evidence of mental capacity is clear.
-14-
a physician to assist a terminally ill patient in selecting or
hastening the moment of death, a State may constitutionally
require not only an assessment of general r 2ntal capacity,
but some particularized assessment of the patient’s end-of-
life decision. If allowed to address the issue openly, without
fear of legal or ethical repercussions, mental health
professionals can provide such assessments. See, ¢.g.,
Holtby, Social Work, Suicide, and Self-Deliverance, |
National Social Work AIDS Network Readings and Writings
No. 3, 30 (1996); Quill et al., Proposed Clinical Criteria for
Physician-Assisted Suicide, 327 New Eng. J. Med. 1380,
1381-82 (1992); J. Werth, supra, at 55-80. Moreover, the
involvement of mental health professionals and the use of
open discussion and evaluation can facilitate the sort of full
consideration that leads to an informed and deliberate
decision, whatever it may ultimately be.
1. “Inherent irrationality”
It may be argued that any decision to hasten the end of
life must be either irrational or a product of mental illness.
See, e.g., Brief for the American Suicide Foundation,
Amicus Curiae, Supporting Reversal (Case No. 96-110) 5-
11, 13 ("Am. Cur. Br. for the ASF"). That argument,
however, assumes its conclusion. For example, one of the
guiding principles for mental health professionals is client
autonomy — allowing and encouraging clients to take control
of their lives and assume responsibility for their decisions.
In the argument for the inherent irrationality of suicide,
however, a patient who chooses to forgo medical treatment
is said to make only “a judgment about how to live before
one dies,” id. at 13, while a patient who desires to exercise
essentially the same control over the final portion of his or
her life by choosing the time and manner of death is
characterized as “afflicted” by a “rigidity” that reflects
-15-
“impaired thought processes and irrationality,” id. at 8.
Similarly, the right to forgo treatment is treated as “rooted
in our abhorrence of the violence inherent in forcing medical
interventions on unwilling, competent adults,” but the
essentially identical choice to avoid the same “intense
burdens, such as pain, bodily invasion, and the emotional
suffering that can accompany . . . a course of treatment” by
an active hastening of death is dismissed as necessarily a
product of “mental impairment.” Jd. at 13-14. Thus, the
argument succeeds only because it defines a request for
active assistance in dying as “irrational.”
As with determinations of competency and decision-
making capacity, evaluation of a particular end-of-life
decision must instead focus first and primarily on the
deliberative process involved, not on the decision ultimately
made. “If the reasoning process flows logically from its
starting premises, though the result might be rejected by
most people (e.g., a person refusing potentially life-saving
medical treatment), we cannot say that rational manipulation
is impaired.” P. Appelbaum and T. Gutheil, Clinical
Handbook of Psychiatry and the Law 223 (1991). A patient
who is fully informed, realistic, stable, and not mentally
impaired — ¢ Jetermined, for example, by professional
observation of the patient’s behavior and ability to interact
and communicate — may make a knowing and intelligent
decision to decline (or accept) treatment, or to request (or
decide against) assistance in dying. That is true even if the
decision is based in part on “irrational” or super-rational
factors, such as religious beliefs or other transcendent moral
values.
To be sure, assessing the soundness of a terminally ill
patient’s decision to hasten death will sometimes present
special challenges. In cases of terminal il!ness, the criteria
for measuring the existence of mental disturbance are
-16-
particularly likely to be confounded by the effects of the
physical disease itself. For similar reasons, it may be
difficult to differentiate between normal grief — a reaction
to actual or prospective loss — and clinical depression. See
R. Neils, Dying Well Network: Death with Dignity FAQs
(Frequently Asked Questions) § 4.18 (a copy of which has
been lodged with the Clerk). Indeed, of the nine standard
criteria for diagnosing a “major depressive episode,” several
may be present simply because of physical illness, and six
may appear in a terminally ill patient simply because of
natural grieving over the functional impairment caused by
—— illness and over the impending loss of his or her
ife.
* The American Psychiatric Association's Diagnostic and Statistical
Manual of Mental Disorders lists nine criteria for identifying a Major
Depressive Episode. A grievously ill person who is not clinically
depressed may meet criteria 2, 3, 4, 5, 6, and 9:
1) Depressed mood most of the day, nearly every day, as
indicated by either subjective report (e.g., feels sad or empty) or
observation made by others (e.g., appears tearful);
2) Markedly diminished interest or pleasure in all, or almost
all activities most of the day, nearly every day (as indicated by
either subjective account or observation made by others);
3) Significant weight loss when not dieting or weight gain
(e.g., a change of more than 15% of body weight in a month) or
decrease or increase in appetite nearly every day;
4) Insomnia or hypersomnia nearly every day;
5) Psychomotor agitation or retardation nearly every day
(observable by others, not merely subjective feelings of restlessness
or being slowed down);
6) Fatigue or loss of energy nearly every day;
7) Feelings of worthlessness or excessive or inappropriate
guilt (which may be delusional) nearly every day (not merely self-
reproach or guilt about being sick);
. 8) Diminished ability to think or concentrate, or
indecisiveness, nearly every day (either by subjective account or as
(continued...)
-17-
With training and experience, however, a professional can
distinguish clinical depression from physical illness or grief,
for example on the basis of a patient’s feelings of
worthlessness or excessive guilt. An individual’s sense of
self-worth is typically unaffected by physical illness or grief,
but significantly impaired in cases of clinical depression.
Thus, a depressed patient might inappropriately request
suicide precisely because of feelings of worthlessness and
guilt. For a terminally ill patient, on the other hand, being
able to assert some modicum of control over the course of an
inevitable final illness, by choosing at least the time and
manner of death, may be a final act of will that reflects —
indeed, affirms — self-esteem and individual dignity. The
differences between these situations may sometimes be
subtle, but they are real, and mental health professionals who
work with the terminally ill are qualified to assess them.
