This is the first in a series of discussion papers that will be issued periodically by the Centre for Renewal in Public Policy. It is hoped that these papers will be of timely assistance to those debating key issues in Canadian society. It is one of the purposes of the Centre to facilitate a range of research studies by knowledgable people in each area being discussed. It is hoped that the papers will be copied and widely distributed and that the sources quoted will add to the quality of the debate on each issue. This paper is presented from a medical point of view. In one of its next discussion papers, the Centre will issue a paper by lain T. Benson that will examine euthanasia and assisted suicide from a legal and philosophical persective. This paper was originally presented by Dr. Voth at a meeting on Parliament Hill on March 10, 1994 to which all members of Parliament were invited. That meeting was under the auspices of the Centre for Renewal in Public Policy. The Centre is a non-profit, charitable society established to further education in key areas of public concern. Further information on the Centre and its activities may be obtained by contacting the Development Coordinator for the Centre, Mr. Greg Pennoyer at (613) 567-9010. This paper has been edited for this publication by Philip Marchand and Peter Stockland, both members of the Centre's Research Board, and by lain T. Benson, the Centre's Senior Research Fellow.Executive Summary This paper provides a framework for discussion on the controversial topic of euthanasia and physician assisted suicide. Dr. Voth's examination of what he prefers to label "Death by Choice", offers a unique and thought provoking perspective that will, we hope, be of benefit to all who are interested in the issue. Advances in medical technology, as recent high profile and well publicized cases are forcing Canadians to consider, as never before, the moral implications of adopting "death by choice" as a legislated principle. The paper suggests that it is an issue on which Canadians will inevitably demand a resolution from their elected officials. Among the questions analyzed in the paper is whether or not the State has the authority to restrict an individual's choice to be killed on their own terms. The author suggests that individual actions can and have implications for the broader community which justify cautious and limited intervention by the State. This rationale is central to the paper's development. The article raises a number of concerns regarding how a decision of such magnitude could be effectively reached in a society as diverse as Canada. The Parliamentary process is described as less than an ideal way of achieving the desired consensus, as are potentially divisive and nonbinding national referenda. The article suggests that the mechanism for change is less important than the ability to develop or garner the moral authority that must precipitate any kind of lasting consensus on such a controversial issue. In addition to questioning the decision-making process, the author examines the implications of a decision favouring legalized Euthanasia or "Death by Choice". With the use of historical and current examples, a number of troubling questions and scenarios are presented which are not easily dismissed. Indeed, any future debate on the issue would be negligent if it failed to address these justifiable concerns. The paper concludes by developing a number of proposals which are intended to clarify key questions in the debate, specifically: i) who supports death by choice, ii) why do they support death by choice, and iii) How can the "new" boundaries be guaranteed andor prevented from shifting? Issues of such impact and importance must be grounded in rigorous analysis related to a meaningful conception of the person and society.Recently, it has been all but impossible to pick up a newspaper or watch a television newscast without hearing something on the subject of euthanasia. Yet I cannot recall ever hearing the word 'Euthanasia' mentioned in medical school, except perhaps in the same breath as some other grave felonies occasionally committed by physicians. Most people know by now that the word 'euthanasia' is a Greek word meaning simply 'a good death.' It did not necessarily mean a death that was in any way hastened or caused by a physician. This makes it a very imprecise term which I will use as little as possible. I prefer several other terms which are much more precise. Physician assisted suicide means just what it says. It implies that the decision to end life is not only made by the patient or individual but that at least part of the act is performed by him. Mercy killing means the active ending of a life for reasons of compassion and mercy regardless of whether the person killed had any part in the decision or the act. Death by choice means a death caused by a deliberate decision and act. It is an omnibus term I have created to cover all forms of euthanasia, mercy killing, suicide, or physician assisted suicide. Voluntary euthanasia is mercy killing at the specific request of the patient, usually but not necessarily by physicians. Of course, all of the above are currently forbidden by the criminal law except for suicide. The idea of death by choice has been with us for almost as long as mankind itself has existed, but recently it has been thrust into the centre of the political arena by names like Jack Kevorkian, Nancy B., and most recently Sue Rodriguez. Except for the ill and the dying themselves probably no two groups are more immediately affected by the controversy than parliamentarians and doctors. Parliamentarians will be forced to deal with rewriting the law, if and when this becomes inevitable. I and my