A woman's choice? The gendered risks of voluntary euthanasia and physician-assisted suicide

Medical Law Review

Volumn 15, Issue 1, 2007, Pages 1-33

  George, Katrina ^a,b  

^a UNIVERSITY OF WESTERN SYDNEY   (Australia)

^b UNIVERSITY OF SYDNEY   (Australia)

Author keywords

[No Author keywords available]

Indexed keywords

ALTRUISM; ARTICLE; ASSISTED SUICIDE; CAREGIVER; DECISION MAKING; FEMALE; FEMINISM; HUMAN; LEGAL ASPECT; MALE; NETHERLANDS; PERSONAL AUTONOMY; SEX DIFFERENCE; SOCIAL PSYCHOLOGY; UNITED STATES; VIOLENCE; VOLUNTARY EUTHANASIA; WOMEN'S RIGHTS;

ALTRUISM; CAREGIVERS; DECISION MAKING; EUTHANASIA, ACTIVE, VOLUNTARY; FEMALE; FEMINISM; HUMANS; MALE; NETHERLANDS; OREGON; PERSONAL AUTONOMY; PREJUDICE; SEX FACTORS; SUICIDE, ASSISTED; VIOLENCE; WOMEN'S RIGHTS;

EID: 33847781304     PISSN: 09670742     EISSN: 14643790     Source Type: Journal    
DOI: 10.1093/medlaw/fwl017     Document Type: Article

References (209)

1. Voluntary euthanasia is defined as the intentional killing of a patient at the request of the patient, usually by lethal injection administered by a physician. Physician-assisted suicide is defined as the ending of one's life through the voluntary self-administration of lethal medications prescribed by a physician for that purpose. In this paper, 'assisted death' is a shorthand reference for both voluntary euthanasia and physician-assisted suicide.
2. R. Magnusson, Angels of Death. Exploring the Euthanasia Underground (Melbourne University Press 2002) at 281.
3. For example, women's efforts to secure justice in marriage and family life, financial independence, freedom to participate in public life and paid employment, respect for bodily integrity and freedom from violence.
4. Diane Trumbull, a 45-year-old leukaemia patient, was assisted to die by Dr Quill who later wrote about this experience (see T.E. Quill, 'Death and Dignity-a Case of Individualized Decision Making' (1991) 324 New England Journal of Medicine 691).
5. Janet Adkins, a 54-year-old Oregon woman, suffered from Alzheimer's disease and died with the assistance of Dr Kevorkian. Marjorie Wantz, 58 years old and undiagnosed, suffered from pelvic pain and died with Sherry Miller with the assistance of Kevorkian. Dianne Pretty died of Motor Neurone Disease (MND) in 2002 at age 43 after losing right to die court challenges in England and the European Court of Human Rights. In September 2002, former Voluntary Euthanasia Society member Victoria Vincent, 83 years, was found dead with a bag over her head. Lesley Martin, a euthanasia campaigner, gave her mother Joy Martin a morphine injection in May 1999 as she was dying of cancer, later recording this in a book (see L. Martin, To Die Like a Dog: A Mother, a Daughter, a Promise Kept (M-Press 2002)).
6. Sue Rodriguez suffered from MND and suicided in 2004 after losing a constitutional challenge in the Canadian Supreme Court. Her story was recorded in the documentary At the End of the Day: The Sue Rodriguez Story. Nancy Crick, 69 year old, was not terminally ill when she suicided in 2002 in the presence of 21 family, friends and supporters of voluntary euthanasia with the aim of challenging laws against assisting suicide. She had received advice from voluntary euthanasia campaigner Dr Philip Nitschke as had Sandy Williamson, in her mid-50s, who suffered from MND and suicided in 2002 after significant media interest. Norma Hall, a 72-year-old cancer patient, died in 2001 with advice of Nitschke. Lisette Nigot, healthy and 79 years old, killed herself in 2002 with the advice of Nitschke, her story recorded in the documentary Mademoiselle and the Doctor. Numerous other cases of such women could be cited. However, there are exceptions: For example, Bob Dent who died in 1996 with the assistance of Nitschke was the first person to avail himself of the voluntary euthanasia legislation in the Northern Territory, Australia before that legislation was overturned.
7. J.G. Raymond, Women as Wombs: Reproductive Technologies and the Battle Over Women's Freedom (Spinifex Press 1994) at 100 and 103. Raymond's quotation here refers to women's decisions to use reproductive technologies such as in vitro fertilisation and surrogacy. I argue that the same questions should be asked about women's 'socalled choices' for assisted death.