An assessment of any particular end-of-life decision
should take into account not only the patient’s ability to
reason coherently, but also the information that the patient
has considered in reaching his or her decision. Even if a
patient receives fully adequate medical care, his or her
physicians may be focused on the details of particular
medical problems, rather than on the patient’s entire
circumstances. The patient will also inevitably be under
considerable mental and physical stress. Mental health
professionals can provide objective information and
counseling about the patient’s overall situation, including
*(...continued)
observed by others); and/or
9) Recurrent thoughts of death (not just fear of dying),
recurrent suicidal ideation without a specific plan, or a suicidal
attempt or a specific plan for committing suicide.
American Psychiatric Association, Diagnostic and Statistical Manual of
Mental Disorders 327 (4th ed. 1994).
alternatives of which neither the patient nor his or her
attending physicians may be aware. See N. Peruzzi et al.,
Ethics and Behavior 8-13 (forthcoming 1997); NASW
Statement, supra, at 60. They may, for example, be able to
provide information about alternatives such as ~—
programs, independent or assisted living arrangements, and
potential sources of financial or other assistance. They can
act as liaisons or patient advocates in coordinating
comprehensive care. They are also well positioned to assess
the patient's overall psychological state, and to recognize
signs of misunderstanding, clinical depression, or other
factors which suggest that the patient's decision-making
ability may be compromised. They can offer the patient a
sympathetic sounding-board, identify the factors that appear
to be driving an end-of-life decision, and offer either
confirmation that the facts are as the patient perceives them
to be, or new or different information that may change or
help to inform the patient's decision.
2. Correlation with mental illness
Even if some decisions to request assistance in dying
may be fully informed and intelligently made, it may be
argued that a decision to hasten death is so highly correlated
with mental illness that the State is justified in enacting a
prophylactic rule banning all physician assistance in dying.
Cf. Black and Winokur, Suicide and Psychiatric Diagnosis,
in Suicide Ov or The Life Cycle: Risk Factors, Assessment,
and Treatment of Suicidal Patients 135, 139 (S. Blumenthal
and D. Kupfer eds., 1990) (“few suicides occurred in
persons judged not mentally ill, suggesting that the ‘rational’
suicide is uncommon. ”). In fact, the correlation between all
-19-
and mental illness may be overstated.’ Even if the
’ Research indicating that the majority of individuals who commit
suicide have one or more mental illnesses may be misleading. Even
accepting the data as reported, these studies also show that from 3%-12%
of people who have killed themselves ‘a 10 mental illness. Black and
Winokur, supra, at 139; Clark and Ne.ton-Deutsch, Assessment in
Absentia: The Value of the Psychological Autopsy Method for Studying
Antecedents of Suicide and Predicting Future Suicides, in Assessment and
Prediction of Suicide 144, 148-49, 153-54 (R. Maris et al., eds., 1992).
Other researchers report studies in which more than 25% of completed
suicides did not have a mental disorder and could be considered rational.
See R. Maris, Pathways to Suicide: A Survey of Self-Destructive
Behaviors (1981); Meerloo, The Multifarious Motivations for Suicide, in
Suicide and Mass Suicide 18, 25 (J. Meerloo ed. 1962); Patel, Pathology
of Suicide, 13 Medicine, Science, and the Law 103, 106 (1973). After
studying suicide notes, Tuckman, Kleiner, and Lavell stated that they
“were impressed with the possibility that in a number of cases the suicide
could have resulted from a conscious, ‘rational’ decision reached by
weighing the pros and cons of continuing to live.” Tuckman et al.,
Emotional Content of Suicide Notes, 116 Am. J. Psychiatry 59, 62
(1969). See also Shneidman et al., The Suicide Prevention Center, in
The Cry for Help 6, 13 (N. Farberow and E. Shneidman eds., 1961) (“A
large minority of suicides, usually older persons in physical pain, are
logical and rational and not psychotic.”)
illness may be oversimplified. Tanney noted that dramatic differences
appeared when studies of the association between mental illness and
surveys. He reported that, on average, only 38% of completed suicides
in the general population had a known history of mental disorder, while,
on average, more than 80% of suicides in hospital-based surveys had a
psychiatric disorder or history of care. Tanney, Mental Disorders,
Psychiatric Patients, and Suicide, in Assessment and Prediction of
Suicide 277, 283-84 (R. Maris et al. eds., 1992) Similarly, Temoche,
Pugh, and MacMahon reported all the highest estimates (47 %-94%) of
the percentage of suicides who displayed prior evidence of mental illness
come from studies done after the suicide occurred; in studies dependent
(continued. ..)
correlation holds for suicides in general, however, the
argument for a prophylactic ban is not persuasive in the
context of end-of-life decisions by terminally ill patients. In
that context, physician-assisted “suicide” is far less akin to
what is commonly termed suicide — typically a violent self-
destructive act related to feelings of worthlessness — than it
is to the thoughtful decision to decline life-sustaining
treatment. The latter is a choice that upholds and affirms the
dignity of a fully lived life, and one that many States,
including New York and Washington, have already
recognized as worthy of legal recognition. See, e.g.,
Compassion in Dying, 79 F.3d at 817-20; Quill, 80 F.3d at
727-28.
