Some realism about end of life: The current prohibition and the euthanasia underground

American Journal of Law and Medicine

Volumn 33, Issue 1, 2007, Pages 55-95

  Smith, Stephen W ^a  

^a UNIVERSITY OF BIRMINGHAM   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

EUTHANASIA; HEALTH CARE PERSONNEL; HUMAN; LAW; MEDICAL ETHICS; MEDICAL PRACTICE; PHYSICIAN; PROFESSIONALISM; REVIEW; SUICIDE;

EID: 34249752745     PISSN: 00988588     EISSN: None     Source Type: Journal    
DOI: 10.1177/009885880703300102     Document Type: Review

References (249)

1. Oliver Wendell Holmes, The Path of the Law, 10 HARV. L. REV. 457 (1897), available at http://www.constitution.org/lrev/owh/ path_law.htm.
2. Id. Holmes, of course, is also known for his belief in eugenics, of which his most famous statement on the matter is probably his comment that "three generations of imbeciles is enough." Buck v. Bell, 274 U.S. 200, 207 (1927). While I do support Holmes' view in the introductory quotation, I wish to make it clear that I do not support his statements in Buck v. Bell, nor should anything in this article be taken as an endorsement of those views.
3. For the purposes of this article, it will be necessary to distinguish between different types of end-of-life practices. Physician-assisted suicide will refer to all cases in which a doctor prescribes a method of death (usually but not exclusively lethal drugs), but the patient's own final action brings about death. Active euthanasia, in contrast, involves the doctor performing the final action that brings about death. Active voluntary euthanasia is voluntary euthanasia in which the patient is capable of consenting and consents to the action that brings about death. Involuntary euthanasia, in contrast, involves a patient who is capable of consenting but has not consented. Non-voluntary euthanasia involves cases where the patient is incapable of consenting or refusing consent. This includes cases where a patient is unconscious, is determined to lack capacity or is below the age of consent. The term "assisted dying," when used in the article, refers to the practices of PAS and AVE together.
4. See, e.g., MARGARET BATTIN, ENDING LIFE: ETHICS AND THE WAY WE DIE (Oxford University Press 2005);
5. JOHN GRIFFITHS, ALEX BOOD & HELEEN WEYERS, EUTHANASIA AND LAW IN THE NETHERLANDS (Amsterdam University Press 1998);
6. JOHN KEOWN, EUTHANASIA, ETHICS AND PUBLIC POLICY: AN ARGUMENT AGAINST LEGALISATION (Cambridge University Press 2002);
7. THE CASE AGAINST ASSISTED SUICIDE (Kathleen Foley & Herbert Hendin, eds., Johns Hopkins University Press 2002).
8. See, e.g., HERBERT HENDIN, SEDUCED BY DEATH: DOCTORS, PATIENTS, AND THE DUTCH CURE (W. W. Norton & Co. 1997);
9. KEOWN, supra note 4, at 273-281;
10. THE CASE AGAINST ASSISTED SUICIDE, supra note 4, at 311-332.
11. A more complete definition of instances of abuse will be discussed below.
12. The information from the Netherlands is contained primarily in three research articles on end-of-life practices. See Bregie D. Onwuteaka-Philipsen et al., Euthanasia and Other End-of-Life Decisions in the Netherlands in 1990, 1995 and 2001, 362 LANCET 395, 395-399 (2003);
13. Paul J. van der Maas et al., Euthanasia and Other Medical Decisions Concerning the End of Life, 338 LANCET 669, 669-674 (1991);
14. Paul J. van der Maas et al., Euthanasia, Physician-Assisted Suicide, and Other Medical Practices Involving the End of Life in the Netherlands, 1990-1995, 335 NEW ENG. J. MED. 1699, 1699-1705 (1996).
