The Right to Assisted Dying in the UK

Ali Raza

End of life issues are one of the more complicated and controversial matters in medical law. Assisted Suicide is one of the issues1, currently a contentious one in many countries. Much ink has been expended by legal commentators and academics regarding the legal, ethical and wider issues surrounding this hotly debated topic. The underlying question of the debate is: if a terminally ill person decides that they wish to end their life, is it acceptable for others to assist them? This would normally take the form of a doctor administering a lethal injection, which would end their life painlessly. To answer this question, this paper will be dissected into three sections: the first section will examine and comment on the current law on assisted suicide. The second section will discuss the ethical and moral issues. The third section will consider evidence from abroad. In turn the essay will try to engage into a debate as to the arguments for and against it, to signify the deeply rooted division within academics, as to its legalization. In doing so it will try to reach a reasoned conclusion.

Section I

Under section two of the Suicide Act 1961, assisted suicide is illegal. S2 (1) states that it is an offence to aid, abet, counsel, or procure another to commit or attempt suicide, punishable up to a term of 14 years.2 S2 (4) states that no case shall be instituted without the consent of the Director of public prosecutions.3 This act is not short of critics, Richard Tur believes subsection 2(4) is merely to prevent prosecutions for assisted suicide which are not in the public interest; he goes on to say that it is a legislative attempt to avoid injustice without too seriously compromising sanctity of life.4

There are two reasons why people may need assistance in suicide; firstly, they may be physically incapable of arranging their suicide. Secondly, they may lack the knowledge or expertise needed in a quick and painless death.5The cases of Pretty6 and Purdy7 lie at the heart of the assisted suicide debate. The distinction between the two was that, in Pretty she asked for immunity for her husband, whereas Purdy was asking for prosecutor policy, so that she could make an informed decision about her life. The Pretty case highlighted the

Euthanasia is the other main issue. Suicide Act 1961, S2 (1) 3 Ibid, S2 (4) 4 Richard. HS Tur, Legislative techniques and human rights: The sad case of Assisted suicide (2003) Criminal Law Review 3-12 5 Emily Jackson, Medical Law, Text, Cases, and Materials (OUP Oxford 2006); Pg 916 6 R. (On the application of Pretty) v Director Of Public Prosecutions (2002) 1 AC 800 HL. 7 R (on the application of Purdy) v Director of Public Prosecutions [2009] UKHL 45
1 2

uneasiness surrounding the law. The Uncertainty continued until the Purdy case, which eventually led to the development of the Director of Public Prosecutions guidelines. Keir Starmer QC, DPP, said, what it does is to provide a clear framework for prosecutors to decide which cases should proceed to court and which should not. 8

Proponents for legalization argue there exist Inconsistencies and double standards in the current law. For example a doctors use of drugs to reduce pain will often be justified notwithstanding that this will hasten the moment of death.9 This is known as the doctrine of double effect. What is the difference between prescribing drugs that will ease a persons suffering but kill them in five years and prescribing drugs which lead to death instantly? Both situations lead to death, yet the latter is prohibited. This doctrine is also in conflict with ordinary principles of criminal law. The House of Lords in Woolin10 held that a person has the requisite mens rea for murder if they engage in conduct, which is virtually certain to cause death. Williams believes, when a result is foreseen as certain, it is the same as if it were intended or desired.11 However, a doctor may dispense drugs to ease a persons suffering, knowing fully well that it will hasten death. That does not mean that the doctor intends or desires the persons death despite knowing that it is a virtual certainty. Does this mean that there are problems in basic criminal law itself? Wilkinson sheds further light on this troubled area, he states that no one knows what is going on inside the doctors head when he is administering the drugs. Therefore, the acceptance of this doctrine might make it possible to kill patients intentionally whilst intending that there death is an unintended side effect.12

