Clinical Note Death with Dignity: The Developing Debate Among Health Care Professionals Brittany N. Oakman, Hope E. Campbell, Lindsay M. Runk The right-to-die movement—known variously as death with dignity, physician-assisted suicide, or aid in dying—remains controversial. The recently publicized death of 29-year-old Brittany Maynard, who chose to end her life through physicianassisted suicide, forced many health care professionals to evaluate or re-evaluate their stance on the issue. Currently, only five states have aid-in-dying laws, but many others have bills under consideration. The legalized process for physicianassisted suicide has a strict set of procedures that physicians and patients must follow to ensure the competency and safety of all parties involved. Opposition against legalizing physician-assisted suicide encompasses more than simply moral, religious, or ethical differences. While some individuals believe that physician-assisted suicide gives patients autonomy in their end-of-life care, health care professionals also may have reservations about the liability of the situation. Pharmacists, in particular, play a pertinent role in the dispensing of, and counseling about, the medications used to assist patients in hastening their death. It is imperative that pharmacists be aware of the intended use of the particular medication so that they can make informed decisions about their participation and ensure that they perform all the necessary steps required to remain compliant with the laws or statutes in their jurisdiction. This practice places an increased burden on pharmacists to evaluate their opinion on the concept of death with dignity and whether or not they want to participate. KEY WORDS: Aid-in-dying, Brittany Maynard, Death with dignity, Physician-assisted suicide, Right-to-die movement. Consult Pharm 2015;30:352-5.
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With the death of Oregon native Brittany Maynard on November 1, 2014, at the age of 29, the concept of “death with dignity” has gained renewed attention. When Maynard was diagnosed with brain cancer in California on January 1, 2014, she underwent a partial craniotomy and a partial resection of her temporal lobe in an effort to stop the growth of her brain tumor. In April 2014 she found that not only had her tumor returned, but that it was more aggressive. Doctors prescribed full-brain radiation and gave her no more than six months to live. Maynard researched radiation and knew her quality of life would deteriorate and that there was no treatment that would save her life. She considered hospice care, but because she was young and had a strong heart, she was worried she could live for years while the cancer destroyed her brain. After researching death with dignity, Maynard decided this was the option she would choose.1 She moved to Oregon to take advantage of its Death with Dignity Act. Death with dignity, often referred to as physician-assisted suicide, is the process by which someone ends his or her life through voluntary self-administration of lethal medications.2 (By contrast, in euthanasia, someone other than the patient administers the lethal medications). While supporters of death with dignity believe that it is a way for individuals to end their lives in a humane and dignified way, this process has continued to generate controversy among health care professionals and the public. By providing a brief overview of state legislation involving death with dignity, analyzing the pros and cons of the concept, and discussing the roles of various members of the health care team, this article will attempt to allow pharmacists to develop their own understanding and opinions on physician-assisted suicide. The concept first stirred widespread debate in the 1990s, when Jack Kevorkian, MD, helped many patients end their lives. As of February 2015, there are only five states that have legislative laws or court rulings that have legalized death with dignity: Oregon, Washington, Montana, New Mexico, and Vermont.3-6 Because of the large discrepancy in beliefs between supporters and opponents, the process of legalizing death with dignity has proven to be challenging for the court system. As of February 2015, states introducing initiatives legalizing
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death with dignity or similar legislation include California, Colorado, Florida, Indiana, Maryland, Minnesota, Missouri, Nevada, New Jersey, New York, Pennsylvania, Wisconsin, and Wyoming. Some states have introduced bills granting legalization, but pending lawsuits have deferred enactment.7 It is crucial for pharmacists and health care professionals in these states to be aware of the changes that may be imminent and affect their professions and their participation. Legalization of physician-assisted suicide is based on the concept that it is a patient’s decision to determine how much suffering is tolerable to him or her, since each individual feels pain differently. States that have passed laws legalizing death with dignity tend to side with the argument that favors patient autonomy.8 The terms and conditions pertaining to physician-assisted suicide