8. See, for example, R. Magnusson, supra, n. 2.
9. Analysis of the gender ratios of participants in voluntary euthanasia and physicianassisted suicide was included in a publication by Kaplan et al. in 2002. The present paper has the benefit of more recent data from the Netherlands and Oregon. See K.J. Kaplan, M. Harrow and M.E. Schneiderhan, 'Suicide, Physician-assisted suicide and Euthanasia in Men Versus Women Around the World: The Degree of Physician Control' (2002) 18 Ethics and Medicine 33.
10. M.T. Muller, G.K. Kimsma and G. van derWal, 'Euthanasia and Assisted Suicide: Facts, Figures and Fancies with Special Regard to Old Age' (1998) 13 Drugs & Aging 185.
11. The authors found that no such disproportion is evident in the oldest age group and concluded that the elderly are not vulnerable in relation to assisted death (at 187).
12. Magnusson, supra, n. 2 at 64
13. J. de Haann, 'The New Dutch Law on Euthanasia' (2002) 10 Medical Law Review at 58.
14. Percentages calculated from Table 3, B.D. Onwuteaka-Philipsen, A. van der Heide, D. Koper et al., 'Euthanasia and Other End-of-Life Decisions in the Netherlands in 1990, 1995, and 2001' (2003) 362 The Lancet 395 at 397.
15. See also P.J. van der Maas, J.J.M. van Delden, C.W.N. Looman, 'Euthanasia and Other Medical Decisions Concerning the End of Life' (1991) 338 The Lancet 669.
16. Email from B.D. Onwuteaka-Philipsen to K. George on 8 December 2003. According to B.D. Onwuteaka-Philipsen the relevant data are also published in the Dutch report which she translates as: G. van der Wal, A. van der Heide, B.D. Onwuteaka-Philipsen, P.J van der Maas, 'Medical Decision Making at the End of Life. Practice and Euthanasia Notification Procedure' (2003 Utrecht: De Tijdstroom).
17. Percentages calculated from Table 3, Onwuteaka-Philipsen et al., supra, n. 11.
18. See also P.J. van der Maas, G. van der Wal, I. Haverkate et al., 'Euthanasia, Physician-Assisted Suicide, and Other Medical Practices Involving the End of Life in the Netherlands, 1990-1995' (1996) 335 New England Journal of Medicine 1699, Table 3.
19. B.D. Onwuteaka-Philipsen, supra, n. 12.
20. Percentages calculated from Table 3, B.D. Onwuteaka-Philipsen et al., supra, n. 11.
21. Percentages calculated from B.D. Onwuteaka-Philipsen, supra, n. 12.
22. Ibid.
23. B.D. Onwuteaka-Philipsen, supra, n. 12.
24. This conclusion might be underscored by the data about physician-assisted suicide among psychiatric patients. In practice, only physician-assisted suicide (not euthanasia) is offered to psychiatric patients because the patient's self-ingestion of the fatal dose is considered a final guarantee of voluntariness (Office of Public Prosecutions v. Chabot, Supreme Court of the Netherlands, Criminal Chamber, 21 June 1994, no.96.972
25. J. Griffiths, 'Assisted Suicide in the Netherlands: The Chabot Case' (1995) 58 Modern Law Review at 244).
26. One study estimated that 63% of requests for physician-assisted suicide among psychiatric patients were by women. This might support the observation that when euthanasia is also an option (as it is among the general patient population) women display a stronger preference for euthanasia over physician-assisted suicide than do men. However, this data should be read with caution since the same study estimates that only about two to five physician-assisted suicides occur among psychiatric patients per year, out of approximately 320 requests by men and women: J. H. Groenewoud, P.J. van der Maas, G. van der Wal et al., 'Physician-Assisted Death in Psychiatric Practice in the Netherlands' (1997) 336 The New England Journal of Medicine at 1795-1801.
27. Oregon Department of Human Services, Eighth Annual Report on Oregon's Death with Dignity Act (2006), http://www.oregon.gov/DHS/ph/pas/docs/ year8.pdf. at 20 October 2006.
28. D.E. Meier, C. Emmons, S.Wallenstein et al., 'A National Survey of Physician-Assisted Suicide and Euthanasia in the United States' (1998) 338 New England Journal of Medicine 1193 at 1195.
29. Ibid. at 1195, Table 4.
30. Ibid. at 1195.
31. Ibid. at 1195.
32. S.S. Canetto and J.D. Hollenshead, 'Gender and Physician-Assisted Suicide: An Analysis of the Kevorkian Cases, 1990-1997' (1999-2000) 40 OMEGA 165 at 168 (72% of their sample of 75 assisted suicides were women)
33. K.J. Kaplan, M. Harrow, M.E. Schneiderhan, 'Suicide, supra, n. 7 at 36 (68% of their sample of 93 assisted suicides were women).