colleagues will be forced to live with the consequences of that law. It seems almost certain that this current government will be forced to deal with the question of the Criminal law on death by choice. I believe there are good reasons why you should reexamine this question now. First, our own medical technology has forced the question upon you. The number of people who have watched a friend or a family member spending weeks and months in suspended animation on a respirator waiting for death has increased by the thousands. The prospect of physician assisted suicide frightens them less than the possibility of seeing their family members or themselves as a laboratory preparation on a machine. Second, you will have to deal with the question because it is an inevitable one. It deals with very deeply held convictions of right and wrong and with very deeply felt fears. Such questions are not easily legislated away, or talked away, or hushed into silence. Therefore history will force you to decide this question again even though, in the laws of this country, it has been decided for at least a century. Why should the country's government have any right to decide? A fundamental premise of a liberal democracy is that the individual must be given the largest possible amount of personal liberty in managing his or her life and its inevitable end, death. The state must justify any intervention in the life of the individual. The individual need not justify keeping the state out of his or her life. Therefore the question "Does the State have any right to decree how 1 deal with my life and my death?" is of paramount importance. If the answer is no, then those of us who oppose any form of mercy-killing, have no political grounds on which to base any opposition to death by choice. I believe the State does have certain very legitimate interests in how I manage my life. Some acts, though they appear to involve only the individual, nonetheless have very broad effects on society. For example, to allow even one single individual in Canada, to consent to an assault is to make assault acceptable. If you allow even one person to use his or her own liberty to allow a moral wrong, you have begun the irreversible destruction of the prohibition of assault and weakened the respect for persons in society. Similarly, allowing even one single case of physician assisted suicide in the nation has immediate implications for every citizen of the nation. What was never an option before has now become an option, no matter how many individuals not only did not want the option but are genuinely dismayed and frightened about having it. Human life has become a little less sacrosanct for everyone. Therefore, although it is and should be severely limited, the State does indeed have some very legitimate power over how people manage their bodies, their lives, and life's end. How then should a nation decide the question of a new law on death by choice? The Hippocratic Oath states very clearly "I will not give poison to anyone though asked to do so, nor will I suggest such a plan." Every Code of Medical Ethics since then has either directly or implicitly forbidden any physician from ever taking the life of a patient. But by even raising the question, society has already dismissed traditional medical ethics as a final arbiter. A national referendum on the question has been proposed many times, but I fear that there are too many Canadian groups who will not respect such a decision unless it agrees with what they wanted to do anyway. The judicial option of persuading the courts to ignore, set aside or change laws they do not like, as Holland has done, should alarm everyone who is committed to the preservation of a liberal democracy. If a small group of men and women who are responsible to no one, elected by no one, and appointed without any public review are allowed to rewrite the law, the effective government will have passed from an elected Parliament to a few individuals in a court. Overnight, democracy would be transformed into an oligarchy that is very easily subverted to the ambitions of a corrupt government. Therefore I think the judicial option would be in no one's best interests. As impotent as we may feel in the governmental process from time to time, we still have the right to recall them at election time. We have neither participation nor power in the selection of our judges. The making of laws is best left with Parliament. The courts should be strictly and severely held to enforcing existing laws. The time-honoured Canadian way of dealing with such problems is first demanding that Parliament act on the question and then lobbying furiously for one's side of the question. But if the Government lacks the moral authority for imposing its solution, the question will only reappear and reappear like the slavery question. No doubt, you have thought of many other options, such as referring the decision to a national committee of ethicists; but in the final analysis unless a decision by Parliament, or by a referendum, or by a court, or by any other method or group carries with it a consensus of moral authority the conflict continues to escalate. Moral authority exists when a large majority of the people believe that something ought to be right or wrong, no matter what the law mayor may not say about it. But such majority views must be related to a meaningful conception of morality. Few of us can explain what goes into the formation of our moral convictions. Only a few writers, poets and artists have this skill. Difficult national problems are sometimes resolved when such a person articulates moral convictions in such a way that they find a home in the hearts of the people. In the 18th century a group of