In fact, a number of researchers and clinicians have
recognized that terminal illness, particularly if accompanied
by intractable pain or other special circumstances, presents
a special case for “rational” suicide. See, e.g., Siegel,
Rational Suicide: Considerations for the Clinician, 54
Psychiatric Quarterly 77, 78 (1982) (“We need not argue the
issue whether it is rational for an individual with painful
terminal illness to refuse extraordinary life-saving measures
or to more actively arrange to end his life. Most would agree
it is rational.” ); Quill, Physician-Assisted Death: Progress or
Peril?, 24 Suicide and Life-Threatening Behavior 315
(1994).* Moreover, research on suicide among the
"(...continued)
upon objective criteria measured prior to the suicide, estimates of the
correlation with mental illness were much lower (5%-22%). Temoche
et al., Suicide Rates Among Current and Former Mental Institution
Patients, 138 J. Nervous and Mental Disease 124 (1964).
* In one survey of 39 HIV-positive individuals, researchers concluded
the desire to hasten death was not directly related to clinical depression
(continued...)
-21-
terminally ill must be interpreted with caution, because the
cases likely to be studied are those that can be readily
identified as “suicides,” whereas other research indicates that
many hastened deaths among terminally ill patients are never
documented as such. S. Jamison, Final Acts of Love:
Families, Friends, and Assisted Dying 5-6 (1995); R. Ogden,
Euthanasia, Assisted Suicide, and AIDS 71-83 (1994). Asa
result, the research cited by opponents of hastened death
must be viewed within an appropriately restrictive context,
and it must be realized that it may not be possible to
generalize the results. Several of the Coalition members
listed in Appendix A have experience with literally hundreds
of individuals who have died of terminal illnesses, and each
could relate numerous stories of assisted deaths that were not
reported as suicides. These professionals and the others who
are members of the Coalition have chosen to join in this
submission in part because their work has convinced them
that the assertion that anyone, including terminally ill
individuals, who wishes to hasten his or her own death must
be depressed or otherwise mentally impaired is simply not
borne out by either research or experience.
Recent research has found that a significant percentage
of mental health professionals believe that hastening death
can be a reasonable choice, and even have experience
working with individuals who have made such decisions. In
a national survey of a random sample of members of the
American Psychological Association’s Division of
Psychotherapy, 81% of the respondents (with a 50%
response rate) stated that they believed that an individual
*(...continued)
as measured by the Beck Depression Inventory (the most widely accepted
means of making swift diagnoses of depression). Jones and Dilley,
Rational Suicide and HIV Disease, 8 Focus: A Guide to AIDS Research
and Counseling 5 (July 1993).
could make a rational decision to control the time and
manner of his or her own death. Werth and Liddle,
Psychotherapists’ Attitudes Toward Suicide, 31
Psychotherapy: Theory, Research and Practice 440 (1994).
In another study, using a sample of psychologists who were
members of the National Register of Health Care Providers
in Psychology, 86% of the respondents (again with a 50%
response rate) indicated that they believed in rational suicide.
J. Werth, supra, at 47. Twenty percent of the participants in
the latter study stated that they had worked with patients
whose hastened deaths could be considered “rational”
suicides in the sense described above. J. Werth, supra, at
53; see also Pope et al., Ethics of Practice: The Beliefs and
Behaviors of Psychologists as Therapists, 42 Am.
Psychologist 993, 1003 (1987).
Similar results have been found in surveys of
psychiatrists. One study of physicians in Washington State
found that of five categories of physicians, “psychiatrists
were most supportive of” assisted suicide and euthanasia.
Cohen et al., Aftitudes Toward Assisted Suicide and
Euthanasia Among Physicians in Washington State, 331 New
Eng. J. Med. 89, 91-92 (1994) (especially graphs). A more
recent report found that two-thirds of the respondents to a
survey of Oregon psychiatrists (with a 77% response rate)
“endorsed the view that a physician should be permitted,
under some circumstances, to write a prescription for a
medication whose sole purpose would be to allow a patient
to end his or her life.” Ganzini et al., Astitudes of Oregon
Psychiatrists Toward Physician-Assisted Suicide, 153 Am. J.
Psychiatry 1469, 1469 (1996).
For these reasons, we think it must be accepted that a
decision by a terminally ill patient to hasten his or her own
death may be carefully considered and fully rational — just
as it may be ill informed or the product of impaired
reasoning. Given the opportunity, mental health
professionals are capable of assessing the nature and quality
of a patient’s decision-making process, and therefore of
helping to determine that any decision that is implemented is
a product of the patient’s knowing and intelligent choice.
The decisions below would permit, perhaps for the first
time, a process of free and open discussion and consultation
among patients, their physicians, and mental health
professionals concerning all end-of-life options. Indeed,
States could and should, in our view, require such
consultation in any case in which the patient’s ultimate
choice is to select or hasten the moment of death.’ The
mental health professionals involved would be in a position
to assess the accuracy of the patient’s understanding of his
or her medical condition, including the prognosis and
treatment alternatives; to review the quality of the patient's
deliberative process; and therefore to evaluate the
psychological soundness of his or her final choice. Under
proper circumstances, a choice to control the manner and
* Oregon's * Death With Dignity Act,” for example, adopted by the
State’s voters on November 6, 1994, requires a physician to refer a
patient who requests aid in dying to counseling if the physician believes
that the patient may be depressed or otherwise mentally compromised.
1995 Or. Laws Ch. 3 (1.M. 16). The counseling is to consist of
consultation with a licensed psychiatrist or psychologist to determine
whether the patient is suffering from a psychiatric or psychological
disorder, or from depression causing impaired judgment. We note that
other mental health professionals, including social workers and
professional counselors, who have appropriate training or experience in
working with the terminally ill would also be capable of performing such
evaluations. See also Baron et al., A Model State Act to Authorize and
Regulate Physican-Assistance Suicide, 33 Harv. J. on Legis. 1 (1996),
which proposes a specific series of procedural requirements designed to
prevent mistaken decisions. In particular, the model act requires a review
of the patient's competence by suitably trained mental health
professionals.
hasten the time of death is neither inherently irrational nor
indicative of mental illness. Rather, such a choice may be
the final expression of a terminally ill patient’s individual
autonomy.