34. S.S. Canetto and J.D. Hollenshead, supra, n. 25 at 182.
35. See also K.J. Kaplan, M. Harrow and M.E. Schneiderhan, supra, n. 7 at 37.
36. This comment was about the first 47 cases of the sample for which both psychological and physical post-mortem data were available: K.J. Kaplan, M. Harrow and M.E. Schneiderhan, supra, n. 7 at 33.
37. There are other studies that analyse the incidence of assisted death according to gender. However, they do not report the gender characteristics separately for euthanasia and physician-assisted suicide. A 1998 US study of 355 randomly selected oncologists revealed 17 cases of euthanasia and 20 cases of physician-assisted suicide. One case remained ambiguous. Among these 38 patients, 60.5% were women. (E.J. Emanuel, E.R. Daniels, D.L. Fairclough and B.R. Clarridge, 'The Practice of Euthanasia and Physician-Assisted Suicide in the United States: Adherence to Proposed Safeguards and Effects on Physicians' (1998) 280 Journal of the American Medical Association 507 at 509).
38. A study was conducted of a randomly selected 1925 deaths that occurred in 1998 in Flanders, Belgium. At the time assisted death was illegal. Twenty-five cases of euthanasia and physician-assisted suicide were disclosed. Of these deaths, 15 were women (L. Deliens, F. Mortier, J. Bilsen et al., 'End-of-Life Decisions in Medical Practice in Flanders, Belgium: A Nationwide Survey' (2000) 356 The Lancet 1806 at 1808 Table 2).
39. There is also a study of more than 20,000 deaths that occurred between June 2001 and February 2002 in the Netherlands, Switzerland, Denmark, Sweden, Belgium and Italy. The gender breakdown varied significantly. But broadly the data discloses that in four of these countries, males were more likely to receive assisted death, and in two of these countries, women were more likely (A. van der Heide, L. Deliens, K. Faisset et al., 'End of life Decision-Making in Six European Countries: Descriptive Study' (2003) 362 The Lancet 345 at 348 Table 3).
40. For example, H. Kuhse, P. Singer, P. Baume, M. Clark and M. Rickard, 'End-of-Life Decisions in Australian Medical Practice' (1997) 166 Medical Journal of Australia 191.
41. Gail Tulloch has recently noted the importance of monitoring the reasons women decide for assisted death where empirical data permit (although she does not examine the available data herself): G. Tulloch, 'A feminist utilitarian perspective on euthanasia: From Nancy Crick to Terri Schiavo' (2005) 12 Nursing Inquiry at 159.
42. In 1999, Diane Raymond concluded that there was not enough data to justify an inference that women are 'worse off' with assisted death. This paper has the benefit of more recent data and draws more widely from a variety of interdisciplinary studies to shed light on women's reasons for deciding for assisted death: D. Raymond, '"Fatal Practices": A Feminist Analysis of Physician-Assisted Suicide and Euthanasia' (1999) 14 Hypatia at 6.
43. T.L. Beauchamp and J.F. Childress, Principles of Biomedical Ethics (5th edn.) (Oxford University Press 2001) at 58.
44. S.S. Canetto and J.D. Hollenshead, supra, n. 25 at 184-185.
45. S.H. Miles and A. August, 'Courts, Gender and "The Right to Die"' (1990) 18 Law, Medicine and Health Care 85 at 92.
46. See also J.A. Parks, 'Why Gender Matters to the Euthanasia Debate' (2000) 30 Hastings Center Report.
47. S.H. Miles and A. August, supra, n. 33.
48. The same study also shows that other marginalised groups similarly demonstrate less support for assisted death: 73% of Anglos, 65% of Hispanics and 53% of Blacks were in favour. E. Morrow, 'Attitudes of Women from Vulnerable Populations Toward Physician-Assisted Death: A Qualitative Approach', (1997) 8 The Journal of Clinical Ethics 279 at 279.
49. H.G. Koenig, D. Wildman-Hanlon, K. Schmader, 'Attitudes of Elderly Patients and Their Families Towards Physician-assisted Suicide' (1996) 156 Archives of Internal Medicine 2240 at 2240.
50. S. Arber and J. Ginn, 'Gender and Inequalities in Health in Later Life' (1993) 36 Social Science and Medicine 33 at 37; and see studies cited therein.
51. M.A.Woodbury, K.G. Manton and D. Blazer, 'Trends in US Suicide Mortality Rates 1968 to 1982: Race and Sex Differences in Age, Period and Cohort Components' (1988) 17 International Journal of Epidemiology 356 at 360.
52. Oregon Department of Human Services, supra, n. 20
53. B.D. Onwuteaka-Philipsen, A. van der Heide, D. Koper et al., supra, n. 11.
54. S.S. Canetto, 'Elderly Women and Suicidal Behaviour' in S.S. Canetto and D. Lester (eds) Women and Suicidal Behaviour (Springer Publishing Company 1995) 215-233 at 221.