men wrote, "We hold these truths to be self-evident, that all men are created equal." And a nation was born as many people discovered that this proclamation indeed expressed their own deepest feelings about governance. In the 20th century, Martin Luther King gave a short speech that began, "I have a dream" and captured the deepest levels of moral feeling in the USA. It gave new impetus to the Civil Rights Movement. These rare people are moral philosophers. Usually men or women of deep personal faith, without which they would never understand the depth of moral conviction, they were able to cast in simple words moral principles that lay in the hearts of the masses of ordinary people. They succeeded not by challenging or denying our moral convictions, but by calling forth the deepest and best of our convictions. I most assuredly do not claim to be a moral philosopher. My goal is much more modest. I hope to provide a framework for thinking about the problem that will make it easier for a moral philosopher to emerge somewhere, sometime. Today I want to share three fears with you and present three proposals. I begin with the fears because I am used to dealing with fears. I spend a lot of time at a job I did not ask for, but have nevertheless come to appreciate for what it has taught me. I am the Chairman of our hospital's research ethics board whose job is to examine all research proposals of our staff, both nursing and medical, to determine if they are scientifically and ethically useful and sound. Much of our work involves looking carefully at reasonable fears of harm that may come from a given research project involving human subjects. Politicians may well coin slogans like, "We have nothing to fear but fear itself!" but physicians who live that way end up with ethical scandals on their hands. Overturning 2000 years of medical ethical historical tradition has infinitely greater potential for harm than any research project I have ever looked at in about 8 years as a hospital research ethicist.The "Slippery Slope" The first fear is the fear of the slippery slope. The idea of the "slippery slope" in ethics states that there are certain ethical limits that must never be crossed, for if they are, society loses all sense of limits and successive limits are ever more rapidly simply knocked out of the way. The subject of the slippery slope has been both written and talked to death a thousand times so it is worth considering why it is so important to the opponents and also the proponents of death by choice. No doubt you are thinking, no, no! Not the slippery slope again!" Yes, we discuss it because we must discuss it. I quote from the American writer Richard John Neuhaus in a recent conference on Bioethics and the Holocaust: Judgment at Nuremberg was premised on the now frequently derided notion of the slippery slope. Those who deride and dismiss that metaphor are, I believe, rejecting the commonsensical observation that one thing is connected with another and one thing frequently leads to another. If we give ourselves permission to do one thing, we are inescapably inviting the question about permission to do the next thing.1On a slippery slope a single leap from the top to the bottom is always unthinkable, but the individual steps always seem entirely rational and logical. Let me review the possible individual steps on the slippery slope of death by choice for you as I have gleaned them from proponents. If we were to legalize suicide, would not the next rational step be to legalize assisted suicide for those who want it? Well, we did legalize or at least de-criminalize suicide some time ago and the request for physician assisted suicide is being placed before Parliament repeatedly. If we then legalized physician assisted suicide, why should we not legalize voluntary euthanasia, especially for those who could not possibly commit suicide either with or without assistance? Well, the request has already been dealt with and rejected by the narrowest of margins by the Supreme Court. The next step might not seem so plausible at this point, if it were not for the fact that the death by choice groups so consistently use rights oriented language, as opposed to a simple broadening of what a physician mayor may not do within the fIduciary relationship with the patient. Broadening of tolerance is one thing, but rights oriented language implies compulsion. If I have a right to something, then someone can be compelled to give it to me, and everyone must have equal access to that right. If a conscious person has the right to death by choice, then are we not depriving the unconscious person of that right by requiring that only those able to consciously assent to euthanasia may exercise this right? Enter the substituted judgment where someone else chooses death on your behalf. This is mercy killing without consent or request. If we are giving the right to death by choice to only those who are suffering irreversible disease and pain, what about those who by reason of chronic disease or else just psychic pain no longer enjoy a good quality of life? Enter both voluntary and involuntary mercy killing for reasons other than severe or irreversible disease. Do you see how the rights oriented approach changes the view of the slippery slope? Where will it all end? Will the moral centre of not only the profession of medicine but also the nation as a whole eventually collapse when the taking of a human life is so easily negotiated? Will we return to the pre-Hippocratic days when the coming of a physician was feared lest he or she be planning the death of the patient? As an optimist, my first response would be, "Of course not! Don't talk nonsense! All societal trends carry the seeds of excess within