It is a well-established principle that a competent patient has the right to refuse treatment even if their refusal will lead to their death.13 The issue is as Pattinson states, a doctor, who complies with a valid refusal of treatment, (i.e.: stopping a ventilator or food supply) is not viewed as actively ending or assisting in the ending of a patients life. In contrast a doctor
DPP guidelines can be accessed at the CPS website, alongside Keir Stramers statement. http://www.cps.gov.uk/news/press_releases/144_09/ (last access, 03/01/2012) 9 Lord Donaldson in Re J (Wardship medical treatment) (1991) 2 WLR 140, 10 R v Woolin (1999) 1 AC 82 HL 11 Glanville Williams, Sanctity of Life and the Criminal Law (Faber London 1957) 286 12 Stephen Wilkinson, Palliative care and the doctrine of double effect, in Donna Dickenson, Malcolm Johnson, and Jeanne Samson Katz (eds), Death, Dying and Bereavement, (2nd Ed Sage London 2000) 299-302. 13 See, Lord Goffs judgment, In Airedale NHS Trust v Bland (1993) AC 789 Also see, British Medical Association guidance to doctors; Withholding and withdrawing life prolonging treatment: guidance for decision making (2 nd Ed 2001) paras 9.1-9.3 Also see, Ms B v An NHS Trust EWHC 429
8

who leaves pills bedside to a patient to swallow commits a crime.14 The former is described as carrying out an omission or negative act, whereas the latter is seen as a positive act procuring the death of the patient. Not only has this principle contradicted basic principles of criminal law15 it has attracted vehement criticism from academics. Kennedy states, to describe turning off the machine as an omission represents an attempt to solve the problem by logic chopping.16 Otlowski, similarly suggest such an omission represents an approach, which favours practicality rather than logic.17 Jackson believes that the current stance on life shortening practices is incoherent and morally irrelevant, if we are prepared to engage in practices, which may end a patients life, then there is no logical reason why we should not also allow doctors to give their patients lethal injections. She further alludes to the point that the current lawful means of hastening death results in an in inhumane and distressful death, whereas the unlawful means is humane.18 It appears academics are not the only ones furious with such a standpoint, Lord Mustill describes it as intellectually and morally dubious.19 Does letting someone die become just as morally unacceptable as assisting in killing them? The current law does not seem to think so, this is a major loophole in the law and proponents of legalization have pounced to seize the opportunity to question it. Their arguments are based on reason and logic and the law must address them sooner rather than later if it is to continue using this incoherent approach. The DPP guidance20 has also been the subject of widespread criticism. The Commission on Assisted Dying21 offers a wonderful analysis into the limitations of the guidance. Professor Raymond Tallis states that, it has created uncertainty and confusion in the law, where people feel more vulnerable to the lottery of the law.22 Diametrically differing David Congdon thought that the DPP had probably got the balance about right, in what is frankly a very difficult area.23 One man taking part in a DEMOS focus group stated, What it boils
Shaun Pattinson, Medical Law and Ethics, (3rd edition Sweet & Maxwell 2011), Page 541 An omission can constitute the actus reus of murder if the defendant was under a duty to act. The issue was raised in the case of Anthony Bland 16 Ian Kennedy, Treat Me Right Essays in Medical Law and Ethics, (Clarendon Press); (1991) page 351 17 Margaret Otlowski, Voluntary Euthanasia and Common Law (OUP Oxford 2000) 163 18 Emily Jackson, Whose Death is it Anyway? Euthanasia and the Medical Profession (2004) 57 Current legal Problems 415 - 442 19Airedale NHS Trust v Bland (1993) AC 789, at (887) 20 Supra note 8 21 The Commission on Assisted Dying, January (2012-01-05), (DEMOS), page 92-105 Can be accessed at the DEMOS website; http://www.demos.co.uk/publications/thecommissiononassisteddying (last access, 24-01-12) 22 Ibid, Written evidence from Healthcare Professionals for Assisted Dying, cite n199 23 Ibid , pg 90
14 15

down to is Director of Public Prosecutions why? Who elects him? The legal system needs to be sorted out, you cant leave it to one man.24 Frey further argues that the current approach discriminates against those who may be suffering unbearable pain but because they are not attached to a ventilator or life support machine, etc, they have no lawful means of ending their lives.25 The 2012 report also shows that the current approach also discriminates against those who are physically not capable of ending their own life. Tony Nicklinson who was paralysed following a stroke in 1995 told the commission, it takes away the right to determine where, when and how a person may die as soon as that person becomes disabled and needs help, such discrimination is wrong and would not be tolerated in any other situation.26 The report offers a comprehensive analysis of the limitations of the current approach27, but due to a word constraint, this essay is unable to offer a detailed account.