Cc. Assessing the Voluntariness of a Decision
The mental health professionals who work with
terminally ill patients are as concerned as others that those
patients who decide to hasten their own deaths make that
decision free of any form of coercion or undue influence.
They are equally concerned that a patient's choice may be
merely impulsive, or that the patient may be so ambivalent
that the simple passage of time is likely to change his or her
mind. See, e.g., Am. Cur. Br. for the ASF 9-10. Although
these dangers are real, they may largely be avoided by
appropriate state regulation of the process by which such
individuals request and receive physician assistance,
including mandatory waiting periods and the involvement of
mental health professionals in the sorts of evaluations and
counseling described above.'® This may be accomplished
without, at the same time, denying patients who are in a
position to make free, in‘ormed, and intelligent decisions the
opportunity to do so. Indeed, the active and open
involvement of mental health professionals in counseling
terminally ill patients about end-of-life issues may well be
the best guarantee that all such patients will have the
'° For example, Section 3 of the proposed Model Act to Authorize and
Regulate Physician-Assisted Suicide also contains requirements that “the
request must be competent, fully informed, voluntary, and enduring.”
See Baron, supra note 8, at 26. The proposed statute also mandates that
a professional mental health care provider “evaluate the patient to
determine that his or her decision is fully informed, free of undue
influence, and not distorted by depression or any other form of mental
illness.” Jd. at 18.
information and support necessary to make their own
decisions, based on their own values, about the course of
their own treatment and, ultimately, their own manner of
dying.
Assessments of whether a particular decision reflects
independent determination or improper outside influence,
like assessments of capacity to make reasoned decisions, are
as familiar to mental health professionals as they are to the
law. Mental health professionals are used to working, in a
wide variety of contexts, with individuals who may be
susceptible to pressure, suggestion, or intimations of
authority. With a strong commitment to patient autonomy as
a guiding principle, mental health professionals are uniquely
suited to serve as counselors and advocates for terminally ill
patients to protect against any improper pressure on this
most sensitive of decisions. That is true whether the pressure
in question arises from physicians, hospital administrators,
third-party payers or “managed care” controllers, family
members, or other inappropriate or treatable sources such as
clinical depression, feelings of worthlessness, transient
mental disorders, the effects of alcohol or other drugs,
financial concerns, inadequate palliative care, or a lack of
social support.
Concerns with respect to voluntariness and the risk of
coercion apply equally in the case of terminally ill
individuals who refuse, or request the discontinuation of,
life-sustaining treatment. Those choices have nonetheless
been made available to patients, under whatever safeguards
individual States have deemed appropriate. Indeed, it is
possible that recognition of the right at issue in these cases,
together with the sort of independent counseling
requirements that the States might be expected to enact in
this context, would increase the level of information and
support available to all patients, and thereby actually
decrease the number who choose to end their own lives. In
any event, open discussion of end-of-life issues, and active
involvement by mental health professionals, would
significantly enhance confidence that any patient who
requests assistance in hastening the end of his or her life
does so as a matter of free choice.''
baal ~ ™
Recognition of a right to physician assistance in dying
might well decrease those suicides that are of greatest
legitimate concern to the State. Frank discussion of end-of-
life issues between terminally ill patients, their treating
physicians, and appropriate mental health professionals
would necessarily raise the issues of capacity to make
reasoned decisions, rationality, adequate information,
exploration and availability of alternatives, and voluntariness
discussed in this brief. Informed exploration of those issues
might lead to the provision of appropriate treatment where
all available methods have not been tried, and to the
prevention of irrational and coerced deaths by those
'' With or without legal sanction, and with or without active or tacit
professional assistance, some number of terminally ill patients already
make their own decisions about exactly how and when to end their lives.
One important effect of a decision affirming the judgments below might
be to remedy an inequality akin to, but different from, that identified by
the Second Circuit in Quill: the inequality between those patients who
already have, whether through wealth, personal acquaintance, or mere
physical ability, the de facto “right” to choose the time and manner of
ending their battle with illness, and those whom disadvantage or disability
consigns to live or die based solely on the medical and moral judgments
of others. From the point of view of patient autonomy, surely it would
be better to create a system under which some who have the power to die
would receive the support or counseling that might convince them to live,
while those who would truly choose to hasten their own ends would have
the opportunity to do so without regard to fundamentally inconsequential
criteria such as poverty or physical disability.
-27-
individuals who are not competent or rational (and whom the
State has the greatest interest in protecting).
Similarly, because it is generally not legal to assist a
patient to die, patients who wish to control their own deaths
often reflect and act alone, without the benefit of counseling.
They often believe that they must protect others by killing
themselves in isolation, or earlier than they might otherwise
choose, so they can be sure that they will still be able to
carry out their own decision; or they may involve significant
others, while feeling torn because doing so puts those
individuals at risk both legally and emotionally. In either
case, the results are often tragic. S. Jamison, supra, at 120-
54; R. Ogden, supra, at 89-90. Drugs taken to hasten death,
for instance, may not be properly absorbed, putting the
patient at risk of further disability or prolonged suffering as
a result of liver or kidney failure. Significant others may
then be forced to become deeply involved. In desperation,
they may even resort to violent measures, in which case the
resulting post-traumatic stress compounds the tragedy.
Holtby, Social Work, Suicide, and Self Deliverance, in |
National Social Work AIDS Network Readings and Writings
No. 3, 30 (1996). The availability of legal, regulated means
for seeking assistance in dying, including the involvement of
mental health professionals, would reduce these problems,
and would allow professionals to deal openly with issues of
emotional closure with a patient’s family and helping the
family to support the suffering individual. See, e.g. , Lester,
Easing the Legacy of Suicide: Counselor Assisted Suicide, in
Changes (forthcoming 1997); J. Werth, supra, at 100.