15. The Annual Reports from Oregon are most easily found on the website for the Oregon Department of Human Services. Oregon Department of Human Services, State of Oregon: Death with Dignity Act, http://www.dhs.state.or.us/ publichealth/chs/pas/pas.cfm (last visited Apr. 9, 2007).
16. See Luc Deliens et al., End-of-Life Decisions in Medical Practice in Flanders, Belgium: A Nationwide Survey, 356 LANCET 1806, 1806-1811 (2000);
17. Helga Kuhse et al., End-of-life Decisions in Australian Medical Practice, 166 MED. J. AUSTL. 166, 191 (1997);
18. Agnes van der Heide et al., End-of-Life Decision-Making in Six European Countries: Descriptive Study, 361 LANCET 345, 345-350 (2003).
19. ROGER S. MAGNUSSON, ANGELS OF DEATH: EXPLORING THE EUTHANASIA UNDERGROUND (Yale University Press 2002). The interviewees were given pseudonyms in the book.
20. Id. at 284. Thus, while this article will mention particular interviewees, the names used are the pseudonyms used in Angels of Death.
21. Id. at 2. The importance of the fact that a majority of the interviewees were involved in the treatment of HIV/AIDS should not be underestimated. In all likelihood, the nature of the treatment of HIV/AIDS, its effect on close-knit communities (often considered to be outside the mainstream), and the prevalence of providers originating from those communities had an impact on the research. Magnusson further pointed out that the HIV/AIDS community was likely to be more organized than other treatment communities. E-mail from Roger Magnusson, Associate Professor, University of Sydney, to Stephen W. Smith, Lecturer in Law, University of Birmingham (July 14, 2006) (on file with author). He went on to point out that significant elements of his research, especially the recruitment and "networking" components, were likely a result of that unique community. Id.
22. MAGNUSSON, supra note 9, at 284.
23. See id.
24. Id. at 282-283. The recruitment process involved general invitations posed at seminars and conferences, flyer distributions, and letters to community groups.
25. Id.
26. Id. at 131, tbl.7-2.
27. Id.
28. Id.
29. Id. at 132.
30. See id. For example, one such rumor, relayed by a prominent physician, involved two doctors "who 'you can call . . . and they'll come over and kill you. Sometimes they go together and sometimes they go one at a time; they wear disguises . . . Groucho Marx masks.'"
31. Id.
32. Id. at 132, tbl.7-3. This involved situations such as injecting the patient with a lethal drug cocktail or other actions that would put the interviewee at the heart of the actions resulting in death.
33. Id. at 132-133.
34. Id. at 132, tbl.7-2, 133.
35. Id. at 132, tbl.7-2, 134.
36. Id. at 136, tbl.7-4.
37. Id. at 138.
38. See id.
39. Id. at 137. This table has been modified and reproduced with the author's permission. E-mail from Roger Magnusson, Associate Professor, University of Sydney, to Stephen W. Smith, Lecturer in Law, University of Birmingham (Sept. 7, 2006) (on file with author).
40. BATTIN, supra note 4, at 4 (quoting Seneca, Letters to Lucilius, in THE STOIC PHILOSOPHY OF SENECA (Moses Hadas ed. & trans., Norton 1958)).
41. BATTIN, supra note 4, at 4.
42. Of course, determining whether a life has been a "good one" or a "full one" involves many subjective judgments about the type of life one wants to lead or those things one thinks are important. Nothing here should be construed as arguing for any specific conception about the valuation of life (or which parties are entitled to make such valuations), but merely that lifespan by itself is usually an insufficient criteria for such a determination.
43. BATTIN, supra note 4, at 4.
44. Obviously, some may argue that suicide can never be a rational response. As noted above, that argument, however, is not universally accepted. Additionally, as I argue below, even if one accepts that suicide should be discouraged it does not necessarily follow that assisted dying should not be legalized.
45. RICHARD A. POSNER, AGING AND OLD AGE 243-253 (The Univ. of Chicago Press 1995).
46. Id. at 246. The costs of committing suicide include not just the pain, etc. of the actual suicide but also the lost benefits of continued existence.