are relatively similar in each state where it is legal. Oregon, Vermont, and Washington have specific laws legalizing physician-assisted suicide, while in Montana and New Mexico it was legalized via a court ruling. Vermont is currently the only state that clearly defines the pharmacist’s role, stating that pharmacists are not liable for participating in physician-assisted suicide by providing the medications as long as they follow their state’s legislation in “good faith.” Oregon and Washington’s laws only address health care professionals in general, saying that they will be provided immunity from prosecution if they participate in physician-assisted suicide.3-6 Whether a state does or does not recognize the legality of physician-assisted suicide, the statutes developed establish guidelines to protect physicians from adverse legal consequences. In Oregon there is a strict process that patients and physicians must follow before the patient can actually choose to end his or her life via lethal doses of medications. Before agreeing to physician-assisted suicide, patients must be thoroughly evaluated by a consulting physician to determine if they will die from their terminal illness within six months and that they do not have a mental disorder that may cloud their judgment. The consulting physician must review the patient notes from the primary physician to confirm, in writing, the patient’s terminal diagnosis. To receive a prescription for a lethal
dose of medication, the patient needs to make a verbal request and reiterate the verbal request to the physician no fewer than 15 days after making the initial oral request. After two verbal requests, a written request must then be given to the physician, and the prescription must be written no less than 48 hours after receiving the written request.7 A physician who is registered as a dispensing physician is required to dispense the lethal dosage of medication directly to the patient. If the physician is not a dispensing physician, he or she then must contact a pharmacist beforehand to explain the purpose of the prescription, and the physician must deliver the prescription directly to the pharmacist or send it by mail. The pharmacist is then allowed to dispense the medication directly to the patient, the physician, or the patient’s agent. There is no requirement that the physician be present upon administration of the lethal dosage of medication.2,9 Supporters of death with dignity believe that the legislation simply protects patients’ First Amendment rights in allowing them to make their own decisions regarding their health. In the majority of patients who choose to end their own life, the threat of losing their optimal quality of life is usually the deciding factor in their decision.10 When faced with a terminal diagnosis, these individuals feel very strongly that they want to die pain-free and when they still have control of their own decisions. Since each individual deals with death differently, proponents of physician-assisted suicide maintain that patients should be able to decide for themselves when they feel they are no longer functioning in a way that they see appropriate or worthwhile. While there are numerous supporters of physicianassisted suicide, the majority of the public are either undecided or feel strongly that it should not be legal. The main argument against death with dignity from health care professionals is that it is in direct violation of the Hippocratic Oath that every physician must take before beginning the practice of medicine. Under the Hippocratic Oath, physicians agree to do everything in their power to protect their patients.9 With physician-assisted suicide, the opposition argues that it causes physicians to falsify the patient’s death by stating it was a result of a terminal illness
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Clinical Note rather than truly a “suicide” by a lethal dose of medication. Many health care professionals feel that physician-assisted suicide could be avoided if better end-of-life care were available.8 However, almost 25% of physicians do not discuss end-of-life decisions or the option of hospice with their terminally ill patients.11 Just as physician-assisted suicide gives patients the opportunity to die pain-free and as comfortable as possible, programs like hospice attempt to satisfy those same needs for patients while offering supportive and comfort care. In fact, a large number of patients use hospice services in conjunction with physician-assisted suicide.9 There are numerous hospice centers across the country that offer patients a peaceful, calm environment to spend their last few days or months. To be admitted to hospice, patients must have a terminal diagnosis with a life expectancy of six months or fewer. In a hospice environment, physicians, nurses, chaplains, and social workers work together to ensure patients die comfortably while meeting the needs and wishes of patients and their families. Maintaining quality of life is crucial, so they do everything in their power in terms of creating a serene and pleasant environment.12 Hospice also involves the patient’s family in the dying process through