55. See, for example, L.M. Kohm and B.N. Brigner, 'Women and Assisted Suicide: Exposing the Gender Vulnerability To Acquiescent Death' (1998) 4 Cardozo Women's Law Journal 241, at 267-268.
56. L.A. Roscoe, J.E. Malphurs, L.J. Dragovic and D. Cohen, 'Antecedents of Euthanasia and Suicide Among Older Women' (2003) 58 Journal of the American Medical Women's Association 44 at 46.
57. L.A. Roscoe, J.E. Malphurs, L.J. Dragovic and D. Cohen, 'A Comparison of Characteristics of Kevorkian Euthanasia Cases and Physician-Assisted Suicides in Oregon' (2001) 41 The Gerontologist 439 at 443.
58. R. Hunter, 'Deconstructing the Subjects of Feminism: The Essentialism Debate in Feminist Theory and Practice' (1996) 6 The Australian Feminist Law Journal 135 at 138.
59. L. Bender, 'A Lawyer's Primer on Feminist Theory and Tort' (1988) 38 Journal of Legal Education 3 at 5-6.
60. This is a perspective most closely associated with radical feminism which regards the male-female relationship as the model of all power relationships: See, for example, K. Millett, Sexual Politics (Doubleday 1970)
61. R. Rowland and R.D. Klein; 'Radical Feminism: Critique and Construct', in S. Gunew (ed) Feminist Knowledge: Critique and Construct (Routledge 1990) 271-303.
62. From this perspective, women's oppression is the first and deepest oppression and the most widespread, existing in virtually every society: A.M. Jagger and P.S. Rothenberg, (eds), Feminist Frameworks (McGraw-Hill 1984).
63. See also, for example, M. French, Beyond Power: On Women, Men and Morals (Summit Books 1985)
64. R. Morgan, Going Too Far (Vintage Books 1978) at 9.
65. As of September 2005, 'the global average for women in parliaments stands at 16.0%. Additionally, women have achieved 30% representation or more in national parliaments in 19 countries. However, progress has been uneven and slow, and in some cases, there have been significant setbacks'. United Nations Division for the Advancement of Women (DAW), Equal Participation of Women and Men in Decision-Making Processes, with Particular Emphasis on Political Participation and Leadership, Report of the Expert Group Meeting, Addis-Ababa, Ethiopia, 24-27 October 2005. Access to structures of power goes beyond political representation, however.
66. See also, for example, Dorothy Smith who argues: 'Being excluded, as women have been, from the making of ideology, of knowledge, and of culture means that our experience, our interests, our ways of knowing the world have not been represented in the organisation of our ruling nor in the systematically developed knowledge that has entered into it'. The Everyday World as Problematic, (Northeastern University Press 1987) at 17-18.
67. For example, in Australia, women's average weekly earnings are 66% of those of men (factoring in data on all work, including part-time work) and '16% of females and 7% of males earned less than $200 per week in August 2000, whereas 2% of females and 7% of males earned $1400 or more per week.' Australian Bureau of Statistics, Employee Earnings, Benefits and Trade Union Membership, Cat 6310.0, August 2000, at 3,
68. quoted in R. Graycar and J. Morgan, The Hidden Gender of Law (Federation Press 2002) at 146.
69. For details of the US situation see L.M. Kohm and B.N. Brigner, supra, n. 41 at 257-259.
70. Worldwide, the 'feminisation of poverty' means that the gap between impoverished men and impoverished women has continued to widen. Of the 1.5 billion people living in poverty, the majority are women: United Nations Department of Public Information, The Feminization of Poverty (May 2000). http://www.un.org/womenwatch/daw/followup/session/presskit/ fs1.htm at 15 March 2006.
71. C. Smart, 'Law's Power, the Sexed Body, and Feminist Discourse' (1990) 17 Journal of Law and Society 194 at 201.
72. However, the relationship between psychoanalysis and the socio-historical concerns of feminism is controversial: See T. Brennan, 'An Impasse in Psychoanalysis and Feminism' in S. Gunew (ed) A Reader in Feminist Knowledge (Routledge 1991).
73. See, for example, T. Grillo, 'Anti-Essentialism and Intersectionality: Tools to Dismantle the Master's House' (1995) 10 Berkeley Women's Law Journal 16.
74. See, for example, R.W. Connell, Gender and Power: Society, the Person and Sexual Politics (Polity Press 1987);
75. L. Segal, Slow Motion: Changing Masculinities, Changing Men (Virago 1990).
76. R. Rowland and R.D. Klein, supra, n. 45 at 298.
77. Indeed, Carol Smart, for example, notes that 'women have resisted and negotiated constructions of gender' and warns that 'we should not slip into a new form of determinism which suggests that, because power constructs, it produces women in some predetermined, calculated, powerless form'. C. Smart, 'The Woman of Legal Discourse', in N. Naffine (ed) Gender and Justice (Ashgate 2002) 30 at 40.