Section II

Respect for patient autonomy is one the strongest arguments in favour of legalizing assisted suicide, and has been at the forefront of the fight for legalization. Jackson believes if Human freedom is to have real meaning, it must involve the right to take what others may see as unwise or even bad decisions in respect of themselves; were that not so, freedom would be rather illusory.28 We live in so-called liberal society, where we embrace free will, where people can act on their mind with certain exceptions. So should people of sound mind have the right to end their life? Law argues that people have a profound interest in how they die. Giving patients power over how they die is a critical feature for autonomous decisionmaking. Assisted suicide gives them a measure of autonomy, when they have lost control over other significant aspects of their life.29 Keown believes that such an approach is loose talk and overlooks the wider repercussions on society.30 Jackson highlights the problem of relying exclusively on the principle of autonomy, just because a person wants to die is not a sufficient reason for a doctor to give her a lethal

Ibid, Bazalgette and Cheetham, Report to the Commission on Assisted Dying, cite n200 RG Frey, Distinction in death 17-42 in Gerald Dworkin, RG Frey, and Sissela Bok, Euthanasia and Physician Assisted Suicide: For and Against (CUP Cambridge 1998) 36 - 38 26 Supra note 21, Written statement from Tony Nicklinson, cite n224 27 Ibid, pg92 - 105 28 Jackson (note 5), page 914 29Sylvia Law, Physician assisted death: An essay on constitutional rights and remedies (1996) 55 Maryland Law Review 292 30 John Keown, Euthanasia, Ethics and Public Policy: An argument against legalization (CUP Cambridge 2002) 54
24 25

injection.31 Advocates of legalization have foreseen such a problem, and propose that the ultimate decision would lie in the hands of the doctor, who could legitimately turn down a patients request.32

The Value or sanctity of life is a fundamental ethical argument, which lies at the core of the assisted dying debate. It is an argument that can be conceptualised in a number of ways and thus produce different conclusions.33 On one hand there is the argument against legalization, this often derives from the religious idea that life is god given, and it is not for us to decide when to end it. The 2012 commission on assisted dying received a number of submissions from representatives of different religions affirming the above. 34 The report also notes that there are changing attitudes in Christianity and Judaism, which suggest a shift from the traditional though of outright prohibition, to circumstances where assisted suicide should be accepted. 35 Otlowski believes that religion is a matter of personal commitment, it should not dominate the law nor impinge on the freedom of others. Her argument carries weight, we live in an increasingly secular society, where the freedom of non-believers must be respected. 36 Diametrically differing, there is the argument that a human life should not be made to suffer, people should be allowed to die with dignity. In other words life is an instrumental vehicle to other goods; if that vehicle is substantially broken, maybe its time to abandon it.37

Campbell illustrates that the slippery slopes argument is one that is cited strongly by opponents of legalization. She believes that even if doctor assisted suicide was to be morally permissible and effectively regulated, the cumulative effect of legal toleration would produce greatly undesired effects.38 Therefore, what are these undesired effects? Academics have voiced the concern that patients may be the subject of professional abuse. Battin believes that a terminal illness
Jackson (note 5), Page 941 David Orentlicher, The Alleged Distinction between euthanasia and the withdrawal of life sustaining treatment: conceptually incoherent and impossible to maintain (1998) University of Illinois Law Review 837, 847-8. 33 Supra note 21, page 73 34 Ibid, page 73 -77 35 Ibid, See also this story of a doctor helping his patients to die out of Christian compassion, http://www.guardian.co.uk/society/2010/jun/19/howard-martin-doctor-euthanasia (last access, 2101-12). 36 Otlowski ( note 17), page216 37 Supra note 21, page 74 38 Courtney S Campbell, 'Aid-in dying and the taking of human life; Journal of Medical Ethics 1992,18,128-134
31 32