47. Id.
48. Id.
49. Id.
50. Id. at 247-248.
51. Id. at 250-253.
52. Id. at 252-253.
53. See Oregon Department of Human Services, supra note 7.
54. For additional reports, see Oregon Department of Human Services, Death with Dignity Act Annual Reports, http://oregon.gov/DHS/ph/pas/ar-index.shtml (last visited Apr. 9, 2007).
55. For example, one patient appears to have been prescribed lethal medication in 2003, but was still alive as of December 31, 2004. OR. DEP'T OF HUMAN SERVS, OFFICE OF DISEASE PREVENTION & EPIDEMIOLOGY, SEVENTH ANNUAL REPORT ON OREGON'S DEATH WITH DIGNITY ACT 12 (2005), http://oregon.gov/DHS/ph/pas/ docs/year7.pdf.
56. See MAGNUSSON, supra note 9, at 213-214.
57. Id. at 82.
58. Id. at 82-83.
59. Id.
60. Id. at 80.
61. Id.
62. Id. at 113.
63. Id.
64. Id.
65. Id. at 250.
66. See OR. DEP'T OF HUMAN SERVS, OFFICE OF DISEASE PREVENTION & EPIDEMIOLOGY, EIGHTH ANNUAL REPORT ON OREGON'S DEATH WITH DIGNITY ACT 4 (2006), http://oregon.gov/DHS/ph/pas/docs/year8.pdf [hereinafter EIGHTH ANNUAL REPORT].
67. See id. at 12, 19-21 tbls.1 & 2.
68. See id. at 19-21 tbls.1 & 2.
69. Id.
70. Id. It appears that the division between the regions East and West of the Cascade Mountains provides a rough demarcation of socio-economic standing; with the western regions of the state being more affluent than the eastern regions.
71. Id.
72. See, e.g., Not Dead Yet, http://www.notdeadyet.org./ (last July 12, 2006). It is worth mentioning that there are two separate arguments about disability. The first is that those with disabilities such as paralysis (i.e. non-terminal disabilities) will be subject to pressure to choose assisted dying. The second is that those with terminal illness are often disabled as a result of the illness (e.g. someone with motor-neuron disease becoming wheelchair-bound as a result). There does not appear to be any statistical evidence on either point.
73. I wish to make it clear that by indicating that these three practices may result in death does not mean that they should be considered legally or morally wrong, that the death was intended, or that doctors should not be engaging in these practices. All I mean is to suggest that these are end-of-life medical decisions in which one possible (even probable) result is that the patient dies.
74. For example, the much publicized case of Terry Schiavo involved a dispute about whether to remove tube feeding and hydration from a woman alleged to be in a persistent vegetative state. See Not Dead Yet, supra note 55. While not directly comparable, because Terry Schiavo was considered incompetent to make decisions, those with disabilities were among the most vocal supporters of keeping Terry Schiavo alive.
75. See id. This was out of the fear that similar things could to happen to them.
76. See id.
77. MAGNUSSON, supra note 9, at 19.
78. Id.
79. Id. (emphasis in original).
80. Several of these stories involve patients resorting to particularly 'messy' suicides, including, among other things, jumping off buildings after failed communications with practitioners. See id. at 246;
81. see also supra text accompanying notes 46-48.
82. Luke Gormally, Walton, Davies, Boyd and the Legalization of Euthanasia, in EUTHANASIA EXAMINED: ETHICAL, CLINICAL AND LEGAL PERSPECTIVES 113, 124 (John Keown ed., 1995).
83. Id.
84. Id.
85. There is another problem with Gormally's suggestion. One of the distinguishing factors relied on by those arguing against legalizing assisted dying is that there is an intent to kill the patient in cases of PAS and AVE which does not exist in cases of withdrawing and withholding treatment. If, however, patients that appear to be withdrawing or withholding treatment for suicidal reasons are allowed to do so, it seems to make that distinction meaningless.