78. 'Some 45% of sexual violence and some 55% of physical violence [against women] was committed by a current partner, a previous partner or a boyfriend/girlfriend or date'. Data derived from the Australian Bureau of Statistics, Women's Safety Australia (Commonwealth of Australia 1996),
79. quoted in Graycar and Morgan, supra, n. 47 at 303.
80. A Wallace, Homicide: The Social Reality (NSW Bureau of Crime Statistics and Research 1986)
81. quoted in D. Brown, D. Farrier, S. Egger and L. McNamara, Criminal Laws (The Federation Press 2001), at 492.
82. Ibid. at 494.
83. Ibid. at 492.
84. J. Mouzos, Homicidal Encounters: A Study of Homicide in Australia 1989-1999, (Australian Institute of Criminology 2000)
85. quoted in D. Brown et al., supra, n. 53 at 496
86. Similarly in Australia in 1999-2000: 'almost half of all female victims... were killed as a result of a domestic altercation, jealousy or termination of a relationship', J. Mouzos, Homicide in Australia 1999-2000 (Australian Institute of Criminology 2001) at 5.
87. K. Polk, When Men Kill: Scenarios of Masculine Violence, (Cambridge University Press 1994)
88. quoted in D. Brown et al., supra, n. 53, at 497.
89. See also K. Polk and D. Ranson, 'The Role of Gender in Intimate Homicide' (1991) 24 Australian and New Zealand Journal of Criminology at 15;
90. J. Stubbs (ed) Women, Male Violence and the Law (Institute of Criminology 1994).
91. P. Weiser Easteal, Killing the Beloved: Homicide Between Adult Sexual Intimates (Australian Institute of Criminology 1993) at 84-85.
92. C. Bean, Women Murdered by the Men They Loved (Harrington Park Press 1992) at 43
93. quoted in ibid at 91.
94. S.M. Wolf, 'Gender, Feminism, and Death: Physician-assisted suicide and Euthanasia' in S.M. Wolf (ed.) Feminism and Bioethics Beyond Reproduction (Oxford University Press 1996) 282-317, at 284-285.
95. S.S. Canetto and J.D. Hollenshead, 'Older Women and Mercy Killing' (2000-2001) 42 OMEGA 83 at 86.
96. For example, in NSW, Australia between 1968 and 1981, 85% of homicide offenders were men: A. Wallace, Homicide: The Social Reality (NSW Bureau of Crime Statistics and Research 1986) at 492.
97. S.S. Canetto and J.D. Hollenshead, supra, n. 61 at 87.
98. M. Otlowski, 'Mercy Killing Cases in the Australian Criminal Justice System' (1993) 17 Criminal Law Journal at 10.
99. D. Cohen, M. Llorente and C. Eisdorfer, 'Homicide-Suicide in Older Persons' (1998) 155 American Journal of Psychiatry 390 at 392.
100. J.E. Malphurs and D. Cohen, 'A Newspaper Surveillance Study of Homicide-Suicide in the United States' (2002) 23 The American Journal of Forensic Medicine and Pathology 142 at 146, 147.
101. Weiser Easteal, supra, n. 58 at 53.
102. For example, in NSW, Australia between 1968 and 1981, 64% of homicide victims were men: A. Wallace, supra, n. 53 at 491.
103. And'... females were likely as to kill a female as a male... Females were more likely to be killed by a male than by a female... while males were equally likely to be killed by a male or female.' S.S. Canetto and J.D. Hollenshead, supra, n. 61 at 88.
104. D. Cohen, 'Homicide-Suicide in Older People' (2000) 17 Psychiatric Times 49 at 8 August 2006.
105. P. Weiser Easteal, supra, n. 58 at 91.
106. Ibid. at 108.
107. Ibid. at 108.
108. D. Cohen, 'An Update on Homicide-Suicide in Older Persons: 1995-2000' (2000) 6 Journal of Mental Health and Aging 195 at 197. Suicide pacts do occur in the elderly, but are very rare events, representing less than 0.1% of all dyadic deaths:
109. D. Cohen, 'Homicide-Suicide in Older People' (2000) 17 Psychiatric Times 49-52
110. cited in J.E. Malphurs and D. Cohen, 'A State Wide Case-Control Study of Spousal Homicide-Suicide in Older Persons' (2005) 13 American Journal of Geriatric Psychiatry 211 at 212.