can place a person in a particularly compromised position. The physician has the capacity to shape a patients choice by selective control of information.39 Wolf further highlights that a patients judgment may be debilitated by their condition, thus it may be hard to determine whether their wish to die is genuine.40 However, such an argument fails to take into consideration that if the law was to be reformed, it would put stringent safeguards in place to deal with such an issue.41 Yet, Callahan and White state that, doctor and patent discussions cannot be controlled, and thus to some extent the risk will always exist.42 Biggs picks up an issue, which may not be so easy to address, she states severely ill patients may not want to burden their families and friends and thus request assisted suicide. Even though she is predicting what may happen in hindsight, her argument is reasoned, people feel concerned at the prospect of being cared for ,and society no longer value them once they reach this state. 43 Thus, they may feel that assisted suicide is the only viable option. However, a notable point is that, not everybody feels this way, many people want to live their life to the end, thus such an argument must not be generalised. Gormally further argues that assisted suicide may be a convenient and cost effective solution as opposed to the expensive palliative care to terminally ill patients for the NHS.44 The 2012 commission acknowledges while such issues exist, they are largely over emphasized.45

Some commentators believe that an improvement in the level of palliative care makes the idea of legalising assisted suicide redundant.46 The idea being that if everybody received optimum care, no one would seek assisted suicide. However, Jackson further points out that evidence from Oregon47 highlights that, while optimum care may be able to minimize
Margaret Pabst Battin, The least worst death, Essay in Bioethics on the End of Life (OUP Oxford 1994) 167-71; See also, Leon R Kraas and Nelson Lund, Physician Assisted Suicide, Medical Ethics and the Future of the Medical Profession (1996) 35 Duquesne Law Review 395, 406 8. 40 Susan M Wolf, Pragmatism in the Face of Death: The Role of facts in the Assisted suicide Debate (1998) 82 Minnesota Law Review 1063, 1074-7 41 Supra note 21, Key elements that should underpin a safeguarded framework for assisted dying, (Ensure the person has been fully informed of all available options for treatment and care, page 29). 42 Daniel Callahan and Margot White, The Legalization of Physician-Assisted Suicide: Creating a Regulatory Potemkin Village (1996) 30 University of Richmond Law Review 1, 8-11. 43 Hazel Biggs, I Dont Want to be a Burden! A Feminist reflects on womens Experiences on Death and Dying in S. Sheldon and M Thompson (eds), Feminist Perspectives on Health Care Law (Cavendish London 1998) 279 95, 292, 294 -5 44 Luke Gormally, Euthanasia and Assisted Suicide: 7 Reasons why they should not be legalized 286 290 in Donna Dickenson, Malcolm Johnson, and Jeanne Samson Katz (eds), Death, Dying and Bereavement (2nd Ed Sage London 2000) 285 287. 45 Supra note 21, page 185-189 46 Jackson (note 5), page 947 47 Oregon department of Human services, Fifth Annual report on Oregons Death with Dignity Act (2002); can be accessed here; http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAc t/Documents/year5.pdf; (last access, 25-01-12)
39

physical pain, it is less clear that it can eradicate mental anguish.48 This was later affirmed in the 2012 commission.49 The House of Lords select committee on assisted dying reports, that the Voluntary Euthanasia Society took the view that no amount of palliative care can address some patients concerns, there are patients for whom even the best of palliative care is not dealing with their pain.50 The commission on Assisted Dying reports that the current economic climate means that the funding required to provide optimum level of palliative care for everyone is no longer a practical option. The limited amount of resources has led to unequal access to end of life care.51 A number of social and health care professionals who gave evidence to the 2012 commission shed further light on the deficiencies of the current system of palliative care. Suzie Croft and Dr Tookman, state that certain conditions are favoured by the system, i.e.: Cancer patients, whereas those with heart problems may not be given preference.52 Nonetheless, the commission continues to support improvements in palliative care, it does not see assisted dying as an alternative to end of life care and vice versa.53In addition, The European Association on Palliative Care reports from its findings from jurisdictions where assisted suicide is legal, that there is no reason why palliative care and assisted suicide cannot exist together.54