86. This practice of traveling to a jurisdiction where PAS and/or AVE is allowed is referred to as "suicide tourism." See Swiss Assisted Suicide 'May be Illegal', BBC NEWS, Apr. 16, 2003, http://news.bbc.co.uk/2/hi/uk_news/2952123.stm. However, 'suicide tourism' does not appear to be a problem among many of the locations allowing some form of assisted death. Oregon, Belgium and the Netherlands all have some sort of residency requirement or require the patient to have a long-standing relationship with the doctor before requesting PAS and/or AVE. Switzerland, on the other hand, apparently does not have such a requirement and there has been an increase of patients going to Switzerland to commit suicide.
87. See Britons Who Chose Assisted Suicide, BBC NEWS, Jan. 24, 2006, http://news.bbc.co.U.K./1/hi/health/ 4643802.stm. Thus, Switzerland seems to be the primary destination for 'suicide tourism.'
88. This is particularly a problem in jurisdictions without universal health care in which patients may already be paying large sums for necessary medical care.
89. Again, the remarks of Mark are instructive. See MAGNUSSON, supra note 9, at 19. As noted above, Mark participates in assisted dying because of a lack of options for the patients he sees. In particular, Mark is concerned with the lack of support from doctors. As he states "a physician should follow a patient out to the end in a supportive way . . . that ought to be a physician's role; I end up there by default."
90. Id.
91. A slippery slope argument describes an argument urging that one practice should not be accepted because it will inevitably lead to the acceptance of a practice that should not be; despite our best efforts to resist that move. For further information, see, e.g., David Enoch, Once You Start Using Slippery Slope Arguments, You're On A Very Slippery Slope, 211 OXFORD J. LEGAL STUDS. 629 (2001)
92. and Eugene Volokh, The Mechanisms of the Slippery Slope, 116 HARV. L. REV. 1026, 1032 (2003).
93. For an examination of slippery slopes within the contexts of the euthanasia debate, see Stephen W. Smith, Evidence for the Practical Slippery Slope in the Debate on Physician-Assisted Suicide and Euthanasia, 13 MED. L. REV. 17 (2005).
94. Van der Maas et al., supra note 7, at 673-674.
95. See, e.g. John Keown, Euthanasia in the Netherlands: Sliding Down the Slippery Slope?, in EUTHANASIA EXAMINED: ETHICAL, CLINICAL AND LEGAL PERSPECTIVES 261, 270 tbl.1, 289 (John Keown ed., 1995).
96. Onwuteaka-Philipsen et al., supra note 7, 395-396;
97. van der Maas et al., supra note 7, at 673-674;
98. Onwuteaka-Philipsen et al., supra note 7, at 396 tbl.1; see also tbl.2.
99. See Kuhse et al.,
100. supra note 8, at 191-196.
101. Id. at 195.
102. Id.
103. Deliens et al., supra note 8, at 1806.
104. KEOWN, supra note 4, at 135 n.41. The interviews were not done because the researchers feared that doctors would not discuss their practices in person with an interviewer, particularly if they were going to relate practices that were illegal.
105. Kuhse et al., supra note 8, at 192. Magnusson's subsequent research shows that this assumption might have been in error, but there was no reason to believe so at the time.
106. KEOWN, supra note 4, at 135 n.41. It appears, however, that the mistranslated question in the Australian study was not a question dealing with non-voluntary and involuntary euthanasia.
107. Clive Seale, Professor of Sociology, Brunel Univ., Address at the Institute of Medical Law, University of Birmingham, Investigating End-of-Life Decision Making in U.K. Medical Practice (March 22, 2006). Instead, it was a question about non-treatment decisions.
108. Id. So, it is unclear how the mistranslation would have changed the data for cases of non-voluntary and involuntary euthanasia.