111. N. Naffine, Feminism and Criminology (Allen and Unwin 1997) at 146-147.
112. S.S. Canetto and J.D. Hollenshead, supra, n. 25 at 187;
113. S.M.Wolf, supra, n. 60 at 289.
114. C. Gilligan, In a Different Voice, Psychological Theory and Women's Development (Harvard University Press 1982) at 70.
115. Ibid. at 149.
116. Ibid. at 131-132.
117. See, for example, Mary Jeanne Larrabee, 'Gender and Moral Development: A Challenge for Feminist Theory' in Mary Jeanne Larrabee (ed.) An Ethic of Care, Feminist and Interdisciplinary Perspectives (Routledge 1993) at 5;
118. Mary Brabek, 'Moral Judgment: Theory and Research on Differences between Males and Females' in Mary Jeanne Larrabee (ed.) An Ethic of Care, Feminist and Interdisciplinary Perspectives (Routledge 1993) at 45.
119. Catherine G. Greeno and Eleanor E. Maccoby, 'How Different Is the "Different Voice?"' in Mary Jeanne Larrabee (ed.) supra, n. 80 at 197.
120. Catherine G. Greeno and Eleanor E. Maccoby, 'How Different Is the "Different Voice?"' in Mary Jeanne Larrabee (ed.) ibid at 196.
121. Similarly, Friedman sees female altruism less as an empirical fact than as a powerful ideological construct: M. Friedman, What Are Friends For? Feminist Perspectives On Personal Relationships and Moral Theory (Cornell University Press 1993) in R. Tong, Feminine and Feminist Ethics (Wadsworth Publishing Company 1993).
122. N. Naffine, Law and the Sexes: Explorations In Feminist Jurisprudence (Allen and Unwin 1990) at 137.
123. Similarly, Carlen and Worrall see the construction of the 'normal woman' as 'coping, caring, nurturing and sacrificing self-interest to the needs of others.' P. Carlen and A.Worrall, Gender, Crime and Justice (Open University 1987) at 3.
124. N. Loraux, Tragic Ways of Killing a Woman (Harvard University Press 1987) at 8.
125. Outside of tragic literature, there are cases of male altruistic suicide in Greek and Roman culture, but rarely motivated by self sacrifice for the sake of loved ones which appears to be more characteristically female. Male altruistic suicides were usually social inferiors such as male servants who loyally followed their masters to death. There are also cases of male (and female) self sacrifice to save another person or a whole community, for example, to stave off a curse: See A. van Hooff, 'Paetus, It Does Not Hurt: Altruistic Suicide in the Greco-Roman World' (2004) 8 Archives of Suicide Research, 43. A tradition of obligatory male suicide existed in some primitive societies. Durkheim identified cultural norms in societies such as the ancient Goths that expected old or sick men to suicide: See S. Stack, 'Emile Durkheim and Altruistic Suicide' (2004) 8 Archives of Suicide Research 9 at 12.
126. A. van Hooff, supra, n. 84 at 49, 50.
127. A. van Hooff, Ibid. at 55.
128. A. van Hooff, Ibid. at 49.
129. N. Loraux, supra, n. 84 at 12.
130. However, men might also be abandoned if they had broken the law, for example: H. Biggs, 'I Don't Want To Be a Burden! A Feminist Reflects on Women's Experiences of Death and Dying' in S. Sheldon and M. Thomson (eds.) Feminist Perspectives On Health Care Law (Cavendish Publishing Limited 1998), 279-295, at 288-289.
131. D. Lester, 'Assisted Suicide and the Elderly' in D. Lester (ed.) Now I Lay Me Down: Suicide in the Elderly (Charles Press Publications 1993) at 232-233.
132. Committing suttee was believed to guarantee the woman, her husband and seven generations of her family direct access to heaven, thus releasing them from the painful cycle of birth and rebirth: L. Vijayakumar, 'Altruistic Suicide in India' (2004) 8 Archives of Suicide Research 73 at 76.
133. L. Vijayakumar, Ibid. at 77.
134. D. Lester, supra, n. 90 at 232-233.
135. Ibid. at 233.
136. E.J. Emanuel, D.L. Fairclough, E.R. Daniels and B.R. Clarridge, 'Euthanasia and Physician-Assisted Suicide: Attitudes and Experiences of Oncology Patients, Oncologists, and the Public' (1996) 347 The Lancet at 1807.
137. L.J. Schneiderman, R. Kronick, R. Kaplan, J.P. Anderson and R.D. Langer, 'Attitudes of Seriously Ill Patients Toward Treatment That Involves High Costs and Burdens on Others' (1994) 5 Journal of Clinical Ethics 109.
138. M.E. Suarez-Almazor, M. Belzile and E. Bruera, 'Euthanasia and Physician-Assisted Suicide: A Comparative Survey of Physicians, Terminally Ill Cancer Patients, and the General Population' (1997) 15 Journal of Clinical Oncology 418.