education and support services both before and after the death. While the role of physicians is widely documented, many are questioning what role pharmacists have in physician-assisted suicide and if they are required by law to participate. Pharmacists have autonomy in using their own ethical or moral judgment when it comes to filling a prescription for this purpose. As with most prescriptions, the pharmacist is able to decline to fill the medication, but he or she has to respect the physician-patient relationship and the patient’s wishes.13 It is imperative that the pharmacist knows the intended purpose of the prescription to be able to properly counsel the patient on the medication. Secobarbital, followed by pentobarbital, are currently the drugs of choice for physician-assisted suicide.2 The lethal dose prescribed is 9 g of secobarbital capsules or 10 g of pentobarbital liquid ingested at one time.2 When a prescription medication is being taken for this purpose, it is important that the
354
patient understand how to properly use the medication to avoid complications. For instance, the patient must be told to ingest the entire dose of the medication on an empty stomach and in a short period of time to prevent falling asleep before the entire lethal dose has been taken.10 Pharmacists should also recommend that patients take an antiemetic prior to ingesting the medication to decrease the incidence of nausea and vomiting. An issue that may arise with legalizing physician-assisted suicide is the potential for abuse, which puts an added burden on pharmacists to ensure that the medication is being used for the appropriate purpose. One case of suspected abuse involved Kate Cheney, an 85-year-old woman who was diagnosed with inoperable stomach cancer. Her daughter was accused of “doctor shopping” after consulting multiple practitioners to identify one who would determine her mother was competent to choose physician-assisted suicide. To ensure that her daughter was not coercing her, Cheney was evaluated without her daughter present, and a family meeting was conducted. Eventually, it was deemed that she was competent and acting on her own and was then able to receive the lethal medications, which she chose to administer about a month later.14,15 It is not always easy to detect coercion, and health care professionals need to be deliberate in evaluating each patient case for any potential abuse or undue influence. The concept of death with dignity has generated renewed discussion among health care professionals in the months leading up to and after Maynard’s death. There is an ongoing debate among all parties involved as to whether death with dignity is a morally acceptable act for health care professionals, including physicians and pharmacists. On March 30, 2015, the American Pharmacists Association (APhA), issued a policy statement that discourages pharmacist participation in lethal executions on the basis that such activities are fundamentally contrary to the role of pharmacists as providers of health care.16 Though the issue of physician-assisted suicide was not specifically addressed, it could be implied that APhA is opposed to pharmacists in this role as well. Preparation of lethal medications could create role confusion for patients who see pharmacists as a source of healing, and not death.17
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While there are currently only five states that recognize the legality of physician-assisted suicide, many other states are reviewing physician-assisted suicide or similar programs in an attempt to honor patients’ rights and wishes for a peaceful death. The ongoing debate will continue to gain more media attention as different state legislatures review potential legislation on the right-to-die movement. Brittany N. Oakman, BSc, is a 2015 PharmD candidate, Belmont University College of Pharmacy, Nashville, Tennessee. Hope E. Campbell, PharmD, BCPS, is assistant professor of pharmacy practice, Belmont University College of Pharmacy. Lindsay M. Runk, BSc, is a 2015 PharmD candidate, Belmont University College of Pharmacy. For correspondence: Hope E. Campbell, PharmD, BCPS, Belmont University College of Pharmacy, 1900 Belmont Boulevard, #330 McWorther Hall, Nashville, TN 37212-3757; Phone: 615-460-6530; Fax: 615-460-6537; E-mail: [email protected]. Disclosure: No funding was received for the development of this manuscript. The authors have no potential conflicts of interest. © 2015 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2015.352. References 1. Maynard B. CNN Opinion. My Right to Death with Dignity at 29. Available at http://www.cnn.com/2014/10/07/opinion/maynardassisted-suicide-cancer-dignity/. Accessed November 10, 2014. 2. Fass J, Fass A. Physician-assisted suicide: ongoing challenges for pharmacists. Am J Health Syst Pharm 2011;68:846-9. 3. Oregon Public Health Division. The Oregon Death with Dignity Act: Oregon Revised Statutes. Available at www.oregon.gov/DHS/ ph/pas/docs/statute.pdf. Accessed November 17, 2014. 4. Washington State Hospital Association. Death with Dignity Act. Available at http://www.wsha.org/files/i1000%20text.pdf. Accessed November 17, 2014.