them, yet society does not always go to hell-in-a-hand-basket quite that easily. But as a research watchdog, as I am not always kindly referred to at times, my fIrst response must be, "Let's look at any evidence we can find. If we can find any evidence at all that this scenario is a reasonable possibility, then the burden of proof rests on the would-be researcher to prove that these dangers can be avoided, and that proof must take much more solid form than mere bland reassurances." At this point, unpleasant as it may be, we must look at the history of Nazi Germany. That the moral centre of the German nation and its medical community did collapse is beyond question. But two questions remain. Why did it happen? Can it happen again? Hitler did not begin or invent voluntary euthanasia or involuntary euthanasia. These were already firmly in place when he carne to power.2 All he did was adapt them and pervert them to his own purposes. The question we must answer, at least in our minds is, "If the German medical profession had held fIrm to its Hippocratic roots and refused to participate in any kind of killing, no matter how apparently benevolent the motivation, would they have been so easily corrupted?" No one in the many euthanasia movements of which I have read has anything but abhorrence for the acts of Nazi Germany. The question that bothers me is whether the changes in law and practise they seek would make it too easy for another monster to corrupt the medical profession. Will a loosening of laws against death by choice dismantle vital moral defences that every nation and especially their medical communities simply must keep up for eternity? Is the monster of the Holocaust real enough that it is well worth setting the limits a long way from that extreme? Germany today certainly feels that it is worth it, which is why it refuses to even discuss broadening the age-old law on assisted suicide.3 Turning from Germany to Holland, things become easier, historically speaking, for there is no shortage of data. The guidelines for any form of death by choice have been clearly spelled out by the courts together with the Royal Dutch Medical Association. We only need to ask how well these guidelines are being followed. If they are being strictly or at least fairly strictly followed, and if there is no evidence of gradually broadening limits, then, at least in Holland fear of the slippery slope phenomenon is without grounds. The first guideline was that euthanasia may be carried out if the patient has persistently, consciously and of his own free will requested it. According to Attorney-General Remmelink's government-commissioned report, about .8 to 1.6% of all of Holland's annual 129,000 deaths per year are the result of life-terminating acts without either explicit or persistent request. That would be about 1000 deaths a year. If you allow the explanation that in about half of these cases euthanasia was at least discussed or requested beforehand before the patient became comatose, that still leaves about 500 deaths a year where the first requirement or guideline was not fulfilled.4 The second guideline is that suffering must be unbearable with no hope of recovery or improvement. According to the same report, only 46% of requests for euthanasia listed pain as the reason. Of the some 1000 cases of non-voluntary euthanasia, only 30% were done because of uncontrollable pain. The rest were done for reasons such as low quality of life, no prospect of improvement, no useful treatment to offer, or 'failure to die after withdrawal of treatment'.5 The third guideline is that the physician must consult with a colleague about the appropriateness of the request. The Remmelink report did not address this question in any of the English discussions I found. However, when commenting on this requirement at the International Conference on Euthanasia, Wachter (Director of the Institute for Bioethics in Maastricht) felt that it was a complete charade since a compliant colleague could be found so easily.6 In a privately received excerpt of a translation of the Remmelink report, it was noted that about 20% of physicians did not ask for consultation and 40% considered the guideline unimportant. Based on the government's own Attorney-General's report, the so-called 'strict' guidelines for euthanasia in Holland are frequently ignored. What the guests at the Maastricht conference, especially those from America, found most disturbing was the casual ease with which the evidence for widespread endemic non compliance with the guidelines was brushed aside.7 8 Perhaps the most disturbing information to come out of the Remmelink report and two other similar studies done at the same time was the knowledge that very few physicians follow another guideline, which is that every death caused by the physician must be reported as a case of euthanasia. Yet according to the figures derived from the Remmelink report and actual numbers of voluntary euthanasia reported, about 90% of cases of voluntary euthanasia are listed as natural deaths.9 When 90% of all cases of death by choice are simply listed as natural deaths, the Dutch statistics on their experience of euthanasia are clearly of no value. When most physicians practising euthanasia are not only not following the guidelines but are quite unconcerned about their failure to do so, the profession has a serious moral problem. If I followed the Alberta Health Care billing guidelines in that way, I would already be in prison. Doesn't the life of patients deserve greater moral solicitude than my income? The Royal Dutch Medical Association is currently preparing guidelines for terminating the lives of incompetent patients, e.g. severely defective newborns, and