Protection of the public would thus be enhanced, not
diminished, by bringing physician assistance in dying under
the scrutiny of the law.
The process of discussion and counseling that should
accompany any end-of-life decision often does lead patients
to choose some option other than assisted suicide — even if
the patient actively considers that course as one possibility.
In fact, anecdotal reports and some recent research suggest
that giving some patients a credible option, or even the
means, to hasten death if they decide to do so in the future
may decrease the patient’s desire to die immediately, and
even enhance the quality of the patient’s remaining life, thus
reducing the risk that a patient will act impulsively or
prematurely. See Back et al., Physician-Assisted Suicide and
Euthanasia in Washington State: Patient Requests and
Physician Responses, 275 JAMA 919, 922 (1996); Block and
Billings, supra, at 2045; See M. Battin, The Death Debate-
Ethical Issues in Suicide 202 (1996), quoting C. Owens et
al., Cancer Patients’ Attitudes to Final Events in Life: Wish
for Death, Attitudes to Cessation of Treatment, Suicide and
Euthanasia, 3 Psycho-Oncology 1 (1994). It is worth
emphasizing that the cases before this Court involve what is
presently, and is likely to remain, a minority of patients who
reach a carefully considered decision to hasten the end of
life, even after a thorough exploration of the alternatives.
As mental health professionals, we have no interest in
“promoting” assisted suicide. Our interest lies, instead, in
the promotion of patient autonomy, balanced by concern for
the welfare and protection of the public, and in the sound
development of the law to that end.
-29-
CONCLUSION
The judgments of the courts of appeals should be
affirmed.
Respectfully submitted,
EDWARD C. DUMONT
Counsel of Record
125 Broad Street
New York, NY 10004
(212) 558-4000
Of Counsel
TAMAR FEDER
LEE A. THORSON
BIRMINGHAM, THORSON &
BARNETT, P.C.
Counsel for the
Washington State
Psychological Association
Dated: December 10, 1996
-30-
Individuals’ affiliations are provided for identification only.
The views expressed are those of individual coalition
members and not necessarily those of any institution or
organization with which they may be affiliated.
PSYCHOLOGISTS
Bob Barret, Ph.D.
Licensed Psychologist, North Carolina
Professor, Department of Counseling, Special
Education and Child Development
University of North Carolina at Charlotte
Co-Chair, Association for Gay, Lesbian and Bisexual
Issues in Counseling
Charlotte, North Carolina
Mae Billet-Ziskin, Ph.D.
Licensed Psychologist, California
Emeritus Professor, Los Angeles City College
Fellow, American Psychological Association
Past President, California Psychological Association
Los Angeles, California
Laura S. Brown, Ph.D.
Clinical Professor of Psychology, University of
Washington
President, American Psychological Association Division
35, Psychology of Women
Past President, Washington State Psychological
Association
Past President, American Psychological Association
Division 44, Society for the Psychological Study of
Gay and Lesbian Issues
Fellow, American Psychological Association
Divisions 9, 12, 29, 35, 42, 44; American
Psychological Society
Private Practice, Seattle, Washington
Gerald C. Davison, Ph.D.
Professor of Psychology, University of Southern
California
Past President of the Association of the Advancement of
Behavior Therapy
Fellow, American Pscyhological Association Division 12;
American Psychological Society
Licensed Psychologist, California
Faye Girsh, Ed.D.
Licensed Psychologist, Colorado
Executive Director, Hemlock Society USA
Denver, Colorado
Judith R. Gordon, Ph.D.
Clinical Professor of Psychology, University of
Douglas C. Haldeman, Ph.D.
Clinical Instructor, Department of Psychology,
University of Washington
Instructor, Department of Counselor Preparation,
Seattle University
President, American Psychological Association Division
44, Society for the Psychological Study of Lesbian
and Gay Issues
Chair, Committee on Lesbian, Gay and Bisexual Concerns
of the American Psychological Association
Governance Committee of the Public Interest
Directorate
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Private Practice, Seattle, Washington
Steven C. Hayes, Ph.D.
Foundation Professor and Chair, Department of
Psychology, University of Nevada
President-Elect, Association for the Advancement of
Behavior Therapy
Past President, American Association of Applied and
Preventive Psychology
Past President, American Psychological Association,
Division 25, Experimental Analysis and Behavior
Past Secretary-Treasurer of the American Psychological
Society
Fellow, American Psychological Society
Neil S. Jacobson, Ph.D.
Professor of Psychology, University of Washington
Past President, Association for Advancement of Behavior
Therapy
Fellow, American Psychological Association
Divisions 12, 43; American Psychological Society
Licensed Psychologist, Washington
Stephen Jamison, Ph.D.
Licensed Psychologist, California
Director, Life & Death Consultations
Mill Valley, California
Craig D. Kain, Ph.D.
Licensed Psychologist, California
Chair, Graduate Program in Psychology
Antioch University at Los Angeles
Los Angeles, California
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Arthur Kobler, Ph.D.
Clinical Professor of Psychology, University of
Washington, retired
Private Practice, Seattle, Washington, retired
Robert K. Kohlenberg, Ph.D.
Associate Professor of Psychology, University of
Washington
Private Practice, Seattle, Washington
David Lester, Ph.D.
Professor, Department of Psychology
Richard Stockton College, Pomona, New Jersey
Executive Director, Center for Study of Suicide
Past President, Interna:« ..al Association for Suicide
Prevention
Blackwood, New Jersey
Bruce S. Liese, Ph.D.
Associate Professor of Family Medicine and Psychiatry
and Associate Chair for Research, Department of
Family Medicine, University of Kansas Medical
School
Director, Kansas City Center for Cognitive Therapy
Marsha M. Linehan, Ph.D.