5. Rice J. Robert Baxter v. State of Montana and Steve Bullock. In the Supreme Court of the State of Montana (No. DA 09-0051), brief amicus curiae of International Task Force on Euthanasia & Assisted Suicide. Helena, Montana. LexisNexis Academic; Accessed November 17, 2014. 6. Vermont Department of Health. Patient Choice and Control at End of Life. Available at http://www.leg.state.vt.us/docs/2014/Acts/ ACT039.pdf. Accessed November 17, 2014. 7. Death with Dignity National Center. The Dignity Report: DDNC Spring 2010 Newsletter. Available at www.deathwithdignity. org/2010/03/24/spring-2010-newsletter. Accessed November 10, 2014. 8. ProCon.org. Top 10 Pros and Cons: Should Euthanasia or Physician-Assisted Suicide Be Legal? Available at http://euthanasia.procon.org/view.resource.php?resourceID=000126. Accessed November 10, 2014. 9. Woolfrey J. What happens now? Oregon and physician-assisted suicide. Hastings Center Report 1998;28:9-17. 10. Faber-Langendoen K, Karlawish J. Should assisted suicide be only physician assisted? University of Pennsylvania Center for Bioethics Assisted Suicide Consensus Panel. Ann Intern Med 2000;132:482-7. 11. Berge N, Prerost F, Foltz P. Attitudes of physician assistants to hospice care and assisted suicide. Perspective on Physician Assistant Education 2001;12:177-80. 12. Alive Hospice. Why Alive Hospice? Available at http://www. alivehospice.org/about/about-alive/. Accessed November 10, 2014. 13. American Society of Health-System Pharmacists. ASHP statement on pharmacist’s decision-making on assisted suicide. Am J Health Syst Pharm 1999;56:1661-4. 14. Barnett EH. A family struggle: is mom capable of choosing to die? The Oregonian October 17, 1999:G01. 15. Steinbock B. The case for physician assisted suicide: not (yet) proven. J Med Ethics 2005;31:235-41. Accessed February 16, 2015. 16. Spinnler M. APhA House of Delegates adopts policy discouraging pharmacist participation in executions. American Pharmacists Association. Available at http://www.pharmacist.com/apha-housedelegates-adopts-policy-discouraging-pharmacist-participationexecution. March 30, 2015. Accessed May 4, 2015. 17. White B. American Pharmacists Association votes to discourage pharmacists from participating in executions. Bioethics Today blog. Albany Medical College. Available at http://www.amc.edu/ BioethicsBlog/post.cfm/american-pharmacists-association-votes-todiscourage-pharmacists-from-participating-in-executions. Accessed May 4, 2015.
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With the death of Oregon native Brittany Maynard on November 1, 2014, at the age of 29, the concept of “death with dignity” has gained renewed attention. When Maynard was diagnosed with brain cancer in California on January 1, 2014, she underwent a partial craniotomy and a partial resection of her temporal lobe in an effort to stop the growth of her brain tumor. In April 2014 she found that not only had her tumor returned, but that it was more aggressive. Doctors prescribed full-brain radiation and gave her no more than six months to live. Maynard researched radiation and knew her quality of life would deteriorate and that there was no treatment that would save her life. She considered hospice care, but because she was young and had a strong heart, she was worried she could live for years while the cancer destroyed her brain. After researching death with dignity, Maynard decided this was the option she would choose.1 She moved to Oregon to take advantage of its Death with Dignity Act. Death with dignity, often referred to as physician-assisted suicide, is the process by which someone ends his or her life through voluntary self-administration of lethal medications.2 (By contrast, in euthanasia, someone other than the patient administers the lethal medications). While supporters of death with dignity believe that it is a way for individuals to end their lives in a humane and dignified way, this process has continued to generate controversy among health care professionals and the public. By providing a brief overview of state legislation involving death with dignity, analyzing the pros and cons of the concept, and discussing the roles of various members of the health care team, this article will attempt to allow pharmacists to develop their own understanding and opinions on physician-assisted suicide. The concept first stirred widespread debate in the 1990s, when Jack Kevorkian, MD, helped many patients end their lives. As of February 2015, there are only five states that have legislative laws or court rulings that have legalized death with dignity: Oregon, Washington, Montana, New Mexico, and Vermont.3-6 Because of the large discrepancy in beliefs between supporters and opponents, the process of legalizing death with dignity has proven to be challenging for the court system. As of February 2015, states introducing initiatives legalizing