comatose and demented elderly patients.10 It seems a foregone conclusion that their guidelines will be readily accepted by compliant courts who see no need to wait for laws to justify such actions, especially since public opinion will likely support them. You might say that Holland is not Canada, but my response is that neither are guinea pigs humans, yet we take very seriously the warnings that animal research gives us.The Repression of Dissenting Opinions The second fear is that the legalization of death by choice will result in the repression of all dissenting opinions. It is very difficult for anyone in Holland to voice publicly any dissenting opinions to the current policy and nearly impossible for opponents of euthanasia to publish their opinions in Holland. Of eleven existing television corporations only one allows opponents of euthanasia to express their views.11 12 When the European Standing Committee for Medical Ethics and the World Medical Association voted to condemn Dutch euthanasia the only publication to report what should have been news of profound importance to the nation was a small pro-life bimonthly.13 The reason for this almost fanatical desire to suppress dissent is simply the result of an imbalance of perceived guilt or responsibility. If you believe that the Edmonton Oilers are doomed to perpetual oblivion in the post-Gretzky era and I believe you are wrong, each of us has about the same amount of face to lose if we are wrong. Not so with a question like death by choice. If I am wrong the most I can be accused of in the court of history is that I have been overly conservative in my view of the sanctity of human life. That doesn't frighten me very much. If the death by choice proponents are judged wrong by the same court, they risk being accused of reckless homicide. That risk will always tend to drive them in the direction of ruthless repression of dissent.The Threat of Coercion The third fear I want to look at is that the freedom of death by choice may extinguish other more precious freedoms. It may bring with it the repression and coercion of those who are either opposed to it or else simply do not want the option of deciding. This coercion involves both the patients and the health care providers. Some coercion is already inherent in death by choice legislation. When death by choice is not legal or available, everyone has the right to remain alive by default. If a person makes no decision at all, that person will be kept alive as long as this is reasonably possible. If death by choice is an option, though, he or she is in the awkward position of having to justify his or her continued existence. Even the lay public knows that any kind of terminal care is expensive, even just simple hospice-style care. The presence of the option of death by choice already creates pressure to opt for it 'for the public good'.14 Does this kind of pressure exist in any verifiable way? In one survey of Dutch nursing homes 93% of inhabitants were opposed to the practise of euthanasia and 95% were opposed to legalizing it. 50-60% of these same inhabitants were fearful of involuntary termination.15 16 These are very sobering statistics. Do they have reason to be afraid, or are they just paranoid? Yes, they have lots of reason to be afraid. Both voluntary and involuntary euthanasia are broadly supported by the Dutch public, i.e. by those who are not old and ill. The Dutch literature is full of opinion polls citing broad support among students, ordinary citizens, and even physicians for involuntary euthanasia for a variety of reasons ranging from old age through incurable illness and, yes, even simple economic expediency.17 18 19 Does it apply in North America? How I wish I could be certain, but I have to use the best evidence available. All the writings by the various proponents of death by choice that I read were very reassuring about the absolute need to guard the conscience of the conscientious objector. Would they stick to this agenda once they found legislation going their way? I don't know, but none of the evidence I can find elsewhere is reassuring. Soon after the recent California referendum on death by choice a few years ago, a TV station repeated the poll but categorized the responses. I quote from the New York Times report, "Polling showed support for Proposition 161 lowest among women, older voters, Asians and blacks. It was highest among voters under 30 and those with postgraduate education and incomes over $75,000."20 Another poll found the same result.21 This raises a question that absolutely demands a straight answer; "Who is in favour of death by choice for whom?" If those who stand to gain most by legalized death by choice are in favour of it for those who stand to lose most by it and who also constitute society's least articulate and least able to defend themselves in the public forum, how can coercion possibly be avoided? The message of the rich, young and favoured to the less favoured and especially the elderly is very clear: "We think you old people should get out of the way." In the well-justified national discussion of sexual abuse of women patients by physicians much importance is given the great power imbalance between a male physician and his female patient. What about the power imbalance between the young and the old? I would like to share three proposals for your consideration with you. Each of these is aimed at answering a specific question. The first question is, "Who favours death by choice?" Is it really mainly the young, the rich, the healthy, the wealthy or is it truly the old, the handicapped, the poor and the disadvantaged? Yes, I know you would have no trouble collecting case histories such as the well-publicized case of Sue