Professor of Psychology, University of Washington
Adjunct Professor of Psychiatry and Behavorial Sciences,
University of Washington
Director of Suicidal Behaviors Research Clinic
University of Washington
Director of Substance Abuse Research Clinic
University of Washington
Director of Behavioral Research and Therapy Clinic
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G. Alan Marlatt, Ph.D.
Professor of Psychology and Director of Addictive
Behaviors Research Center, University of Washington
Past President of Association for Advancement of
Behavior Therapy
Fellow, American Psychological Association,
Divisions 12, 25, 28, 38, 50;
American Psychological Society
Licensed Psychologist, Washington
David J. Martin, Ph.D.
Director of HIV Mental Health Services at Harbor-
University of California at Los Angeles Medical
Center
Associate Clinical Professor of Psychiatry and
Biobehavioral Sciences, University of California at
Los Angeles School of Medicine
Rob Neils, Ph.D.
Founder and President, Dying Well Network,
Spokane, Washington
Hospice consultant
Private Practice, Spokane, Washington
Jacqueline B. Persons, Ph.D.
Director of the Center for Cognitive Therapy,
Oakland, California
Associate Clinical Professor of Psychiatry,
University of California at San Francisco
Private Practice, San Francisco, California
Robert H. Remien, Ph.D.
Licensed Psychologist, New York
Research Scientist and Assistant Professor, HIV Center for
Clinical and Behavioral Studies, New York State
Psychiatric Institute and Columbia University
New York, New York
James R. Rogers, Ph.D.
Licensed Psychologist, Ohio
Associate Professor, Department of Counseling
Youngstown State University
Youngstown, Ohio
Michael Siever, Ph.D.
Private Practice, San Francisco, California
Past Director of Operation Recovery in San Francisco
(an outpatient substance abuse treatment program)
Peter Thompson, Ph.D., M.Div.
Clinical Instructor of Psychology, University of
Washington
Private Practice
James L. Werth, Jr., Ph.D.
Licensed Psychologist, Arkansas
Mental Health Clinician and Clinical Assistant
Professor of Psychology, University of Arkansas
Fayetteville, Arkansas
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ne Oe a aN nS ede —s
PSYCHIATRISTS
George Burnett, M.D.
Private Practice, Santa Barbara, California
Ivan B. Gendzel, M.D.
Clinical Associate Professor, Department of
Psychiatry and Behavioral Sciences
Stanford University School of Medicine
Life Fellow, American Psychiatric Association
Fellow, American Group Psychotherapy Association
Palo Alto, California
Eric Glassgold, M.D.
Assistant Clinical Professor of Psychiatry,
University of California at San Francisco
Consultant-liaison Psychiatrist, Department of Public
Health, San Francisco and San Francisco Hospital
General Medical Center
Fred Gottlieb, M.D.
Clinical Professor of Psychiatry
University of California, Los Angeles
Los Angeles, California
Lawrence Hartmann, M.D.
Harvard Medical School
Past President, American Psychiatric Association
Cambridge, Massachusetts
Charles H. Kramer, M.D.
Professor Emeritus of Psychiatry and Behavorial Sciences,
Northwestern University Medical School
Founder and Past Director of Center for Family Studies,
Institute of Psychiatry, Northwestern Memorial
Hospital
E. James Lieberman, M.D.
Clinical Professor of Psychiatry
George Washington School of Medicine
Life Fellow, American Psychiatric Association
Washington, DC
Judd Marmor, M.D.
Emeritus Professor of Psychiatry
University of Southern California School of Medicine
Past President, American Psychiatric Association
Los Angeles, California
Richard Martinez, M.D.
Medical Ethicist, Program in Health Care Ethics,
Humanities & Law, University of Colorado
Health Science Center
Denver, Colorado
Jean Munzer, M.D.
Attending Psychiatrist, St. Lukes Hospital (Retired)
New York, New York
Silver Spring, Maryland
Richard R. Palmer, M.D.
Clinical Faculty, Fellow, American Psychiatric
Association, George Washington University
School of Medicine
Washington, DC
William Pollin, M.D.
Assistant Surgeon General, United States Public
Health Service (Retired)
Director, National Institute of Drug Abuse (Retired)
Life Fellow, American Psychiatric Association
Bethesda, Maryland
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Lyman C. Wynne, M.D., Ph.D.
Professor of Psychiatry, University of Rochester,
New York
Special Consultant to Director-General, World Health
Organization, Schizophrenia Research Programs
Past Chair, Board of Trustees, American Association of
Marriage and Family Therapists Research and
Education Foundation
Past Member, Board of Directors, American Association
of Marriage and Family Therapists
Past President, American Family Therapy Association
Past Chair of Psychiatry, University of Rochester School
of Medicine & Dentistry, and Psychiatrist-in-Chief,
Strong Memorial Hospital, Rochester, New York
Past Member, American Psychiatric Association Task
Force on DSM-III
Past Member, American Psychiatric Association Work
Group to Revise DSM-III
COUNSELORS
Pornthip Chalungsooth, Ed.D.
Licensed Professional Counselor, Arkansas
Mental Health Clinician, University of Arkansas
Fayetteville, Arkansas
Jay Craver, M.A.
Registered Mental Health Counselor
Private Practice, Seattle, \/ashington
Charlene M. Kampfe, Ph.D.