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Death with Dignity: The Debate Among Health Care Professionals
death with dignity or similar legislation include California, Colorado, Florida, Indiana, Maryland, Minnesota, Missouri, Nevada, New Jersey, New York, Pennsylvania, Wisconsin, and Wyoming. Some states have introduced bills granting legalization, but pending lawsuits have deferred enactment.7 It is crucial for pharmacists and health care professionals in these states to be aware of the changes that may be imminent and affect their professions and their participation. Legalization of physician-assisted suicide is based on the concept that it is a patient’s decision to determine how much suffering is tolerable to him or her, since each individual feels pain differently. States that have passed laws legalizing death with dignity tend to side with the argument that favors patient autonomy.8 The terms and conditions pertaining to physician-assisted suicide are relatively similar in each state where it is legal. Oregon, Vermont, and Washington have specific laws legalizing physician-assisted suicide, while in Montana and New Mexico it was legalized via a court ruling. Vermont is currently the only state that clearly defines the pharmacist’s role, stating that pharmacists are not liable for participating in physician-assisted suicide by providing the medications as long as they follow their state’s legislation in “good faith.” Oregon and Washington’s laws only address health care professionals in general, saying that they will be provided immunity from prosecution if they participate in physician-assisted suicide.3-6 Whether a state does or does not recognize the legality of physician-assisted suicide, the statutes developed establish guidelines to protect physicians from adverse legal consequences. In Oregon there is a strict process that patients and physicians must follow before the patient can actually choose to end his or her life via lethal doses of medications. Before agreeing to physician-assisted suicide, patients must be thoroughly evaluated by a consulting physician to determine if they will die from their terminal illness within six months and that they do not have a mental disorder that may cloud their judgment. The consulting physician must review the patient notes from the primary physician to confirm, in writing, the patient’s terminal diagnosis. To receive a prescription for a lethal
dose of medication, the patient needs to make a verbal request and reiterate the verbal request to the physician no fewer than 15 days after making the initial oral request. After two verbal requests, a written request must then be given to the physician, and the prescription must be written no less than 48 hours after receiving the written request.7 A physician who is registered as a dispensing physician is required to dispense the lethal dosage of medication directly to the patient. If the physician is not a dispensing physician, he or she then must contact a pharmacist beforehand to explain the purpose of the prescription, and the physician must deliver the prescription directly to the pharmacist or send it by mail. The pharmacist is then allowed to dispense the medication directly to the patient, the physician, or the patient’s agent. There is no requirement that the physician be present upon administration of the lethal dosage of medication.2,9 Supporters of death with dignity believe that the legislation simply protects patients’ First Amendment rights in allowing them to make their own decisions regarding their health. In the majority of patients who choose to end their own life, the threat of losing their optimal quality of life is usually the deciding factor in their decision.10 When faced with a terminal diagnosis, these individuals feel very strongly that they want to die pain-free and when they still have control of their own decisions. Since each individual deals with death differently, proponents of physician-assisted suicide maintain that patients should be able to decide for themselves when they feel they are no longer functioning in a way that they see appropriate or worthwhile. While there are numerous supporters of physicianassisted suicide, the majority of the public are either undecided or feel strongly that it should not be legal. The main argument against death with dignity from health care professionals is that it is in direct violation of the Hippocratic Oath that every physician must take before beginning the practice of medicine. Under the Hippocratic Oath, physicians agree to do everything in their power to protect their patients.9 With physician-assisted suicide, the opposition argues that it causes physicians to falsify the patient’s death by stating it was a result of a terminal illness