109. Clive Seale, National Survey of End of Life Decisions Made by U.K. Medical Practitioners, 20 PALLIATIVE MED. 3, 3-10 (2006).
110. Id. at 6, tbl.2. All of the incidents involved AVE, not PAS.
111. Id.
112. Id.
113. Van der Heide et al., supra note 8, at 345.
114. Id. at 347, tbl.2.
115. Id.
116. While not specifically related, there is another interesting fact that has arisen from the data surrounding jurisdictions that allow assisted dying. As noted above, the rate of AVE, particularly in the Netherlands, continues to rise. In addition, the rate of AVE in Belgium, where it has recently been legalized, has increased from 17 cases of AVE per month in the period from September 23, 2002 to December 31, 2003 to 29 cases per month in 2004. See HOUSE OF LORDS SELECT COMM. ON THE ASSISTED DYING FOR THE TERMINALLY ILL BILL, ASSISTED DYING FOR THE TERMINALLY ILL BILL, 2004-5, H.L. 86-Im at 73-74, available at http://www.parliament.the-stationery-office.co.uk/pa/ ld200405/ldselect/ldasdy/86/86i.pdf [hereinafter HOUSE OF LORDS SELECT COMM.]. This is a rather marked increase. However, when one considers the rate of uptake in Oregon, where only PAS is legal, the rates are much smaller. In fact, the highest rate appears to be in 2003, where PAS accounted for 13.6 out of every 10,000 deaths in Oregon.
117. See EIGHTH ANNUAL REPORT, supra note 50, at 11. The different rates for AVE and PAS do not relate to the slippery slope arguments, as such, but may provide an important consideration about which assisted dying practices should be legal.
118. This argument only relates to the 'empirical or practical' slippery slope. There is an additional argument, the 'logical' slippery slope, used in connection with euthanasia that relies on the logical, rather than empirical, connections between PAS and AVE, on the one hand, and non-voluntary and involuntary euthanasia, on the other. The name is a bit of a misnomer, as this argument really concerns consistency and is based upon a misconception of how the interests involved in euthanasia interact. For further information, see Stephen W. Smith, Fallacies of the Logical Slippery Slope in the Debate on Physician-Assisted Suicide and Euthanasia, 13 MED. L. REV. 224 (2005).
119. MAGNUSSON, supra note 9, at 141-143, 120-121. This may be another instance where the community in which Magnusson researched is important. The fact that the interviewees were primarily involved in the HIV/AIDS and gay communities may mean that these particular rituals were more frequent and more important than in other health care communities. That does not mean that those in, for example, the cancer community will not go through similar rituals, but they may not have been as prevalent a theme.
120. See id. at 141-143.
121. Id.
122. See infra note 97.
123. MAGNUSSON, supra note 9, at 141-143.
124. Id. at 139.
125. Id. at 223-224.
126. Id.
127. Id.
128. In fact, there is anecdotal evidence to support such a conclusion. For example, a U.K. doctor by the name of Anne Turner recently traveled to Switzerland to enlist assist suicide. The news reports surrounding her death indicated that her family was present and there was even a 'last dinner' the night before her suicide. See Sean O'Neill, Why a Retired GP Chose to End Her Life Seven Years Before Time, THE TIMES, Jan. 25, 2006, http://www.timesonline.co.U.K./tol/news/U.K./article719367.ece. Even those she did not inform prior to her death were sent personal letters that arrived after her death.
129. See Sarah Boseley & Clare Dyer, 'I believe I must end my life while I am still able', THE GUARDIAN, Jan. 25, 2006, http://www.guardian.co.U.K./medicine/story/ 0,,1694235,00.html#article_continue.
130. One of the proponents of this view is Leon Kass. For more on Kass' position, see his seminal article on the subject: Leon Kass, Neither for Love Nor Money: Why Doctors Must Not Kill, 94 PUB. INT. 25 (1989).