Nationally Certified Counselor, University of Arizona
Tucson, Arizona
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Jinny Tesik
Nationally Certified Grief Counselor, Association
for Death Education and Counseling
Adjunct Faculty, City University of Seattle and the
Graduate Program in Psychology, Antioch University,
Seattle, Washington
Founder and Director, Grief and Loss Center, Seattle,
Washington
Founder and Past President, Western Washington
Bereavement Specialists Association
SOCIAL WORKERS
Deborah Cummings, ACSW
Clinical Social Worker
Detroit, Michigan
Lois Chapman Dick, MSW
Clinical Social Worker
Kirkland, Washington
Michael Evans, MSW, JD
Private Consultant to mental health professionals on ethics
Michael Holtby, LCSW, BCD
Psychotherapist, Private Practice
Denver, Colorado
Ilene Kaplan, MS, MSW
Clinical Social Worker
Avon, Connecticut
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John E. King, ACSW, LCSW
Licensed Certified Social Worker
Professor, Department of Sociology,
University of Arkansas
Fayetteville, Arkansas
Midge Levy, ACSW
Home Care and Hospice Social Worker
Member, Executive Committee of the Washington State
Chapter of the National Association of Social Workers
Seattle, Washington
Sallie J. Troy, MSW, ACSW, LCSW
Licensed Clinical Social Worker
National City, California
David Wertheimer, ACSW, M.Div.
ACCESS Project Manager for King County Mental Health
Office, Seattle, Washington
Adjunct faculty, Graduate Program in Psychology,
Antioch University, Seattle, Washington
Private Practice, Seattle, Washington
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National Association of Social Workers
oie ee
Client Self-determination in End-of-Life Decisions
BACKGROUND
End-of-Life decisions are the choices made by a
person with a terminal condition regarding his or her
continuing care or treatment options. These options may
include aggressive treatment of the medical condition, life
sustaining treatment, palliative care, passive euthanasia
voluntary active euthanasia, or physician-assisted suicide.
For the purposes of this policy statement, these terms are
defined as follows:
Terminal and irreversible condition means a
continual profound comatose state with no reasonable chance
of recovery or a condition caused by injury, disease, or
illness, which, within reasonable medical judgment, would
produce death within a short time and for which the
application of life-sustaining procedures would serve only to
postpone the moment of death. There is no universally
accepted definition of “a short time,” but in general it is
considered to be less than one year (American Hospital
Association, 1991).
Client self-determination means the right of the
client to determine the appropriate level, if any, of medical
intervention and the right for clients to change their wishes
about their treatment as their condition changes over time or
during the course of their illness Self-determination
assumes that the client is mentally competent.
Incompetent means lacking the ability, based on
reasonable medical judgment, to understand and appreciate
the nature and consequences of a treatment decision,
including the significant benefits and harms of and
reasonable alternatives to any proposed treatment decision
Advance health care directive is a document in
which a person either states choices for medical treatment or
designates who should make treatment choices if the person
should lose decision-making capacity. Although the term
“advance directive” generally refers to formal, written
documents, it may also include oral statements by the patient
(American Hospital Association, 1991).
Life-sustaining treatment is medical intervention
administered to a patient that prolongs life and delays death
(American Hospital Association, 1991).
Medically inappropriate life-sustaining procedures
means life-sustaining procedures that are not in accord with
the patient’s wishes or that are medically futile.
Palliative care is medical intervention intended to
alleviate suffering, discomfort, or dysfunction but not to cure
(American Hospital Association, 1991).
Passive euthanasia is the withholding or
withdrawing of life-sustaining treatment. It is the forgoing
of treatment, sometimes called “letting die.” The right-to-
die rulings such as in the Karen Ann Quinlin case establish
the right under certain circumstances to be disconnected
from artificial life support.
Voluntary active euthanasia is a physician’s
administering a lethal dose after a clearly competent patient
makes a fully voluntary and persistent request for aid in
dying. This is the active termination of a patient's life by a
physician at the request of the patient.
Physician-assisted suicide is a patient's ending his
or her life with the means requested of and provided by a
physician for that purpose. The physician and the patient are
both involved. Nurses or significant others may also be
involved, but the physician has the responsibility for
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providing the means. In all cases, the patient will have been
determined competent to make such a decision.
Some argue that little distinction exists between
euthanasia and physician-assisted suicide other than
mechanical or technical difference as to who—the patient or
the physician—triggers the event. Others (for example,
Quill, 1991) maintain the difference is significant in that in
assisted suicide the final act is the patient’s; the risk of subtle
coercion from doctors, family, or other social forces is
reduced; the balance of power between patient and physician
is more equal; and there is less risk of error, coercion, or
abuse.
There has been a proliferation of state legislation
related to assisted suicide, including Washington State's
“Death with Dignity” initiative, which was narrowly
defeated in a referendum in 1991, and bills that were in
progress in 1993 in the California, lowa, Maine, Michigan,
and New Hampshire state legislatures. (The Michigan bill
required social work counseling to qualified applicants for
assisted suicide.) Currently, 37 states outlaw actively
helping a patient to die (Brody, 1992).
The Patients’ Self-Determination Act of 1990,
included in the Omnibus Budget Reconciliation Act of 1990,
requires all hospitals participating in Medicare or Medicaid
to ask all adult inpatients if they have advance directives, to
document their answers, and to provide information on state
laws and hospital policies. Other health agencies such as
home health and hospice have instituted similar requirements
(American Hospital Association, 1991). In many of these
facilities, svcial workers are called on to work with patients
regarding advance health care directives and end-of-life
decisions.
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ISSUE STATEMENT
Advances in medical capabilities and technology
have made it possible to extend life through artificial means
that were heretofore unimaginable. Although this level of
care often provides enormous benefits for patients, it may
also present difficult and increasingly complex ethical
choices for patients, their families, and health care
professional. Inappropriate or unwanted utilization of
medical technology may lead to lessened quality of life, loss
of dignity, and loss of integrity of patients.
State and federal legislation related to advance
health care directives has raised public awareness about the
right of patients to participate in medical decision making,
including end-of-life decisions. The individuals most
immediately facing end-of-life decisions are those with a
terminal and irreversible condition, a progressive chronic
illness, or chronic intractable pain.