139. E.J. Emanuel, D.L. Fairclough and L.L Emanuel, 'Attitudes and Desires Related to Euthanasia and Physician-Assisted suicide Among Terminally Ill Patients and Their Caregivers' (2000) 15 The Journal of the American Medical Association 2460;
140. E.J. Emanuel, D. Fairclough, J. Slutsman, E. Omandsun and L.L. Emanuel, 'Predictors and Outcomes of Significant Caregiving Needs and Economic Burdens Among Terminally Ill Oncology Patients: Results of the Commonwealth-Cummings Project' (1998) 17 Journal of Clinical Oncology 422a.
141. H. Biggs, supra, n. 89 at 289. See a similar argument in L.M. Kohm and B.N. Brigner, supra, n. 41 at 260-261.
142. See a similar argument in L.M. Kohm and B.N. Brigner, supra, n. 41 at 260-261.
143. S.S. Canetto and J.D. Hollenshead, supra, n. 25 at 179.
144. Ibid. Table 4 at 178.
145. Ibid. at 180.
146. D. Cohen, supra, n. 70.
147. J.E. Malphurs and D. Cohen, supra, n. 66 at 147.
148. A similar pattern is evident in another study, J.E. Malphurs and D. Cohen, supra, n. 74 at 213.
149. See, for example, C.M. Milroy, M. Dratsas and D.L. Ranson, 'Homicide-Suicide in Victoria, Australia' (1997) 18 American Journal of Forensic Medicine and Pathology 369 at 369.
150. D. Cohen, M. Llorente and C. Eisdorfer, 'An Analysis of Contemporary State Statutes About Assisted Suicide' (1998) 155 American Journal of Psychiatry 390 at 393.
151. J.E. Malphurs and D. Cohen, supra, n. 74 at 213
152. Ibid. at 215.
153. P. Weiser Easteal, supra, n. 58 at 101.
154. Ibid. at 91.
155. See studies cited in S.S. Canetto, supra, n. 40 at 225.
156. Ibid. at 226.
157. There is other evidence that points to the influence of the sociocultural context on methods of suicide. Hendin sees a connection between the sociocultural acceptance of guns in the United States and the frequency of their use as a method of suicide. Similarly, because men's use of firearms has greater social acceptance, they are more likely than women to choose firearms as a method of suicide. Hendin has noted that in New York City the chosen method for 50% of African-American suicides is jumping from buildings. 'So much of the life of Harlem is lived in and on top of these tenements that they occupy the conscious and unconscious life of their inhabitants and come to provide a tragic setting for black suicide': H. Hendin, Suicide in America (1982 W.W. Norton & Co)
158. quoted in H.I. Kushner, 'Women and Suicide in Historical Perspective', in J. McCarl Nielsen (ed.) Feminist Research Methods (Westview Press 1990) 193-206, at 201.
159. S.S. Canetto, supra, n. 40 at 226.
160. S.S. Canetto, supra, n. 40 at 225.
161. See, for example, Hester Eisenstein, Contemporary Feminist Thought (G.K. Hall 1983)
162. quoted in R. Putnam Tong, Feminist Thought: A More Comprehensive Introduction (Westview Press 1998) at 49;
163. R. Rowland and R.D. Klein supra, n. 45 at 278.
164. S.S. Canetto, supra, n. 40 at 227.
165. S.S. Canetto and J.D. Hollenshead, supra, n. 25 at 182.
166. L.H. Chaudron and E.D. Caine, 'Suicide Among Women: A Critical Review' (2004) 59 Journal of the American Medical Women's Association 125 at 126.
167. S.S. Canetto and J.D. Hollenshead, supra, n. 61 at 95-96.
168. S.M.Wolf, supra, n. 60 at 289.
169. Kaplan et al. suggest another possible interpretation of the pattern in gender preferences for death. They argue that research indicates women 'tend to receive and utilize social supports more than men... It would be reasonable, then, that women considering a hastened death may be more sensitive to physician support and control than men.': Kaplan, Harrow and Schneiderhan, supra, n. 7 at 40.
170. S.M. Wolf, supra, n. 60 at 293.
171. B.J. Kelly, P.C. Burnett, D. Pelusi et al., 'Association Between Clinician Factors and a Patient's Wish to Hasten Death: Terminally Ill Cancer Patients and Their Doctors' (2004) 45 Psychosomatics 311-318 at 317.
172. S.H. Miles, 'Physicians and Their Patient's Suicides' (1994) 271 Journal of the American Medical Association 1786 at 1786.
173. B.J. Kelly, P.C. Burnett, D. Pelusi et al. supra, n. 121 at 317.
174. S.H. Miles. Ibid.
175. H.M. Bratt, 'Passive Way to End Life Lures Women', The Detroit Free Press (Detroit, 25 October 1991),
176. quoted in S.S. Canetto and J.D. Hollenshead, supra, n. 64 at 193.