The effect on the doctor patient relationship is one of the strongest arguments against legalization. For a just debate both the patient and doctors views must be considered. The 2012 commission provides first hand evidence into the different views of healthcare professionals.55 The fundamental issue is that legalization would lead to detrimental trust issues between the patient and doctor. What can be concluded from this report is that doctors are very much split in their views on the above point. For example one doctor said, Hastening death of patients is not part of medical practice and any change in legalising killing or assisted suicide would damage the trust and relationship between patients and

Jackson (note 5), page 948 Supra note 21, page 120 121, see Professor Michael Bennett, Dr Adrian Tookman evidence. 50 Assisted Dying for the Terminally Ill Committee, Assisted Dying for the Terminally Ill Bill First Report (2005) para 88; can be accessed here; http://www.publications.parliament.uk/pa/ld200405/ldselect/ldasdy/86/8602.htm, (last access 2401-12) 51 T Hughes-Hallet, A Craft and C Davies, Funding the Right Care and Support for Everyone: Creating a fair and transparent funding system; the final report of the Palliative Care Funding Review (2011). http://palliativecarefunding.org.uk/wp-content/uploads/2011/06/PCFRFinal%20Report.pdf (last access, 18-01-12) page 11 52 Supra Note 21, page 111 53 Ibid, page 314 54 Ibid, page161; Chambaer et al, Palliative care development in countries with a euthanasia law. 55 Ibid, page 85-87 & 125-9
48 49

doctors.56 On the other hand another physician believed that legalisation of assisted dying could improve the doctorpatient relationship.57 A 2004 poll found that 70 per cent of patients stated that legalization of assisted suicide would not affect their trust or relationship with the doctor, whereas 9 per cent said it would.58 Despite these positive findings, Jackson has questioned their validity, stating that much depends on the way in which a particular question is framed.59 The General Medical Council took the view that to allow physician assisted suicide would have profound implications for the role and responsibilities of doctors60. The question is would doctors really want to specialize in assisting a patient to die? A view shared by the British medical Association.61 Are doctors trained to kill? If it were to be legalized, would the training of doctors need to be revamped? Or should we leave it to professional practitioners? Academics such as Kass and Lund62 and Jackson believe that an absolute taboo against medical killing is necessary to preserve patient trust in the medical profession.63 Section III The final step in considering whether or not assisted suicide should be legalized in this country is to examine evidence from other states where this practice is legal. Unsurprisingly the problem is that commentators cannot agree on the lessons we can learn from the Dutch and Oregon examples. Griffiths suggests that the Netherlands example portrays the benefits that flow from openly regulating a socially dangerous medical practice. While he accepts that physicians have long engaged in underground activity64, he accepts such practice cannot be controlled. However he states that those who criticize the Dutch are confused about the direction in which the slippery slope is tilting.65 However, Keown believes that the benefits of regulation arguments merit scepticism. He states that a majority of cases still go unreported and unchecked.66 Meanwhile, there are two other

Ibid, Anonymous written evidence from a physician, page 84 Ibid, evidence from Dr Field from the Medical Protection Society, page 127 58 Supra note 50, para 77 59 Jackson (note 5), page 954 60 Supra note 50, para 42 61 Ibid, para 43 62 Leon R Kass and Nelson Lund, Physician Assisted Suicide, Medical Ethics and the Future of the Medical Profession (1996) 35 Duquesne Law Review 395, 402 408-10, 418-9, 424 63 Jackson (note 5), page 955 - 956 64 RS. Magnusson, Euthanasia: above ground, below ground (2004) 30 Journal of Medical Ethics 441-, 441-1, 445; believes that the alternative to legalization is that it will be performed illegally, hence the term underground. 65 John Griffiths, Assisted Suicide in the Netherlands: The Chabot chase (1995) 58 Law Review, pages 232-48 66 Keown (Note 30), page 146-147, 149
56 57