Rodriguez. Remember that it is just as easy to collect case histories for the other side of the question. My proposal is that you seek to answer it by polls reliably conducted by third parties at a very long arm's length from any of the interest groups, including my own. This means that polls conducted by organizations such as Dying with Dignity as well as those conducted by the various right to life groups can have no validity. Indeed they must even be prohibited from writing the questions for another agency. As a research ethicist, I can assure you that it is not difficult to write any questionnaire to obtain whatever result you desire. The second question is, "Assuming that there are truly large numbers of people who want the right to death by choice in some form or another, why do they want it?" If my experience as a physician who sees very many dying people reflects the general population, then the majority of them want it because they fear pain and they fear being abandoned. Their fears are real and their requests are modest. They want to be cared for and they want human companionship. My proposal is that you begin immediately to look for ways of encouraging the hospice movements and the palliative care facilities in the nation. Patients who feel they will be cared for, will have their pain relieved and will not be deprived of human companionship seldom express the wish for death. I know that much leadership for these twin goals should be coming from my profession, and I accept the responsibility for talking to them and inspiring them at any opportunity. The third question is; "How will you guarantee that the boundaries of any form of death by choice will not shift as soon as they have been laid down as they have done everywhere else?" Remember that many who have written extensively on the subject in North America have given every indication that they have no intention of stopping with voluntary forms of euthanasia.22 23 24 This will require not only a carefully crafted law that absolutely cannot be manipulated by compliant courts, but also a rock solid moral consensus among physicians that there are limits which must never be crossed. Right now, the closest thing we have to such a moral consensus is the Hippocratic tradition of medical ethics which has as its core a reverence for life embodied in the injunction, "I will not give poison to anyone though asked to do so, nor will I suggest such a plan". Companion to this core of ethics was the concept that this was a covenant not with the government of the day but with the gods as the Greeks knew them. This meant that this was a covenant that could not be broken, not even by an edict of government or the will of the majority. That is what I mean by a rock solid moral consensus on ethical limits. If you legalize death by choice you will have eliminated the last of the Hippocratic tradition. What can you offer to replace it as a guarantee that the new boundaries of reverence for life will not shift? My last proposal is quite simply that you ask the medical profession for such a declaration of binding moral limits and evidence that they will not shift. If we cannot provide it, then do not remove the last remaining limit.Notes 1 Caplan, Arthur L.: When Medicine Went Mad 1992, Humana Press N.J. USA, p 2252 Alexander, L.: Medical Science Under Dictatorship, New England Journal of Medicine 1949; Vo1.241: pp 23 Schone-Siefert, B.; Rippe, K.: Silencing the Singer, Antibioethics in Germany Hastings Centre Report 1991; :204 Maas, P.J. van der; Delden, J.M. van; Pignenborg, L.; Looman, C.W.N.: Euthanasia and Other Medical Decisions Concerning the End of Life The Lancet 1991; 338:669-{j745 Have, H.A.M.J. ten; Welie, J.V.M.: Euthanasia, Normal Medical Practice? Hastings Centre Report 1992; 22:366 Wachter, M.A.M. de: Euthanasia in the Netherlands Hastings Centre Report 1992; 22:25.7 Have, H.A.M.J. ten; Welie, J.V.M.: Euthanasia, Normal Medical Practice? Hastings Centre Report 1992; 22:38.8 Capron, A.M.: Euthanasia in the Netherlands, American Observations Hastings Centre Report 1992; 22: 319 Wachter, M.A.M. de: Euthanasia in the Netherlands Hastings Centre Report 1992; 22:2310 Wachter, M.A.M. de: Euthanasia in the Netherlands Hastings Centre Report 1992; 22:2511 Fenigsen, R.: Euthanasia in the Netherlands Issues in Law & Medicine 1990; Vol. 6: pp. 233.12 Bostrom, B.A.: Euthanasia in the Netherlands: A Model for the United States? Issues in Law & Medicine 1989; Vol.4: pp 48013 Fenigsen, R.: Euthanasia in the Netherlands Issues in Law & Medicine 1990; Vol. 6: pp. 23314 Brock, D.: Voluntary Active Euthanasia Hastings Centre Report 1992; 22: 17.1815 Bostrom, B.A.: Euthanasia in tbe Netherlands: A Model for the United States? Issues in Law & Medicine 1989; Vol.4: pp 47716 Fenigsen, R.: A Case Against Dutch Euthanasia Hastings Centre Report, Special Supplement 1989; :2617 Bostrom, B.A.: Euthanasia in the Netherlands: A Model for the United States? Issues in Law &: Medicine 1989; Vol.4: pp 483- 484.18 Fenigsen, R.: Euthanasia in the Netherlands Issues in Law &: Medicine 1990; Vol. 6: pp. 237-23919 Fenigsen, R.: A Case Against Dutch Euthanasia Hastings Centre Report, Special Supplement 1989; :2520 The New York Times; 14 February 1993, Section 4, p. 1 Help for the Helping Hands in Death.21 Thomasmaa, D.C.: The Range of Euthanasia American College of Surgeons Bulletin August 1988; 73: 1022 Hollander, R.: Euthanasia and Mental Retardation: Suggesting the Unthinkable Mental Retardation April 1989; 27:6023 Van Der Sluis, I.: The Practice of Euthanasia in the Netherlands Issues in Law &: Medicine 1989; Vol.4: pp 45724 Wennberg, R.N.: Terminal Choices; Euthanasia, Suicide and the Right to Die 1989 W.B. Eerdmans Pub. Co.; pp. 206210