As advocates for the rights of individuals; as
providers of mental health services; and as workers in
hospitals, hospices, nursing homes, and crisis centers, social
workers regularly deal with quality-of-life issues and choices
related to life and death. Social workers have requested
guidelines that are compatible with professional and personal
ethics, legal parameters, and respect for client self-
determination. Furthermore, other professionals look to
social work for guidelines on these complex issues:
Social work values, our traditional role as advocates
and enablers, and our self-awareness and conscious
use of self should serve as justification for engaging
people in open and honest debate, recognizing the
biases that society and the health care system have
had with respect to the backgrounds, lifestyles, and
iliness of different groups of patients. ... The
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social work community has the opportunity and the
obligation to educate, organize, and advocate for a
more widespread and extensive debate of these life
and death matters. (Mizrahi, 1992)
, In acknowledging and affirming social work’s
commitment to r: spect diverse value systems in a pluralistic
society, end-of-life issues are recognized as controversial
because they reflect the varied value systems of different
groups. Consequently, the National Association of Social
Workers (NASW) does not take a position concerning the
morality of end-of-life decisions, but affirms the right of the
individual to determine the level of his or her care.
It is also recognized that de facto rationing of health
care based on socioeconomic status, color, ability to pay,
provider biases, and government policy differentially affects
people's right to choose among viable service alternatives
and their ability to give truly informed consent. The social
worker should work to minimize the effect of these factors
in determining the care options available to individuals:
. In examining the social work role in working with
clients around end-of-life decisions, the following issues
must be addressed:
® the legal parameters that affect social work practice (for
example, limits of confidentiality, state laws prohibiting
assisted suicide, the potential for civil liability)
@ the potential conflict of social work values with those of
other health care professionals
© the emerging pressures for cost control and rationing of
healthcare (for example, temptation of health care institutions
and insurers to encourage use of end-of-life practices to
control costs)
@ the possibility of patients feeling obliged to choose death
rather than becoming a burden (Brock, 1992)
@ the societal limits on individual self-determination and
autonomy
@ the necessity to define safeguards to protect individual
and society in the implementation of end-of-life practices
POLICY STATEMENT
NASW’s position concerning end-of-life decisions
is based on the principle of client self-determination. Choice
should be intrinsic to all aspects of life and death.
The social work profession strives to enhance the
quality of life; to encourage the exploration of life options;
and to advocate for access to options, including providing all
information to make appropriate choices.
Social workers have an important role in helping
individuals identify the end-of-life options available to them.
This role must be performed with full knowledge of and
compliance with the law and in accordance with the NASW
Code of Ethics (NASW, 1993). Social workers should be
well informed about living wills, durable power of attorney
for health care, and legislation related to advance health care
directives.
A key value for social workers is client self-
determination. Competent individuals should have the
opportunity to make their own choices but only after being
informed of all options and consequences. Choices should
be made without coercion. Therefore, the appropriate role
for social workers is to help patients express their thoughts
and feelings, to facilitate exploration of alternatives, to
provide information to make an informed choice, and to deal
with grief and loss issues.
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Social workers should not promote any particular
means to end one’s life but should be open to full discussion
of the issues and care options. As a client is considering
his or her choices the social worker should explore and help
ameliorate any factors such as pain, depression, need for
medical treatment, and so forth. Further, the social worker
should thoroughly review all available options including, but
not limited to, pain management, counseling, hospice,
nursing home placement, and advance health care directives.
Social workers should act as liaisons with other
health care professionals and help the patient and family
communicate concerns and attitudes to the health care team
to bring about the most responsible assistance possible.
Because end-of-life decisions have familial and
social consequences, social workers should encourage the
involvement of significant others, family, and friends in
these decisions. social workers should provide ongoing
support and be liaisons to families and support persons (for
example, caregivers, significant others) with care to maintain
the patient’s confidentiality. When death occurs, social
workers have an obligation to provide emotional and tangible
assistance to the significant others, family, and friends in the
bereavement process.
Social workers should be free to participate or not
participate in assisted-suicide matters or other discussions
concerning end-of-life decisions depending on their own
beliefs, attitudes, and value systems. If a social worker is
unable to help with decisions about assisted suicide or other
end-of-life choices, he or she has a professional obligation to
refer patients and their families to competent professionals
who are available to address end-of-life issues.
It is inappropriate for social workers to deliver,
supply, or personally participate in the commission of an act
of assisted suicide when acting in their professional role.
Doing so may subject the social worker to criminal charges.
If legally permissible, it is not inappropriate for a social
worker to be present during an assisted suicide if the client
requests the social worker’s presence. The involvement of
social workers in the assisted suicide cases should not
depend on race or ethnicity, religion, age, gender, economic
factors, sexual orientation, or disability.
NASW chapters should facilitate their membership’ s
participation in local, state, and national committees,
activities, and task forces concerning client self-
determination and end-of-life decision. Education and
research on these complex topics should be included in the
social work role.
REFERENCES
American Hospital Association. (1991). Put it in writing.
Chicago: Author.
Brock, D.W. (1992). Voluntary Active Euthanasia, 22
Hastings Center Report 22(2), 10-22.
Brody, J.E. (1992). Doctor-Assisted Suicide: Ever
Acceptable? New York Times.
Mizrahi, T., The direction of patients’ rights in the 1990s:
Proceed with caution, 17 Health & Social Work, 17,
246-262.
National Association of Social Workers. (1993). NASW code
of ethics. Washington, DC: Author.
Patients’ Self-Determination Act of 1990, P.L. 101-508, 104
Stat. 1388 et seq.
Quill, T. (1991). Death and Dignity: A case of
individualized decision making. New England Journal of
Medicine, 324, 691-694.
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This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.