notable points, Dutch people have the utmost trust and respect for doctors67, thus the Dutch example may not have international relevance.68 Nys interestingly points out that despite euthanasia and assisted suicide being legal in the Netherlands, it is the latter that is more commonly practiced.69 How significant such a fact will have impact in the UK is not known. Academics are also split in opinion over the success in Oregon; Brock argues that there has been no evidence of abuse.70 However, White and Callahan offer a more convincing argument, the Oregon law does not require doctors to report cases whether they follow the guidelines or depart from them.71 Suggesting Oregon is heading down the slippery slopes alley. Thus, Brody concluded well that, Oregon is powerless to police or detect cases which fall outside its guidelines.72

So is legalization likely? It is clear that the current legal framework is contradictory, discriminate and flawed to say the least. There is a growing consensus among academics and the general population who seek clarity and a change in the law.73 The ever-present conflict between utilitarians and deontologists continues to rage. On the one hand, if we are to become a truly liberal society, legalization is necessary. However, religion has always and will continue to play a major part in society; we must not turn a blind eye on the potentially harmful effects of legalization. Thus, both ethical arguments carry equal weight. The idea of optimum palliative care offers a sensible alternative, however with the limited resources available such a proposal is illusory, furthermore as Pattinson points out medicine is not a science of mathematical certainties,74 in the sense that medicine is not infallible, thus even the best of care and advice may not be enough. The evidence from abroad is inconclusive, with academics failing to agree whether legalization was a success or not. The commission on Assisted Dyings 2012 report represents the best hope for those trying to convince the judiciary to reform the area. It pictures a detailed overview of the current situation and

Supra note 50, para 41 John Griffiths, Alex Bood, and Heleen Weyers, Euthanasia and Law in the Netherlands (Amsterdam UP 1998) page 304 69 Herman Nys, Physician Involvement in a Patients Death: A Continental European Perspective (1999) 7 Medical Law Review, page 208-46, 236 70 Dan W Brock, Misconceived Sources of Opposition to Physician Assisted Suicide (2000) 6 Psychology, Public Policy, and Law 305,309-10 71 Margot White and David Callahan, Oregons First Year: The Medicalization of Control (2000) 6 Psychology, Public Policy, and Law, pages 331-337. 72 Howard Brody, Kevorkian and assisted death in the United States (1999) 318 British Medical Journal, 953-4 73 Supra Note 21, the report has produced evidence from various surveys that indicate a growing consensus among the population in favour of legalization. See pages 60-2 74 Pattinson (note 14), page 592
67 68

offers a detailed analysis of how it could be reformed. However, the report is not neutral; it portrays a very much utilitarian view.

Ultimately, what it comes down to is what the people want. We live in an increasingly secular society where religion no longer dictates. With an increasing accord among the population wanting legalization, one wonders how long the current law can last. Nonetheless there remains a deeply rooted division in society on the assisted suicide debate. What is needed is a balance in the law, a blanket ban in not an ideal response to the unbearable suffering of the terminally ill. As Jackson proposes, it would be more logical to advocate regulations which confine access to patients whose circumstances lie at the top of the moral slope, and prohibit it in all other cases.75

75

Jackson (note 5), page 959

Bibliography Cases
Re J (Wardship medical treatment) (1991) 2 WLR 140 Airedale NHS Trust v Bland (1993) AC 789 R v Woolin (1999) 1 AC 82 HL Ms B v An NHS Trust (2002) EWHC 429 R. (On the application of Pretty) v Director Of Public Prosecutions (2002) 1 AC 800 HL R (on the application of Purdy) v Director of Public Prosecutions [2009] UKHL 45