177. S.S. Canetto and J.D. Hollenshead, supra, n. 25 at 186.
178. L.A. Roscoe, J.E. Malphurs, L.J. Dragovic and D. Cohen, supra, n. 43 at 444.
179. E.J. Emanuel, E.R. Daniels, D.L. Fairclough and B.R. Clarridge, supra, n. 28 at 510.
180. For example, J.G. Canto, W.J. Rogers, N.C. Chandra et al., 'The Association of Sex and Payer Status on Management and Subsequent Survival in Acute Myocardial Infarction' (2002) 162 Archives of Internal Medicine 587; and see studies cited in Roscoe, Malphurs, Dragovic and Cohen, supra, n. 43 at 444.
181. and see studies cited in Roscoe, Malphurs, Dragovic and Cohen, supra, n. 43 at 444.
182. C.S. Cleeland, R. Gonin, A.K. Hatfield, et al., 'Pain and Its Treatment in Out-Patients with Metastatic Cancer' (1994) 330 New England Journal of Medicine 592,
183. quoted in L.A. Roscoe, J.E. Malphurs, L.J. Dragovic and D. Cohen, supra, n. 43 at 444.
184. See also L.M. Kohm and B.N. Brigner, supra, n. 41 at 259-260.
185. J. Bookwala, K.M. Coppola, A. Fagerlin et al., 'Gender Differences in Older Adults' Preferences For Life-Sustaining Medical Treatments and End-of-Life Values' (2001) 25 Death Studies 127 at 129.
186. Arber and J. Ginn, 'Gender and Inequalities in Health in Later Life' (1993) 36 Social Science and Medicine 33 at 37;
187. and see studies cited therein at 33.
188. S.S. Canetto and J.D. Hollenshead, supra, n. 25 at 176.
189. Ibid. Table 1.
190. Ibid. Table 1.
191. Ibid. at 165.
192. Percentages calculated from Table 3, B.D. Onwuteaka-Philipsen, A. van der Heide, D. Koper et al., supra, n. 11.
193. S.S. Canetto and J.D. Hollenshead, supra, n. 25 at 182.
194. The legalisation of physician assisted suicide took effect in Oregon on 27 October 1997: See R. Steinbrook, 'Physician-assisted suicide in Oregon-An Uncertain Future' (2002) 346 New England Journal of Medicine 460.
195. R. Magnusson, supra, n. 2 at 64.
196. Ibid. at 254-255.
197. Ibid. at 107-108.
198. T. Sheldon, 'Only Half of Dutch Doctors Report Euthanasia, Report Says' (2003) 326 British Medical Journal 1164 downloaded from http://bmj.bmjjournals.com/cgi/content/full/326/7400/1164 on 25 November 2003.
199. B.D. Onwuteaka-Philipsen, A. van der Heide, M.T. Muller et al., 'Dutch experience of monitoring euthanasia' (2005) 331 British Medical Journal at 692.
200. The reporting rate of termination of life without an explicit request in 2001 was even lower. Less then 1%, of cases were reported, similar to previous years: D. van Tol, 'The Latest Nationwide Research on Dutch MBPSL Practice: A summary and critical note', (October 2003) N 8 Newsletter MBPSL Regulation of Medical Behaviour That Potentially Shortens Life at 8.
201. B.D. Onwuteaka-Philipsen, A. van der Heide, M.T. Muller et al., supra, n. 144 at 692.
202. Ibid.
203. The substantive requirements for prudent practice in euthanasia and physicianassisted suicide are: The patient's request must be voluntary and well considered; the patient's condition must be unbearable and hopeless; no acceptable alternatives for treatment are available; the method is medically and technically appropriate. The procedural requirements are that another doctor is consulted before proceeding and the case is reported as an unnatural death. Ibid. at 691.
204. D. van Tol, supra, n. 144 at 7.
205. For example, the patient's suffering was stated to be worse, the first initiative more often by the patient, the death more in conformity with procedural requirements etc: J. Griffiths, H. Weyers, A. Blood (eds) Euthanasia and Law in the Netherlands (Amsterdam University Press 1998) at 205.
206. Ibid. at 238.
207. However, as he notes, 'the reporting rate everywhere outside the Netherlands (except for the state of Oregon) is 0' J. Griffiths, 'Dutch Data in the International Debate: A statement by John Griffiths at a briefing session at the House of Lords', (October 2003) n 8 Newsletter MBPSL Regulation of Medical Behaviour That Potentially Shortens Life at 2.
208. S.M. Wolf, supra, n. 60 at 308.
209. K.J. Kaplan, M. Harrow and M.E. Schneiderhan, supra, n. 7 at 42.