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Clinical Note rather than truly a “suicide” by a lethal dose of medication. Many health care professionals feel that physician-assisted suicide could be avoided if better end-of-life care were available.8 However, almost 25% of physicians do not discuss end-of-life decisions or the option of hospice with their terminally ill patients.11 Just as physician-assisted suicide gives patients the opportunity to die pain-free and as comfortable as possible, programs like hospice attempt to satisfy those same needs for patients while offering supportive and comfort care. In fact, a large number of patients use hospice services in conjunction with physician-assisted suicide.9 There are numerous hospice centers across the country that offer patients a peaceful, calm environment to spend their last few days or months. To be admitted to hospice, patients must have a terminal diagnosis with a life expectancy of six months or fewer. In a hospice environment, physicians, nurses, chaplains, and social workers work together to ensure patients die comfortably while meeting the needs and wishes of patients and their families. Maintaining quality of life is crucial, so they do everything in their power in terms of creating a serene and pleasant environment.12 Hospice also involves the patient’s family in the dying process through education and support services both before and after the death. While the role of physicians is widely documented, many are questioning what role pharmacists have in physician-assisted suicide and if they are required by law to participate. Pharmacists have autonomy in using their own ethical or moral judgment when it comes to filling a prescription for this purpose. As with most prescriptions, the pharmacist is able to decline to fill the medication, but he or she has to respect the physician-patient relationship and the patient’s wishes.13 It is imperative that the pharmacist knows the intended purpose of the prescription to be able to properly counsel the patient on the medication. Secobarbital, followed by pentobarbital, are currently the drugs of choice for physician-assisted suicide.2 The lethal dose prescribed is 9 g of secobarbital capsules or 10 g of pentobarbital liquid ingested at one time.2 When a prescription medication is being taken for this purpose, it is important that the
354
patient understand how to properly use the medication to avoid complications. For instance, the patient must be told to ingest the entire dose of the medication on an empty stomach and in a short period of time to prevent falling asleep before the entire lethal dose has been taken.10 Pharmacists should also recommend that patients take an antiemetic prior to ingesting the medication to decrease the incidence of nausea and vomiting. An issue that may arise with legalizing physician-assisted suicide is the potential for abuse, which puts an added burden on pharmacists to ensure that the medication is being used for the appropriate purpose. One case of suspected abuse involved Kate Cheney, an 85-year-old woman who was diagnosed with inoperable stomach cancer. Her daughter was accused of “doctor shopping” after consulting multiple practitioners to identify one who would determine her mother was competent to choose physician-assisted suicide. To ensure that her daughter was not coercing her, Cheney was evaluated without her daughter present, and a family meeting was conducted. Eventually, it was deemed that she was competent and acting on her own and was then able to receive the lethal medications, which she chose to administer about a month later.14,15 It is not always easy to detect coercion, and health care professionals need to be deliberate in evaluating each patient case for any potential abuse or undue influence. The concept of death with dignity has generated renewed discussion among health care professionals in the months leading up to and after Maynard’s death. There is an ongoing debate among all parties involved as to whether death with dignity is a morally acceptable act for health care professionals, including physicians and pharmacists. On March 30, 2015, the American Pharmacists Association (APhA), issued a policy statement that discourages pharmacist participation in lethal executions on the basis that such activities are fundamentally contrary to the role of pharmacists as providers of health care.16 Though the issue of physician-assisted suicide was not specifically addressed, it could be implied that APhA is opposed to pharmacists in this role as well. Preparation of lethal medications could create role confusion for patients who see pharmacists as a source of healing, and not death.17