Statutes
Books Suicide Act 1961 Mental Capacity Act 2005

Battin, P. M, The least worst death, Essay in Bioethics on the End of Life (OUP Oxford 1994) Biggs. H, I Dont Want to be a Burden! A Feminist reflects on womens Experiences on Death and Dying in S. Sheldon and M Thompson (eds), Feminist Perspectives on Health Care Law (Cavendish London 1998). Gormally. L, Euthanasia and Assisted Suicide: 7 Reasons why they should not be legalized 286 290 in Donna Dickenson, Malcolm Johnson, and Jeanne Samson Katz (eds), Death, Dying and Bereavement (2nd Ed Sage London 2000) Griffiths. J, Bood. A, and Weyers. H, Euthanasia and Law in the Netherlands (Amsterdam UP 1998) Jackson. E, Medical Law, Text, Cases, and Materials (OUP Oxford 2006) Keown. J, Euthanasia, Ethics and Public Policy: An argument against legalization (CUP Cambridge 2002) Pattinson. S, Medical Law and Ethics, Sweet & Maxwell; 3rd Revised edition (26 July 2011) Otlowski. M, Voluntary Euthanasia and Common Law (OUP Oxford 2000) RG Frey, Distinction in death 17-42 in Gerald Dworkin, RG Frey, and Sissela Bok, Euthanasia and Physician Assisted Suicide: For and Against (CUP Cambridge 1998) Williams. G, Sanctity of Life and the Criminal Law (Faber London 1957) Wilkinson. S, Palliative care and the doctrine of double effect, in Donna Dickenson, Malcolm Johnson, and Jeanne Samson Katz (eds), Death, Dying and Bereavement, (2nd Ed Sage London 2000)

Journals Brock. W, Dan, Misconceived Sources of Opposition to Physician Assisted Suicide (2000) 6 Psychology, Public Policy, and Law 305,309-10 Brody. H, Kevorkian and assisted death in the United States (1999) 318 British Medical Journal, 953-4 Callahan. D, White. M, The Legalization of Physician-Assisted Suicide: Creating a Regulatory Potemkin Village (1996) 30 University of Richmond Law Review 1, 8-11. Courtney S Campbell, 'Aid-in dying and the taking of human life; Journal of Medical Ethics 1992,18,128-134

Griffiths. J, Assisted Suicide in the Netherlands: The Chabot chase (1995) 58 Law Review, pages 232-48 Jackson. E, Whose Death is it Anyway? Euthanasia and the Medical Profession (2004) 57 Current legal Problems 415 442 Law. S, Physician assisted death: An essay on constitutional rights and remedies (1996) 55 Maryland Law Review 292 Leon R Kraas and Nelson Lund, Physician Assisted Suicide, Medical Ethics and the Future of the Medical Profession (1996) 35 Duquesne Law Review 395, 406 8 Magnusson RS, Euthanasia: above ground, below ground (2004) 30 Journal of Medical Ethics 441-, 441-1, 445 Nys. H, Physician Involvement in a Patients Death: A Continental European Perspective (1999) 7 Medical Law Review, page 208-46, 236 R. HS Tur, Legislative techniques and human rights: The sad case of Assisted suicide (2003) Criminal Law Review 3-12 Orentlicher. D, The Alleged Distinction between euthanasia and the withdrawal of life sustaining treatment: conceptually incoherent and impossible to maintain (1998) University of Illinois Law Review 837, 847-8 Wolf. M Susan, Pragmatism in the Face of Death: The Role of facts in the Assisted suicide Debate (1998) 82 Minnesota Law Review 1063, 1074-7 White. M and Callahan. D, Oregons First Year: The Medicalization of Control (2000) 6 Psychology, Public Policy, and Law, pages 331-337.

Reports Oregon department of Human services, Fifth Annual report on Oregons Death with Dignity Act (2002) Assisted Dying for the Terminally Ill Committee, Assisted Dying for the Terminally Ill Bill First Report (2005) T Hughes-Hallet, A Craft and C Davies, Funding the Right Care and Support for Everyone: Creating a fair and transparent funding system; the final report of the Palliative Care Funding Review (2011) The Commission on Assisted Dying, January (2012-01-05), (DEMOS)