131. See BATTIN, supra note 4, at 57.
132. Those interested in the literature should see the following: BATTIN, supra note 4; GERALD DWORKIN ET AL., EUTHANASIA AND PHYSICIAN-ASSISTED SUICIDE (R.G. Frey ed., Cambridge University Press 1998);
133. Kass, supra note 98.
134. MAGNUSSON, supra note 9, at 18. In addition, Mark appears to have a similar response to many laypeople, as he uses the example of his pet dog being put to sleep to explain why he thinks euthanasia is acceptable.
135. Id. Quite a few people, when discussing whether euthanasia ought to be legal, will use pets as an example. These people point out that we put pets to sleep if they are or appear to be in significant pain or otherwise suffering. They argue that since we consider it acceptable for pets, we ought to consider it acceptable for humans, particularly if they people ask for it.
136. Id. at 69.
137. Id.
138. Id.
139. Id. at 78 (emphasis in original).
140. Id. at 16 (emphasis in original).
141. Id.
142. Even if these practitioners are not being truthful, it does not necessarily follow that they are being intentionally untruthful. They may be trying to rationalize a difficult practice by making the ethical claims that they do. Even if this is the case, the fact that the ethical claims made by these practitioners are similar to those made by average laypersons indicates that the claims deserve consideration.
143. Id. at 106.
144. Id. at 241-244.
145. Id. at 241.
146. Id. at 124-125.
147. Id. at 106.
148. Id.
149. Id.
150. Id.
151. Id.
152. Two of the more famous cases in the U.K. are Glass v. United Kingdom, [2004] 1 FLR 1019, [2004] Fam. 410 (appeal taken from Eng.) and Re Wyatt (a child) (medical treatment: parents' consent), [2004] EWHC 2247 (appeal taken from Eng.). Both of these cases dealt with sick children whose parents wanted treatment to continue despite their physicians' advice.
153. MAGNUSSON, supra note 9, at 225.
154. Id.
155. Id.
156. Id.
157. Id. at 236-237.
158. Id.
159. Id. at 234, 237.
160. Id. at 235.
161. Id.
162. Id.
163. Id. at 236.
164. Id. at 237 (emphasis in original).
165. Id.
166. Id. at 236.
167. Id. at 235. One question worth asking is why Liz did not feel that she could do this now (when arguably any official response would be greater). It is unclear from the anecdote why Liz did not feel that the current prohibition offered her a way to seek support, but it does not appear to have done so.
168. Id. at 107-110.
169. Id.
170. Id.
171. Id.
172. Id.
173. Id. at 105.
174. Magnusson also refers to these people as "revisionists." Id. at 104-110. Perhaps the best example of this phenomenon is Jack Kevorkian, although presumably he was not interviewed for the study.
175. Id.
176. Id. at 106.
177. Id. at 107-110.
178. Id. at 110.
179. Id.
180. Id.
181. Id. at 164.
182. Id.
183. Id. at 164-165.
184. Id.
185. Id. at 165.
186. Id.
187. Gary's story is related at id. at 211,
188. and Gordon's story is related at id. at 206-208.
189. Gordon's story is also troubling because of his reasons for participating. Those reasons included: "I think it was because it was 4 o'clock in the morning, I had a cold, and I felt dreadful and I just wanted to get out of there."
190. See generally Roger Magnusson, "Underground Euthanasia" and the Harm Minimization Debate, 32 J.L. MED & ETHICS 486 (2004) (describing the Euthanasia Underground and arguing that, in light of the prevalence of the practice, regulation might be a way to improve the safety of such practices).
191. MAGNUSSON, supra note 9, at 132-136.
192. Again, as stated previously in the introduction, Magnusson specifically mentions this as a large part of why he got the results that he did. The HIV/AIDS community and the gay health community are likely to be more organized, more structured and more of an actual community than other health groups might be.