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While there are currently only five states that recognize the legality of physician-assisted suicide, many other states are reviewing physician-assisted suicide or similar programs in an attempt to honor patients’ rights and wishes for a peaceful death. The ongoing debate will continue to gain more media attention as different state legislatures review potential legislation on the right-to-die movement. Brittany N. Oakman, BSc, is a 2015 PharmD candidate, Belmont University College of Pharmacy, Nashville, Tennessee. Hope E. Campbell, PharmD, BCPS, is assistant professor of pharmacy practice, Belmont University College of Pharmacy. Lindsay M. Runk, BSc, is a 2015 PharmD candidate, Belmont University College of Pharmacy. For correspondence: Hope E. Campbell, PharmD, BCPS, Belmont University College of Pharmacy, 1900 Belmont Boulevard, #330 McWorther Hall, Nashville, TN 37212-3757; Phone: 615-460-6530; Fax: 615-460-6537; E-mail: [email protected]. Disclosure: No funding was received for the development of this manuscript. The authors have no potential conflicts of interest. © 2015 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2015.352. References 1. Maynard B. CNN Opinion. My Right to Death with Dignity at 29. Available at http://www.cnn.com/2014/10/07/opinion/maynardassisted-suicide-cancer-dignity/. Accessed November 10, 2014. 2. Fass J, Fass A. Physician-assisted suicide: ongoing challenges for pharmacists. Am J Health Syst Pharm 2011;68:846-9. 3. Oregon Public Health Division. The Oregon Death with Dignity Act: Oregon Revised Statutes. Available at www.oregon.gov/DHS/ ph/pas/docs/statute.pdf. Accessed November 17, 2014. 4. Washington State Hospital Association. Death with Dignity Act. Available at http://www.wsha.org/files/i1000%20text.pdf. Accessed November 17, 2014.
5. Rice J. Robert Baxter v. State of Montana and Steve Bullock. In the Supreme Court of the State of Montana (No. DA 09-0051), brief amicus curiae of International Task Force on Euthanasia & Assisted Suicide. Helena, Montana. LexisNexis Academic; Accessed November 17, 2014. 6. Vermont Department of Health. Patient Choice and Control at End of Life. Available at http://www.leg.state.vt.us/docs/2014/Acts/ ACT039.pdf. Accessed November 17, 2014. 7. Death with Dignity National Center. The Dignity Report: DDNC Spring 2010 Newsletter. Available at www.deathwithdignity. org/2010/03/24/spring-2010-newsletter. Accessed November 10, 2014. 8. ProCon.org. Top 10 Pros and Cons: Should Euthanasia or Physician-Assisted Suicide Be Legal? Available at http://euthanasia.procon.org/view.resource.php?resourceID=000126. Accessed November 10, 2014. 9. Woolfrey J. What happens now? Oregon and physician-assisted suicide. Hastings Center Report 1998;28:9-17. 10. Faber-Langendoen K, Karlawish J. Should assisted suicide be only physician assisted? University of Pennsylvania Center for Bioethics Assisted Suicide Consensus Panel. Ann Intern Med 2000;132:482-7. 11. Berge N, Prerost F, Foltz P. Attitudes of physician assistants to hospice care and assisted suicide. Perspective on Physician Assistant Education 2001;12:177-80. 12. Alive Hospice. Why Alive Hospice? Available at http://www. alivehospice.org/about/about-alive/. Accessed November 10, 2014. 13. American Society of Health-System Pharmacists. ASHP statement on pharmacist’s decision-making on assisted suicide. Am J Health Syst Pharm 1999;56:1661-4. 14. Barnett EH. A family struggle: is mom capable of choosing to die? The Oregonian October 17, 1999:G01. 15. Steinbock B. The case for physician assisted suicide: not (yet) proven. J Med Ethics 2005;31:235-41. Accessed February 16, 2015. 16. Spinnler M. APhA House of Delegates adopts policy discouraging pharmacist participation in executions. American Pharmacists Association. Available at http://www.pharmacist.com/apha-housedelegates-adopts-policy-discouraging-pharmacist-participationexecution. March 30, 2015. Accessed May 4, 2015. 17. White B. American Pharmacists Association votes to discourage pharmacists from participating in executions. Bioethics Today blog. Albany Medical College. Available at http://www.amc.edu/ BioethicsBlog/post.cfm/american-pharmacists-association-votes-todiscourage-pharmacists-from-participating-in-executions. Accessed May 4, 2015.
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