193. MAGNUSSON, supra note 9, at 282.
194. Id.
195. Id.
196. Id. at 283.
197. Id. at 131, tbl.7-2.
198. Id. at 179, tbl.9-1.
199. Id.
200. Id.
201. Id.
202. Id. at 175.
203. As Magnusson notes, "As might be expected, given the recruitment strategy . . ., virtually every interviewee who admitted to participating in assisted death knew of others who were similarly involved." Id. at 180.
204. HOUSE OF LORDS SELECT COMM., supra note 86, at 82.
205. MAGNUSSON, supra note 9, at 183.
206. Id. at 1.
207. Id. at 185. The cremation services are of vital importance to those working in the euthanasia underground. If the body is cremated, it eliminates the possibility of police, coroners or other investigatory agencies from finding out what drugs were in the patient's body at the time of death. Without that information, it would be very difficult for authorities to bring murder changes.
208. Id. at 227. Even the case of Dr. Cox in the U.K., which was discovered because of notations he made on the patient's medical chart, could only be brought as an attempted murder case because the body of Lillian Boyes had been cremated. R. v. Cox, 12 BMLR 38 (1992).
209. MAGNUSSON, supra note 9, at 173, 183.
210. Id. at 1, 183-184.
211. MAGNUSSON, supra note 9, at 182. This diagram is reproduced with the author's permission. E-mail from Roger Magnusson, Associate Professor, University of Sydney, to Stephen W. Smith, Lecturer in Law, University of Birmingham (Sept. 7, 2006) (on file with author).
212. Id. at 193.
213. Id.
214. Id. at 89, 219.
215. Id. at 219.
216. One interviewee, Marjorie, who is a community worker and registered nurse, indicated that "[w]e've all done it. You're supposed to [administer] a certain amount of morphine and the rest gets chucked out, well, you don't chuck it out - you give it to the [patient] instead." Id. at 219.
217. Id. at 192 (emphasis in original).
218. Id. at 193.
219. Id. at 192.
220. See id. at 145.
221. Id.
222. Id. at 149.
223. Id. at 145-149.
224. Id. at 145.
225. Id. at 205.
226. Id.
227. Id. at 205-206.
228. Id. at 166-167.
229. Id.
230. Id. at 235.
231. Id. at 236-237.
232. Id.
233. Id. at 235-237.
234. The world became aware of Jack Kevorkian's activities through his media interviews; Timothy Quill became known because of the articles he wrote about his personal experiences in the New England Journal of Medicine; and Dr Cox's actions became known due to indications he made on the patient's medical charts.
235. For those arguing that doctor/patient confidentiality will prevent legalization of PAS and/or AVE see, e.g. Daniel Callahan & Margot White, The Legalization of Physician-Assisted Suicide: Creating a Regulatory Potemkin Village, 30 U. RICH. L. REV. 1, 8-10 (1996).
236. Oregon's Death with Dignity Act requires doctors to report cases of PAS to the Department of Human Services. OR. REV. STAT. § 127.865(1)(b) (2003).
237. The Dutch regulations require that incidents be reported to a review committee. Jurriaan De Haan, The New Dutch Law on Euthanasia, 10 MED. L. REV. 57, 62 (2002).
238. R. v. Cox, 12 BMLR 38 (1992).
239. MAGNUSSON, supra note 9, at 195.
240. Id. at 217.
241. Id. at 217.
242. Id. at 217-218.
243. Id. at 218.
244. Id. at 219-220.
245. Id.
246. Id. at 194-197. This included Zane, a palliative care physician, Russell, a hospital physician, and Liz, the nurse who discussed the case of involuntary euthanasia mentioned previously. Liz indicated that the hospital where she worked would book in patients who were there to receive a lethal infusion of drugs, that nurses would be told "the cocktail is going up," and that the significance of the cocktail was not hidden.
247. Id. at 196. She even claimed that the hospital therapeutics manual contained a "written protocol" or recipe for a euthanasia cocktail.
248. Id.
249. MAGNUSSON, supra note 9, at 105.